Background

Cervical cancer (CC) is a preventable noncommunicable disease if detected early through screening for precancers and appropriately managed.1 The Global Strategy for CC elimination by the World Health Assembly in 2020 mandates countries to develop programmes to reach and maintain a CC incidence rate of below 4 per 100 000 women.2 3 This can be accomplished by accelerating efforts towards the WHO’s multipronged 90:70:90 strategy, which aims to ensure that 90% of girls are fully vaccinated against high-risk human papillomavirus (HPV) by the age of 15 years, 70% of women get screened with a high-performance test by the age of 35 years and again by the age of 45 years and 90% of women with precancerous lesions receive treatment, with 90% of those with invasive carcinoma receiving appropriate management.3

Effective CC elimination efforts need to address sociocultural factors that either facilitate or hinder prevention strategies. The role of men in promoting reproductive health is crucial and cannot be overemphasised. Their involvement in CC prevention and treatment is imperative in achieving the WHO’s goal of eliminating CC by 2030.4 5 Although several empirical studies have explored the role of men in CC prevention in some developing countries,6 7 there is a lack of systematic review on their involvement. Given the immense influence men often have on household decision-making, particularly in matters affecting the well-being of their families in certain developing countries, it is critical to generate sufficient evidence to design interventions that encourage men to support their partners in seeking cervical precancer screening, HPV vaccination and treatment of precancerous lesions of the cervix. Men have enormous potential to contribute to reducing the burden of HPV infection by taking measures to protect themselves and their partners, as well as supporting decisions that promote their general/overall health regarding HPV infections and CC.8 9 Therefore, it is important to compile higher-level evidence to guide interventions focused on men’s involvement in CC prevention. This qualitative systematic review examined the extent of involvement of men in CC prevention in Africa and its implications for the WHO’s CC elimination strategy.

The following questions guided this systematic review:

What are men’s awareness and knowledge regarding CC?

What are the perceptions of men regarding CC and its prevention in Africa?

How do men support and facilitate vaccination, screening and follow-up on treatment of cervical precancerous lesions?

What role do men play in the decision-making process regarding screening and HPV vaccination?

MethodsDesign

A systematic review and narrative synthesis were conducted to understand the role of men in CC prevention in Africa. Prior to this review, a protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol checklist10 and registered in PROSPERO on 26 June 2023. A comprehensive search for relevant literature was conducted in the following electronic databases: Embase, Medline, Global Health, APA PsycINFO, Scopus, Web of Science, CINAHL Plus and the WHO website. The search was conducted in June 2023.

Search strategy and eligibility criteria

The search strategy followed the PICO model: (1) population: all adult men in Africa, involvement of men (nonmedical professionals), male partners or husbands, (2) phenomenon of interest: screening/prevention of CC, (3) context: Africa and (4) outcome: examining influence, support, facilitate, decision-making, knowledge, experiences, attitudes, perceptions and any barriers. The following subject index terms were used: Africa, Early Detection of Cancer, Female, Humans, Male, Papillomavirus Infections, Uterine Cervical Neoplasms and Vaccination. See online supplemental file 1 for the search strategies used for the databases.

Qualitative research papers published in English with full text from 2008 to 2023 and in peer-reviewed journals that received ethical approval were included in this study. However, the views of male medical professionals were excluded from the study. This is because male medical professionals are likely to have positive perceptions about the condition by virtue of being health workers, and this could affect the results of this review if mixed with the general population of men.

Data extraction

Two researchers independently screened titles, abstracts and full texts using the Covidence software. Discrepancies observed were resolved by consensus or through further discussion with the rest of the research team. Microsoft Excel was used to extract data from the studies, including year of publication, country, geographical region, sample size, focus of study, key themes/subthemes and quotations. The contextual and methodological characteristics of each study were presented in a table format.

Quality assessment

The Joanna Briggs Institute critical appraisal checklist for qualitative research was used to assess the methodological quality of the included studies and determine the extent to which each study addressed the possibility of bias in its design, conduct and analysis.11

Data analysis

A narrative synthesis was conducted, guided by the Economic and Social Research Council narrative synthesis framework.12 The framework involves developing a preliminary synthesis, which was done by tabulating the findings of included studies and clustering studies based on the aspects of our review questions they addressed. We then moved to the next stage which involves an exploration of relationships within and between the included studies by scrutinising the characteristics of the studies and their reported findings and factors that explained any differences across them. Finally, we assessed the robustness of the synthesis to ensure that rigour was maintained and the findings were credible. This includes assessing the potential for bias across studies.

Patient and public involvement

It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research.

Results

In total, 1961 records were identified through the electronic database search, with 16 studies meeting all inclusion criteria. The identification process, eligibility assessment, and reasons for exclusion are illustrated in figure 1.

Figure 1

PRISMA flow diagram illustrating the systematic study selection process. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

The included studies were published between 2008 and 2023 and examined the perspectives of n=592 men residing in Ghana (n=3), Nigeria (n=3), Uganda (n=3), Cameroon (n=2), Ethiopia (n=2), Kenya (n=2) and Malawi (n=1). Data were collected through focus group discussions and individual in-depth interviews. The participants represented a diverse range of male roles, including nonmedical professionals, partners, fathers, teachers, adolescent boys and community and faith leaders. Online supplemental file 2 provides a summary of the key characteristics of 16 qualitative studies included in this systematic review.

Five thematic categories were identified in this review, shedding light on the role of men in understanding CC prevention in Africa. The interconnected themes included awareness and knowledge of CC, perception of preventive measures, screening as a preventive measure, HPV vaccination as a preventive measure and men’s involvement. An overview of themes and their corresponding evidence sources is presented in online supplemental file 3. The following section will elaborate on each theme, supported by illustrative excerpts from the participants’ interviews.

Awareness and knowledge of CC

The majority of the studies included in the analysis revealed a notable variability in awareness levels regarding CC among men. Awareness ranged from complete unfamiliarity to a comprehensive understanding. In some cases, this variation was more pronounced between urban and rural populations, with urban participants generally demonstrating a notably higher level of awareness compared with their rural counterparts.13 However, it is worth noting that other studies did not find such marked differences based on participants’ place of residence.14

I have never heard of cervical cancer disease. Is it also a disease that affects women? Then women are really suffering. (Male partner; Binka et al 6)

Remarkably, recent studies have revealed a notable upward trend in awareness levels, underscoring the impact of educational initiatives and public health campaigns. This upward trend was particularly evident when comparing studies conducted within similar sociocontextual settings, such as those conducted by Williams and Amoateng15 and Enyan et al,7 both in urban and periurban areas of Ghana. Over the course of a decade, a discernible evolution in awareness emerged, with the latter study showing that 12 out of 15 participants were aware of CC, compared with the majority of the participants in the earlier study by Williams and Amoateng15 who had never heard of the disease. Participants consistently identified media outlets such as radio and television, as well as places of worship, as their primary sources of information about CC.

I heard of it on the television. I don’t know how it is, but it was being discussed that a woman who has it may not be able to tell whether she has it or not…unless she is examined by the doctor. (Male partner; Enyan et al 7)

Furthermore, participants’ level of awareness seemed to be closely linked to the use of local language descriptors. The availability of accurate terminology in local languages significantly impacted participants' understanding of cancer in general and CC specifically.6 13 16–18 Despite initial awareness gaps regarding the term ‘cervical cancer’, most men recognised the prevalence of CC within their communities when researchers provided thorough descriptions of the disease’s signs and symptoms.15

I have heard of cancers generally but not that of the cervix, I haven’t heard of it or seen anyone affected except this one you are asking. (Male partner; Okedo-Alex et al 19)

Across all 16 studies, a prevailing landscape of limited and often inaccurate knowledge surrounding CC was observed. This dearth of knowledge extended across all facets of CC, including its aetiology, risk factors, clinical manifestations, progression and prognosis, regardless of the participants’ level of awareness.

I did not know anything about this disease. I did not have any idea about the cause, symptoms or any risk factor of the disease. I only overheard it on the television being debated in Parliament as to whether it should be covered in the national health insurance scheme. That is all I know. (Male partner; Binka et al 6)

In fact, I had no knowledge about the disease and how it is caused, but all I knew was that it could kill. And I do not even know its local name. (Male partner; Binka et al 6)

Widespread misconceptions permeated participants’ understanding of the causes and risk factors of CC. These misconceptions encompassed a wide range of beliefs, including, but not limited to, attributing CC solely to female promiscuity rather than considering men promiscuity, suboptimal hygiene practices, exposure to chemicals, history of abortions, use of contraception, the notion of ‘devil’s intervention’, engagement in harmful traditional rituals and adherence to Westernised diets.4 13 14 16 18 20 21

We know that the kind of oil that is used to lubricate the condoms can cause this condition (cervical cancer) especially if it causes reaction to your body and if you use it for a long time. (Male partner; Mwaka et al 18)

…Istihada, meaning punishment that occurs when the devil kicks a woman’s womb. This is an explanation from religious book. (Religious leader; Birhanu et al 13)

Interestingly, male participants often associated CC with sexually transmitted diseases. However, this perceived cause was frequently framed in the context of promiscuity rather than recognising it as a viral infection. This highlights how cultural beliefs are intertwined with the understanding, disclosure and, consequently, prevention and early treatment of CC.4 13 14 17 20 22 For example, the following quotes illustrate the complex interplay of cultural beliefs and the stigma attached to holding women responsible for CC, a perception perpetuated by both men and the wider community.

This infection is through sexual intercourse so the man will know that his wife cheated on him, that is why she has cervical cancer (…) Now the man will start doubting his wife and he may chase her from his home. (Male partner; de Fouw et al 14)

…when a woman is promiscuous, …there is no way she will not have the cancer, so that is what I think can cause the cervical cancer. (Fathers of adolescents; Balogun and Omotade20)

…many women rely on home based traditional treatment as they do not like to disclose the disease to the community owing to its perceived association the diseases with frequent sexual intercourse and multiple sexual partners. (Community leader; Birhanu et al 13)

The role of education level emerged as pivotal in shaping participants’ knowledge, as those with higher education levels tended to exhibit a more refined and accurate understanding of CC.22

Perception of CC

Participants’ perspectives on CC prevention ranged from perceiving the disease as incurable13 16 to considering it a ‘normal’, nonspiritual disease,4 7 as exemplified in the following statements:

what is the point of screening? After all, cancer is a killer; better off not knowing cancer will kill you. (Male partner; Demissie et al 16)

I think it is a disease just like malaria and the others. I believe the lifestyle of women can either make them get the disease or not. It is not a spiritual illness or disease. (Male partner; Enyan et al 7)

A significant proportion of men held the belief that cancer is an inherently fatal, rendering it resistant to both prevention measures and treatment efforts. Aligned with this perspective is a distinct subset of participants, who maintained that seeking medical attention was unnecessary unless visible symptoms or signs were present. Such beliefs pose enormous challenges in fostering proactive and timely preventive interventions, leading to delays in decisions regarding screening, as reported by Datchoua Moukam et al.23

…in our community there is a habit of going to health institutions when it reaches a stage where they are unable to tolerate the pain. (Male partner, Birhanu et al 13)

…Illiteracy is the major problem that may…if the husbands are illiterate, because they will say ‘why? Why are you going, don’t say that you have it’…when somebody is an illiterate they may not see the need to go for screening. (Male partner; Onyenwenyi and Mchunu24)

Perception of preventive measures

Many participants were unaware of available preventive services and mistakenly regarded behaviours, such as abstinence and traditional remedies, which were inaccurately described as risk factors, as preventive strategies to forestall CC. In a few cases, participants expressed that both men and women could contribute to the prevention of CC.

[Wife and husband] should have protected sex so that they do not get any sexually transmitted diseases from each other. (Male partner; Lewis et al 4)

Nonetheless, due to the limited access to information on CC screening services, some men, while acknowledging the potential for prevention and the importance of screening, faced uncertainty on the ‘how’ and ‘where’ aspects of accessing these services.16 19 23

I don’t know if it can be prevented but i know of cancers of the breast and eye as i had a relative who had cancer of the eye and it was treated/prevented. It will be good for me if you [the researcher] explain more. (Male partner; Okedo-Alex et al 19)

If I understand why the test is being done then I will pay happily. (Male partner; Williams and Amoateng15)

The reviewed studies delved into two preventive measures: (1) screening and (2) HPV vaccination. These measures, which constitute integral components of CC prevention strategies, are further explored in the subsequent sections.

Screening as a preventive measure

The examination of CC screening as a preventive measure revealed a range of factors that seemed to shape male partners’ perspectives, engagement and access to this process. These factors included challenges at both the individual and systemic levels, as comprehensively explored by Adedimeji et al,22 Datchoua Moukam et al 23 and Onyenwenyi and Mchunu.24

Significant challenges emerged due to delays in accessing screening centres, primarily influenced by financial constraints and geographical location. Particularly, in societies where men often assume the role of the primary financial providers and transportation facilitators, the burden of covering expenses and arranging transportation introduced an additional layer of complexity to their partners’ decision-making process.6 13 23 24 As a result, financial considerations, intertwined with the broader societal role of men and the limited availability of screening centres in certain areas, magnified the barriers to timely screening participation, especially among those from socioeconomically disadvantaged backgrounds and residing in rural areas.

…Women have to go to modern and expensive health facilities in Addis Ababa to get treatment. However, they cannot afford to go to Addis Ababa and most remain suffering from the diseases. (Male participant; Birhanu et al 13)

Well, the lack of availability of screening centres is also a critical issue. (Male partner; Onyenwenyi and Mchunu24)

Psychological barriers encompassed fears of and stigma related to screening procedures and outcomes, including anxiety over positive results and subsequent actions. Sociocultural factors, such as gender dynamics, religious beliefs and cultural taboos, appeared to shape men’s attitudes towards screening uptake. Interestingly, contradictory viewpoints were shared among male participants, even within the same research study, on topics like being examined by male doctors.4 7 16 23 24 For instance, one participant voiced concerns, stating:

I have heard that male doctors have sexual relations with female patients. If men hear that their wives will be undressed and put on an exam table by a male doctor … we know that once a man sees a woman naked they will want to have sexual intercourse with her. Because of that men hesitate to tell their wives to get screened for cervical cancer. (Male partner; Lewis et al 4)

However, contrasting these hesitations, another participant from the same study, emphasised the importance of professionalism, stating:

Doctors learn confidentiality in their work, and have a responsibility to do their job. It is not like a female doctor is supposed to treat female patients only. (Male partner; Lewis et al 4)

In line with these concerns, some participants expressed a preference for the self-sampling method as a way to protect their partners:

I choose the method where it is the woman herself who takes it. [Laughs] When she samples it herself, she’s not even ashamed since she’s doing it alone. But there are women who are even ashamed to examine their sexual parts in private. (Male partner; Datchoua Moukam et al 23)

HPV vaccination as a preventive measure

Similarly, drawing insights from five research studies,14 17 20 21 25 the exploration of HPV vaccination as a preventive measure revealed a diverse range of attitudes and concerns among fathers, male teachers and male community and religious leaders. Overall, a significant subset of male participants exhibited favourable inclinations towards HPV vaccination for adolescents. Nonetheless, barriers to HPV vaccination were also evident, often rooted in concerns about safety and side effects, distrust, high cost and infertility as well as about promoting promiscuity.14 20 25

Others say that the plan is that doctors want to vaccinate our girls, daughters and end their productivity. That is why some parents do not want to vaccinate and circumcise their children, because many people are saying that they want women to have few children, so we need awareness. (Father, de Fouw et al 14)

We have not heard about people who have been vaccinated so we think they are starting with our children, they are used as guinea pigs or something, people try to see if it can work. (Male teacher; Vermandere et al 21)

Male involvement in decision-making related to HPV vaccination

With regard to the decision-making process related to HPV vaccination within specific groups, the consensus leaned towards a shared decision-making approach involving both parents. Nevertheless, alternative viewpoints emerged, with some suggesting that either the mother or the school headteacher should hold the authority to decide,14 while in certain instances, the ultimate decision rested with fathers, whose perspectives were significantly influenced by traditional and religious leaders.20 Moreover, teachers, given their substantial influence within school environments, were identified as key figures contributing to increased vaccination acceptability.

Teachers spent almost all their time with the children and children really listen to the teachers. Whatever teachers say, a child does not doubt. They can go home and convince the parent ‘this is what the teacher said’. (Male teacher; Vermandere et al 21)

Finally, there was a clear call for increased information dissemination and support for HPV vaccination initiatives in schools. Many groups endorsed school-based immunisation programmes as the most convenient and effective means of reaching preadolescent girls.14 17 20

Also going to the hospital will encourage bribing so we want to avoid that by taking it to school…because somebody tells you, bring something small so that I attend to you faster. And you might not even get the right vaccine even after giving out your bribes. (Male teacher; Vermandere et al 21)

It is a good idea but I suggest, I think the government should do a bit of educating the masses because, if we teachers do not know what cervical cancer is, then how about that mother in the village, she will not accept; so education is very important. (Male teacher; Vermandere et al 21)

Male support

The participants’ perspectives exhibited an evolution after receiving explanatory information. While many initially held reservations about the relevance of preventive measures within their communities, a considerable number shifted towards acknowledging the benefits of these measures. Across the analysed studies, a consensus emerged among participants, indicating their willingness to participate in CC prevention efforts in various African settings actively. As their understanding deepened, concerns and anxieties surrounding preventive measures steadily dwindled, underscoring the profound impact of accurate information. Despite these positive shifts, certain participants remained apprehensive due to concerns about potential stigma and negative side effects associated with prevention.

Because of the prevalence of poverty in this community, some women would not like to go for screening. I will encourage and support her to go for the screening because the disease is dangerous. (Male partner; Binka et al 6)

Men frequently expressed eagerness to provide emotional support to their female partners and daughters, encouraging them to undergo screenings and embrace the preventive measures.4 6 7 Understanding the importance of prevention, men exhibited an increased willingness to provide practical support, such as arranging transportation and offering financial assistance.

This is a condition that can bring problems to the woman so if screening can be done and there is money, then I will encourage her to go and do it so that in the near future if something like that happens, we don’t spend so much on her treatment… You know I can’t divorce her too. So, all is about money. If there is money, I will support her because I need to protect her. I will not wait for her to suffer. (Male partner; Enyan et al 7)

The husband has a very important responsibility because he has the capacity to encourage the woman to get tested more often for cervical cancer. (Male partner; Lewis et al 4)

Male engagement extended to the realm of decision-making, where reports indicated varying degrees of influence. In specific instances, as illustrated by the study conducted by Adedimeji et al,22 men recognised a shared responsibility between genders in preventing CC. They emphasised the importance of both men and women actively participating in the prevention process, which encompassed actions like reducing sexually transmitted infections, addressing risk factors and pursuing screening when feasible.

Preventing cervical cancer is a responsibility both men and women should share equally; it should begin with preventing sexually transmitted infections, avoiding risk factors and obtaining screening when possible. (Male partner; Adedimeji et al 22)

However, in other studies, prevailing gender norms and societal expectations played a pivotal role in shaping women’s decisions regarding preventive measures, with husbands’ viewpoints exerting a significant impact. These dynamics were succinctly captured in one participant’s reflection:

Male involvement is very important as women listen to their husbands more than even the health care workers. They do whatever their husbands tell them as they see their husbands as their second ‘god’. (Male participant; Okedo-Alex et al 19)

Finally, in specific studies, male participants acknowledged their role in raising awareness within their social circles.7 14 15 Male participants indicated that the knowledge they acquired from their respective studies about CC increased their likelihood and enthusiasm to engage proactively in discussions about the topic with their peers and families, thereby contributing to a wider dissemination of knowledge.

I will entreat all men not to take the health of their wives for granted. If their wives complain of any pain they should encourage them to seek medical attention. (Male partner; Williams and Amoateng15)

I will not be different from my colleague. For me, I will be a speaker who will be a voice to move this message to my fellow men because we should not be silent. I will first talk to my family about today’s meeting. (Male partner; de Fouw et al 14)

Discussion

This systematic review aimed to understand the role of men in CC prevention in Africa. The themes that emerged from the analysed studies were awareness of CC, knowledge of CC, perception of preventive measures and men’s involvement. These themes are critical in efforts to eliminate CC on the African continent. Awareness of CC was an important theme that originated from 11 out of the 16 studies reviewed. Studies reported varied levels of awareness ranging from a lack of awareness to a comprehensive understanding of the disease, with a general improvement in awareness over a decade in similar geographical contexts.7 15 The differences in awareness were apparent among rural and urban populations, whereas those in urban areas demonstrated increased awareness. Multiple awareness strategies, including the use of the media, places of worship and local terminologies to describe the disease, were useful in enhancing understanding. This evidence calls for context-specific and targeted interventions to generally heighten CC awareness campaigns, especially in rural communities of Africa.

The evidence showed gaps in knowledge of CC across the 16 studies included in the review. Misconceptions were observed in all aspects of CC, including the cause, risk factors, signs and symptoms, progression and prognosis, irrespective of the level of awareness. For example, according to the findings by Lewis et al,4 Demissie et al,16 Balogun and Omotade20 and Vermandere et al,21 males attributed CC to adherence to Westernised diet, multiple sexual partners, suboptimal hygiene practices, exposure to chemicals, history of abortions, use of contraception and engagement in harmful traditional rituals. Although some have limited knowledge about CC, the misconceptions need to be addressed to enhance supportive care towards CC prevention. Deliberate measures to improve men’s knowledge of CC prevention are therefore paramount. In some developing settings, women have low autonomy in matters related to their health and well-being and may need approval from their partners.26–28 Therefore, male empowerment in health issues affecting women, including CC, will be an important step to prevent the disease. Furthermore, education level was found to be essential in influencing participants’ knowledge, as those with higher education levels exhibited a more refined and accurate understanding of CC.

Evidence from half of the studies included in this review indicates that males hold varying perceptions of CC preventive measures, with some having inaccurate information. This could probably be attributed to a lack of sufficient awareness about the disease. Regarding cervical screening as a preventive measure, the review found that numerous factors influenced male partners’ perceptions, involvement and access to this process, including individual and systemic influences as described by Adedimeji et al,22 Datchousa Moukam et al 23 and Onyenwenyi and Mchunu.24 The review identified that financial and geographical barriers emerged as significant challenges to accessing CC screening, particularly in patriarchal societies where men primarily shoulder the family’s financial responsibility and transportation logistics. This situation creates hurdles to early participation in screening, particularly affecting those from socioeconomically disadvantaged backgrounds and rural settings. Consequently, there is a pressing need to address and improve the financial and geographical barriers to enhance screening uptake.

The findings of the review suggest the need for psychological interventions tailored to men, aimed at reducing fear and mitigating stigma associated with screening outcomes, including anxiety over positive results and subsequent actions. Additionally, sociocultural factors, such as gender dynamics and religious beliefs, play a pivotal role in shaping attitudes towards screening uptake. For example, male involvement in female health matters sometimes faces societal resistance, and religious beliefs, norms and taboos influence screening attitudes, particularly when women are to be examined by male doctors.

Furthermore, we found out that whereas fathers played an important role in decision-making and supported the vaccination of their daughters, male teachers contributed to increasing vaccination acceptability. However, there were apprehensions among male caregivers, teachers and community leaders leading to vaccine hesitancy. Therefore, interventions to improve HPV vaccination among women and girls need to involve men, as the role they play at the household and community levels in Africa could hinder HPV vaccination acceptance.

Strengths and limitations of this study

This review is unique in contributing to the evidence on CC prevention since no previous review has reported the role of men in CC prevention in Africa. The risk of bias is decreased in this review as the study selection and data extraction were independently done in duplicate. Also, the search strategy was restricted to studies published in English. In doing so, studies published only in other languages within the African context might have been excluded. A major weakness is that the included studies had varied qualitative designs and data collection methods, which could potentially affect the interpretation of findings.