Original Ariticle VOL. 20 | NO. 3 | ISSUE XX | JULY-SEPT.

(ONLINE FIRST-2022)

Utilization of Cervical Cancer Screening and Associated

Factors among Women in Bhaktapur, Nepal
Nepal J,1 Poudyal AK,2 Duwal S,3 Gyawali S,4 Basel P5

ABSTRACT
Background

Department of Community Programs,

1 Cervical cancer is the most common cancer among women in Nepal causing highest
Dhulikhel Hospital, Kathmandu University Hospital, cancer mortality among women of reproductive age. However, it can be prevented
Dhulikhel, Kavre, Nepal.
through early and regular screening.
2
Central Department of Public Health,
Institute of Medicine, Tribhuvan University, Objective
Maharajgunj, Kathmandu, Nepal.
To assess utilization of cervical cancer screening, its awareness and perception
3
Department of Community Medicine, among women, and associated factors.
Nepalese Army Institute of Health Sciences,
Bhandarkhal, Kathmandu, Nepal. Method
4
Oxford University Clinical Research Unit-NP, A cross-sectional study was conducted where 360 women of age 30-60 years were
Patan Academy of Health Sciences, randomly selected and interviewed from five administrative wards of Bhaktapur
Lagankhel, Lalitpur, Nepal.
municipality.
5
Department of Community Medicine,
Maharajgunj Medical Campus, Institute of Medicine, Result
Tribhuvan University, Maharajgunj, Kathmandu,
Nepal. Utilization of cervical cancer screening through Pap test or Visual Inspection with
Acetic acid was found in 32.2% women and 47.8% were aware of cervical cancer and
Corresponding Author its screening tests. 100% of them had high level of perceived benefits and facilitators.
Prem Basel More than 80% of them had low level of perceived barriers and susceptibility.
Department of Community Medicine, Women of age group 51-60 years were more likely to perform the screening test
Maharajgunj Medical Campus, (AOR=13.14) whereas unemployed women were at higher odds of performing the
test (AOR=3.29). Women who were aware of cervical cancer and its screening were
Institute of Medicine, Tribhuvan University,
more likely to perform the screening (AOR=53.65). Women having low level of
Maharajgunj, Kathmandu, Nepal.
perceived barriers (AOR=5.83) and high level of perceived seriousness (AOR=6.67)
E-mail: prembasel11@gmail.com
were more likely to perform the screening.
Citation Conclusion
Nepal J, Poudyal AK, Duwal S, Gyawali S, Basel Only one third of women had performed Pap test/VIA and those who were aware
P. Utilization of Cervical Cancer Screening and
Associated Factors among Women in Bhaktapur, of cervical cancer and had high level of perception were more likely to perform the
Nepal. Kathmandu Univ Med J. 2022; Online First. screening. Thus, more rigorous and tailor-made awareness programs should be
developed by health program planners to increase the screening rate among younger
and working women.

KEY WORDS
Awareness, Cervical cancer screening, Perception, Utilization

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INTRODUCTION Ethical approval for the study was received from Institutional
Review Committee (IRC) of Institute of Medicine, Tribhuvan
Cervical cancer is one of the world’s deadliest but most
University (IOM, TU) and formal permission was obtained
easily preventable forms of cancer. Worldwide, it is the
from Bhaktapur municipality office to collect the data. An
fourth most frequent cancer in women with incidence rate
informed verbal and written consent were taken from the
of 13.3% in 2020 and mortality rate of 7.3% where death
respondents after explaining the purpose and procedure
rates are considerably higher in developing countries.1,2 In
of the study. Confidentiality was maintained and voluntary
Nepal, 11.4 million women are at risk of cervical cancer
participation was ensured. Women who did not undergo
with incidence rate higher than worldwide (14.2%) and
cervical cancer screening were personally counseled for it
mortality rate of 9.46%.3 It is the most frequent cancer
with the help of nurses assigned in ward offices.
among women in Nepal and also the first leading cause
of cancer deaths among women.3 Having a scientifically Face to face interview was conducted using structured
established cause, well-organized cervical screening questionnaire. The average time taken to complete one
programs or widespread good quality cytology can reduce face to face interview was approximately 25-30 minutes.
cervical cancer incidence and mortality.4,5 In Nepal, cervical The first section of questionnaire included information
cancer screening coverage rate is only 2.8%.3 about socio-demographic characteristics and validated
questionnaire from Nepal Demographic Health survey
Few studies in Nepal have found that the underutilization
(NDHS) was used to assess wealth quintile and women
of screening services is affected by knowledge and attitude
empowerment index. The second section was related to
of women about cervical cancer and screening tests.6,7
awareness of cervical cancer and its screening, utilization of
Utilization of cervical cancer screening is a health seeking
cervical cancer screening and, perception of cervical cancer
behavior and many complex factors may influence a
screening. The awareness level was divided into aware
woman’s decision about cervical cancer screening. But
and unaware. The participants who had heard of cervical
there has been little work in assessing other factors that
cancer and its screening were regarded as aware and the
can affect utilization of cervical cancer screening such as
participants who had never heard of cervical cancer and
perception of cervical cancer screening, wealth quintile,
its screening were regarded as unaware. If a woman had
women empowerment index, etc.
ever performed Pap smear/VIA test at least once in lifetime
Thus, this study aimed to assess utilization of cervical then she was categorized in ‘yes utilization’. If a woman
cancer screening among women and identify the factors had never done Pap smear/VIA test in her life then she was
that can affect the women’s utilization of cervical cancer categorized in ‘no utilization’. Health Belief Model Scale for
screening which can help health program planners to cervical cancer and pap smear test was used to measure
develop appropriate programs to motivate women to perception. It is a validated tool adapted from a study for
perform cervical cancer screening tests. which permission from author was obtained.10 The tool was
modified according to the context of the study and then
translated in Nepali language which consisted of 42 items
METHODS Likert scale divided into 5 subscales: perceived benefits of
A descriptive cross-sectional study was conducted in pap smear test and health motivation, perceived barriers
randomly selected five administrative wards of Bhaktapur to pap smear test, perceived seriousness of cervical cancer,
municipality, Nepal. The study population were women of perceived susceptibility to cervical cancer, and perceived
age group 30-60 years as this is the target age group for facilitators to cervical cancer screening. The mean score
cervical cancer screening according to national guidelines.9 of each subscale was calculated and if the score of the
Data was collected in 360 women from 26th January to 5th participant was higher than the mean score of the subscales
March, 2020. Women ever diagnosed with cervical cancer then it was considered high perception in that subscale
were excluded from the study. otherwise low perception.

Two stage proportionate sampling method was used where Pre-testing of the questionnaire tool was done in 10% of
at first stage, out of total 10 wards, 5 wards (ward 2, 4, 6, the total sample (36 women) in Suryabinayak municipality
7, 10) were selected through Probability Proportionate to and the tool was revised based on the pre-test. The
Size (PPS) sampling and proportionate sampling was done internal consistency of each subscale of the Likert scale was
to determine the number of women to be selected from assessed using Cronbach’s alpha (α) which ranged from
each ward. After obtaining the list of households of each 0.60 to 0.84.
ward from the respective ward office, systematic random The collected data was systematically coded and entered
sampling was used to reach the households. One eligible in EpiData version 3.1. The entered data was exported to
woman from each household was selected and if more IBM SPSS version 17 where checking, cleaning, editing and
than one eligible woman were living in the household, Kish analysis of the data was performed. Descriptive analysis
method was applied to choose one woman only. was done to report frequency, percentage, mean, median
and standard deviation. Wealth quintile was analyzed using

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Principal Component Analysis (PCA). Chi square test was followed by family or friends 68.3%. Majority were aware
done to examine binary association between dependent that having multiple sexual partner 81.4%, early marriage
and independent variables. Logistic regression analysis was and sexual intercourse 80.7% were the risk factors of
done to identify factors determining utilization of cervical cervical cancer whereas only around 15% of women were
cancer screening. aware that viral infection as a risk factor. Most of the women
were aware that vaginal foul smelling, discharge 86.3%,
vaginal bleeding 76.4% were the sign/symptoms of cervical
RESULTS cancer whereas only 8% were aware that cervical cancer
Among 360 women who participated in the study, more could be asymptomatic. More than half of the respondents
than half of women 52.2% belonged to the age group of 30- 53.4% were aware about the possibility of early detection
40 years. The median age was 40 years. As demonstrated and prevention of cervical cancer. More than two third of
by Table 1, the most prominent ethnic group was Janajati the respondents 68.2% had never heard about pap smear
/Newar 89.7% and religion was Hindu 97.8%. Regarding test/VIA test. Majority of them 97.4% answered that the
the educational status of the study participants, around recommended age for cervical cancer screening was after
two third of the women 63.1% had education of secondary 30 years. Only 8.8% of them were aware that the frequency
level and above. Around three fifth of them 46.9% were of cervical cancer screening was every 3-5 years. Majority
homemakers. Majority of women who participated in the of the women 90.7% had never heard of HPV vaccine.
study were married 93.6%.
Table 2. Awareness and Perception level of women regarding
Table 1. Socio-demographic characteristics of women (n=360)
cervical cancer and its screening (n=360)
Characteristics Number Percentage
Variables Level Number Percentage
Age group (years)
Awareness Aware 172 47.8
30-40 188 52.2
Unaware 188 52.2
41-50 130 36.1
Perceived benefits High 360 100
51-60 42 11.7
Perceived barriers High 41 11.4
Ethnicity
Low 319 88.6
Janajati (Newar) 323 89.7
Perceived seriousness High 301 83.6
Brahmin/Chettri 26 7.2
Low 59 16.4
Dalit 8 2.2
Perceived susceptibility High 44 12.2
Madhesi 3 8
Low 316 87.8
Religion
Perceived facilitators High 360 100
Hindu 352 97.8
Buddhist 8 2.2
As demonstrated by Table 2, nearly half of them 47.8%
Education status were aware about cervical cancer and its screening. All
Illiterate and no formal education 80 22.2 participants 100% had high level of perceived benefits and
Below secondary 53 14.7 perceived facilitators. Majority of the respondents 83.6%
Secondary level and above 227 63.1 had high perceived seriousness whereas most of them
Occupational status 88.6% had low level of perceived barriers and low level
of perceived susceptibility. Table 3 shows that only one
Homemaker 169 46.9
third of women 32.2% had ever performed cervical cancer
Business 121 33.6
screening test.
Service 36 10.0
Agriculture 27 7.5
The bivariate analysis (Chi-square test) showed that age of
women, education level of women, occupation of women,
Daily wage 7 1.9
age at marriage of women, age at first parity of women,
Marital status
number of children of women, women empowerment
Married 337 93.6 index, awareness of women, perceived barriers and
Widowed 12 3.3 perceived seriousness were found to be significantly
Unmarried 9 2.5 associated with utilization of cervical cancer screening with
Divorced 2 0.6 p < 0.05 at 95 percent CI. However, ethnicity, marital status,
wealth index and perceived susceptibility were not found
Among the participants, only 6.7% had any known history to be associated with utilization. So, the study variables
of cervical cancer in their family. Nearly half of them that exhibited significant association with utilization
44.7% had heard about cervical cancer where source of were further subjected to binary logistic regression for
information for most of them 76.9% were health workers adjustment of possible confounders.

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Table 3. Utilization of cervical cancer screening among women Table 4. Association between demographic factors and
(n=360) utilization of cervical cancer screening (n=360)

Variables Number Percentage Characteristics Utilization of cervical cancer screening p-value

Ever performed Pap test/VIA test Yes n(%) Yes n(%) Total n(%)
Yes 116 32.2 Age (in years)
No 244 67.8 30-40 27 (14.4) 161 (85.6) 188 (100) <0.001*
Number of screenings done 41-50 64 (49.2) 66 (50.8) 130 (100)
Once 78 67.2 51-60 25 (59.5) 17 (40.5) 42 (100)
Twice 28 24.1 Education
Thrice or more 10 8.7 Secondary 47 (20.7) 180 (79.3) 227 (100) <0.001*
Time of last screening level and above

Before three years 5 4.3 Below sec- 31 (58.5) 22 (41.5) 53 (100)

ondary level
Before one year 85 73.2
Illiterate 38 (47.5) 42 (52.5) 80 (100)
Within one year 26 22.5 and no formal
Reason for screening education

Health personnel’s advice 108 93.1 Occupation

Family/friends’ advice 6 5.2 Homemaker 82 (48.5) 87 (51.5) 169 (100) <0.001*

Self-initiative 2 1.7 Other than 34 (17.8) 157 (82.2) 191 (100)

homemaker
Service taken from
Wealth quintile
Screening camp 86 74.1
Lowest 27 (37.0) 46 (63.0) 73 (100) 0.091
Hospital 25 21.6
Second 19 (26.8) 52 (73.2) 71 (100)
Clinic 5 4.3
Middle 30 (28.8) 74 (71.2) 104 (100)
Fourth 7 (20.6) 27 (79.4) 34 (100)
After adjustment of possible confounders, table 5 shows Highest 33 (42.3) 45 (57.7) 78 (100)
that women of age group 51-60 years were 13 times more
Women Empowerment Index
likely to perform cervical cancer screening than the women
Low 8 (36.4) 14 (63.6) 22 (100) 0.010*
of age group 30-40 years (AOR=13.140, 95% CI=2.344-
73.670). Women who were homemaker (non-earning Moderate 42 (44.2) 53 (55.8) 95 (100)
women) had 3.2 times greater odds of performing cervical High 66 (27.2) 177 (72.8) 243 (100)
cancer screening than women who were other than *Statistically significant (p<0.05) at 95% CI
homemaker (earning women) (AOR=3.298, 95% CI=1.464-
7.428). Table 6 shows that women who were aware of screening.11 Other studies done in various parts of Nepal
cervical cancer and its screening were 53.6 times more also showed that significant portion of women had never
likely to perform cervical cancer screening than women done any cervical cancer screening test.6-8,12-14 In this study,
who were unaware of cervical cancer and its screening only 32.2% of women had performed Pap test/VIA. Cervical
(AOR=53.645, 95% CI=19.438-148.048). Women with low cancer elimination is a global priority today and World
level of perceived barriers of cervical cancer screening Health Organization has urged countries in its South-East
had 6 times greater odds of performing cervical cancer Asia Region to accelerate efforts to eliminate cervical cancer
screening than women with high level of perceived barriers by 2030.15 Nepal has very low cervical cancer screening
of cervical cancer screening (AOR=5.826, 95% CI=1.248- coverage rate which needs to be addressed sincerely and
27.203). Women with high level of perceived seriousness Nepal has to work rigorously in order to meet the global
of cervical cancer screening were 6.6 times more likely to target of elimination of cervical cancer.
perform cervical cancer screening than women with low In this study women who were aware of cervical cancer
level of perceived seriousness of cervical cancer screening or cervical cancer screening were 53 times more likely to
(AOR=6.665, 95% CI=1.987-22.352). perform cervical cancer screening than unaware women.
But comparatively lesser participants were aware about
cervical cancer and screening tests. Other studies done in
DISCUSSION Nepal also showed that women’s awareness about cervical
Although, The National Guideline for cervical cancer cancer and its screening is inadequate.6,12-14 The study done
screening, 2010 had the objective to screen at least 50% in Mid-western Nepal stated that those women who had
of women aged 30 to 60 years to reduce 10% cervical adequate knowledge were more likely to practice cervical
cancer burden within 5 years.9 Unfortunately, the majority cancer screening.6 Other international studies also showed
(about 95%) of women still never have done cervical cancer a positive relation between knowledge and cervical cancer

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Table 5. Relationship between demographic factors and effective utilization of cervical cancer screening services
utilization of cervical cancer screening (n=360) and health professionals can play a key role in increasing
the utilization of cervical cancer screening services.
Study variables COR AOR 95%CI p-value
Lower Upper Barriers to cervical cancer screening such as embarrassment
Age (in years) to show private parts, fear of vaginal examination, presence
30-40 Ref
of male doctor, lack of time, financial problem, etc. were
found to be more prominent in some studies in Nepal.6,7,18
41-50 5.782 2.992 1.267 7.066 0.012*
The findings in this study is quite contrast as more than
51-60 8.769 13.140 2.344 73.670 0.003*
half 53.6% disagree that they were ashamed to lie on a
Education gynecologic examination table and show their private parts
Illiterate and no Ref to have a Pap smear and nearly half of the women 49.4%
formal education
disagree that they preferred a female doctor to conduct
Below secondary 1.557 2.324 0.560 9.643 0.245 a Pap smear test. Again, majority of them disagree that
Secondary level and 0.289 0.494 0.103 2.376 0.379 paying for Pap test would stop them from performing the
above
test. Perception level of women towards cervical cancer
Occupation and its screening is high in almost all domains in this study.
Other than home- Ref But only perceived barriers and perceived seriousness are
maker
significantly associated with cervical cancer screening.
Homemaker 4.347 3.298 1.464 7.428 0.004* In a recent study done in Nigeria, there was significant
Women Empowerment Index association between: perceived consequences of cervical
Low Ref cancer and readiness to be screened for cervical cancer
Moderate 1.387 0.877 0.155 4.957 0.882 among women (χ2 =44.142, p < 0.001).16 Another study also
High 0.653 1.035 0.123 8.735 0.975 showed relation between perceived barriers and utilization
of cervical cancer screening.19 Most of the studies including
*Statistically significant (p<0.05) at 95% CI
COR= Crude Odds Ratio, AOR= Adjusted Odds Ratio, Ref= Reference this study show that even though perception of cervical
category cancer screening is high, its utilization is low. This may
Table 6. Relationship of awareness and perception with indicate that even though women are positive about
utilization of cervical cancer screening (n=360) performing cervical cancer screening, there are other
influencing factors not in control of women which might
Study variables COR AOR 95%CI p-value prevent them from utilizing cervical cancer screening.
Lower Upper Perception can affect the behavior of the person so
Awareness identifying the level of perception of the potential
Unaware Ref beneficiaries can help to increase the screening behavior
Aware 25.217 53.645 19.438 148.048 <0.001* which is important for the success and benefit of screening
program to control and prevent cervical cancer at national
Perceived barriers
level.
High Ref
Low 5.005 5.826 1.248 27.203 0.025* Higher aged and illiterate women were more likely to
Perceived seriousness
perform cervical cancer screening in this study as shown
in other studies done in Kathmandu and Chitwan and Mid-
Low Ref
western Nepal.6,13,14 Also, women who are homemakers
High 3.567 6.665 1.987 22.352 0.002*
(non-earning women) had greater odds of performing
*Statistically significant (p<0.05) at 95% CI cervical cancer screening similar to a study done in Kenya.20
COR= Crude Odds Ratio, AOR= Adjusted Odds Ratio, Ref= Reference
category The higher aged women, homemakers and illiterate women
are more exposed to the awareness programs conducted
screening practice among women.16,17 Again, in the present in the community and have time to visit screening camps
study majority of the respondents, 93.1% have been advised organized in local wards in comparison with educated
by health personnel for the screening which is in line with women who are employed. This may be the reason of
the study done in Kavre where nearly 70% of women went higher utilization of cervical cancer screening in those
for the screening because of health personnel’s advice.7 women in this study. So, awareness programs need be
Utilization of cervical cancer screening services is a health tailored according to the younger and working age group
seeking behavior and awareness among women is an women so a greater number of women can utilize the
important factor which can influence their behavior to screening services.
increase the utilization rate of cervical cancer screening.
The awareness programs which are being conducted are Though not seen in this study, a recent study done to
not sufficient and more awareness programs need to be assess relation between wealth related inequalities and
launched focusing the target groups which may lead to utilization of cervical cancer screening services in 18

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resource constrained countries demonstrated higher rates CONCLUSION

of utilization of CCS services seen in women in the richest
households (OR = 2.00; 95% CI, p<0.05).21 A study done in This study shows low utilization of cervical cancer screening
Kenya also revealed that cervical cancer screening was more and low awareness among women regarding cervical
prevalent among women who had higher household wealth cancer and its screening. However, given women’s high
index.20 This study indicates that women empowerment perception for cervical cancer screening and the active
index is significantly associated with utilization of cervical participation of health care workers in local community,
cancer screening in bivariate analysis of this study (p = there is an opportunity to enhance community level
0.010). A study done in Kenya studied relation of women’s awareness and streamline screening processes. So, tailor-
autonomy with use of Pap smear test which revealed that made community-based awareness programs according
women’s decision making power had no association with to age and occupation could be created to improve the
use of pap smear test but the prevalence of Pap test history screening status of women. As majority of women do
was 19% higher among women who had sexual autonomy not perceive themselves at risk of cervical cancer, health
than women who did not have sexual autonomy.20 Again workers could help change the perception of susceptibility
another study stated that women who participated in all of cervical cancer of those women.
types of household decision-making were 1.4 times more
likely to have heard of a pap smear (OR = 2.00; 95% CI:1.1,
2.1) compared to women with lower participation levels (p
ACKNOWLEDGEMENT
< 0.05).21 We would like to thank University Grant Commission (UGC),
Bhaktapur, Nepal for the grant support to carry out the
This study used structured questionnaire for assessment
study. We would also like to thank all the dignified faculties
of perception where the experiences and reasons for not
of Central Department of Public Health and Community
performing pap test could not be further explored. As the
Medicine of Institute of Medicine, Tribhuvan University
study was focused on the participant’s perspective, the
(IOM, TU) and also all the participants for their cooperation
service provider perspective of the factors determining
during the study.
the utilization of cervical cancer could not be identified to
design the holistic strategies to improve the utilization of
cervical cancer screening. So, further studies could be done
in the same area focusing on services and service provider
aspects of low utilization of cervical cancer screening.

REFERENCES
1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, 10. Guvenc G, Akyuz A, Açikel CH. Health Belief Model Scale for Cervical
et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence
Cancer and Pap Smear Test: psychometric testing. J Adv Nurs. 2011
and mortality worldwide for 36 cancers in 185 countries. CA: a cancer
Feb;67(2):428-37. doi: 10.1111/j.1365-2648.2010.05450.x. Epub
journal for clinicians. 2021 May;71(3):209-49.
2010 Oct 15. PMID: 20946564.
2. World Health Organization. International Agency for Research on 11. Ranjit A, Gupta S, Shrestha R, Kushner AL, Nwomeh BC, Groen RS.
Cancer. World Source: Globocan 2020. 2021.
Awareness and prevalence of cervical cancer screening among
3. Bruni L, Albero G, Serrano B, Mena M, Collado JJ, Gómez D, et al. women in Nepal. Int J Gynaecol Obstet. 2016 Jul;134(1):37-40. doi:
ICO/IARC Information Centre on HPV and Cancer (HPV Information 10.1016/j.ijgo.2015.11.019.
Centre). Human Papillomavirus and Related Diseases in Nepal
12. Shrestha S, Dhakal P. Knowledge, attitude and practice regarding
Summary Report. 2021.
cervical cancer screening among women attending a teaching hospital,
4. World Health Organization. Global health objectives. Cervical Cancer Bharatpur, Chitwan. J Family Reproductive Health. 2017;11:18-23.
“An NCD we can Overcome” 2018 special call for action. 2018.
13. Ranabhat S, Tiwari M, Dhungana G, Shrestha R. Association of
5. Pan American Health Organization. Plan of Action for Cervical Cancer knowledge, attitude and demographic variables with cervical Pap
Prevention and Control. 2018-2030. 2018. smear practice in Nepal. Asian Pac J Cancer Prev. 2014;15(20):8905-
10. doi: 10.7314/apjcp.2014.15.20.8905. PMID: 25374227.
6. Thapa N, Maharjan M, Petrini MA, Shah R, Shah S, Maharjan N, et
al. Knowledge, attitude, practice and barriers of cervical cancer 14. Shrestha J, Shah R, Tripathi N. Knowledge, attitude and Practice
screening among women living in mid-western rural, Nepal. J Gynecol regarding cervical cancer screening among women visiting Tertiary
Oncol. 2018 Jul 1;29(4). Center in Kathmandu. NJMS. 2013 Dec; 02(02):85-90.

7. Acharya PR, Karmacharya E. Cervical cancer screening behavior and 15. World Health Organization. Global strategy to accelerate the
associated factors among women of Ugrachandi Nala, Kavre, Nepal. elimination of cervical cancer as a public health problem. 2020.
Eur J Med Res. 2017 Sep 19;22(1):32.
16. Wright KO, Aiyedehin O, Akinyinka MR, Ilozumba O. Cervical
8. Ranabhat MK, Thapa B. Factors influencing utilization of cervical cancer: community perception and preventive practices in an
cancer screening services among married women in community, urban neighborhood of Lagos (Nigeria). ISRN Prev Med. 2014 Feb
Chitwan. JCMC. 2017 Sep 30;7(3):42-9. 4;2014:950534. doi: 10.1155/2014/950534. PMID: 24971196.

9. Family Health Division. National Guideline for Cervical Cancer

Screening and Prevention in Nepal. 2010.

Page 205
Original Ariticle VOL. 20 | NO. 3 | ISSUE XX | JULY-SEPT. (ONLINE FIRST-2022)

17. Dutta T, Haderxhanaj L, Agley J, Jayawardene W, Meyerson B. Peer 20. Tiruneh FN, Chuang KY, Ntenda PA, Chuang YC. Individual-level and
Reviewed: Association Between Individual and Intimate Partner community-level determinants of cervical cancer screening among
Factors and Cervical Cancer Screening in Kenya. Prev Chronic Dis. Kenyan women: a multilevel analysis of a Nationwide survey. BMC
2018 Dec 13;15:E157. doi: 10.5888/pcd15.180182. women’s health. 2017 Dec;17(1):1-4.
18. Kafle P, Panth A. Cervical cancer screening practices and barriers 21. Mahumud RA, Keramat SA, Ormsby GM, Sultana M, Rawal LB, Alam
among women in Nepal. Am J Cancer Prevention. 2017;5:31-3. K, et al. Wealth-related inequalities of women’s knowledge of cervical
cancer screening and service utilization in 18 resource-constrained
19. Titiloye MA, Womitenren YT, Arulogun OS. Barriers to utilization of countries: evidence from a pooled decomposition analysis. Int J
cervical cancer screening services among women of reproductive age Equity Health. 2020 Mar 26;19(1):42. doi: 10.1186/s12939-020-
in Ondo, southwest Nigeria. Afr J Biomed Res. 2017 Dec 5;20(3):229- 01159-7. PMID: 32216799
35.

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