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Health Seeking Behaviour of Tiv Women Living with Fibroid in Benue State, Nigeria

Uterine fibroids are the most common benign tumors and one of the foremost causes of infertility among women. While there are several clinic-based studies on the biological context of fibroid, very few had examined its socio-cultural context in a community study in Nigeria. This paper, therefore, examined health seeking behaviour of women living with fibroid in Tiv communities in Benue State, Nigeria. The study participants were selected from 4 Tiv speaking local government areas (Gboko, Makurdi, Ukum and Vandeikya) in Benue State through multi stage sampling technique. Sequential explanatory mixed method of data collection was used. Fibroid occurrence is common among women in age categories 30-39 (51%). All the respondents living fibroid sought treatment, however, 60% of the respondents prefer orthodox medical treatment while the remaining 40% prefer the traditional healing process. Income, proximity to healthcare facility, influence of relatives, friends, and health professionals have stronger influence on the health seeking behaviour of women living with fibroid. The health seeking is combination of both traditional and modern medicines while surgical procedure is less utilised. The study recommends an increased sensitization and awareness about fibroid.

Although there have been attempts to know how women living with fibroids sought treatment, there is gap on how women in areas with little access to health facilities make decision and sought treatment for fibroid. This community based study, therefore explored social and cultural issues while determining prevalence of fibroid and health seeking behaviour among Tiv women in Benue state, Nigeria.

Study Objectives
Specifically, the study intends to: 1. Assess the health seeking behaviour of Tiv women living with fibroid in Benue State. 2. Examine the factors influencing the health seeking behaviour of fibroid patients among Tiv women.

Theoretical Framework Health Belief Model
This study adopted Health Belief Model of behavioural change enunciated by Rosenstock (1974) and Janz and Becker (1984) to foster understanding as to why people use or do not use preventive services. This model identifies individual predisposition towards a given preventive health behaviour which is governed by beliefs and attitudes. In summary, the Health Belief Model (HBM) focuses on individual determinant of utilization of health services, that is, perception of illness, belief in severity, perception of the benefits of taking action and evaluation of the potential barriers associated with the proposed action. The factors influencing behavioural change towards a health behaviour are grouped into three main categories. The first factor is individual perception of susceptibility and severity to a particular illness. The model postulates that persons who see themselves as vulnerable to a health issue will engage in health behaviours to ease their threat of developing health condition (Rosenstock, Strecher and Becker, 1994). A woman who perceives that she is predisposed to developing fibroid is more likely to go for fibroid screening in order to determine whether she has it or not than a woman who does not feel threatened. Perceived severity on the other hand shows the extent to which individuals perceive a particular illness as serious and the consequences of a serious health event or outcome, such as a diagnosis of cancer. This is with the assumption that a person who views a health issue as severe is more likely to engage in illness behaviours that will reduce its severity (Witte, 1992). Perceived severity of the fibroid will determine the kind of treatment that will be adopted.
Second is modifying factors such as perceived threat and environmental factors (demographic variables: age, race, culture, sex, ethnicity, personality, social class, socio-cultural variables, attitude towards a behaviour and subjective norms) and cues to action. Perceived threat goes beyond acknowledging that one's behaviour could result to a specific disease by focusing on just how likely it is that the disease could be developed. A woman who had been delivering safely may not feel threatened by potential pregnancy related complications through fibroid. However, a pregnant woman who has not been doing so may feel very vulnerable if she develops a complication she has never had. The complication could be a symptom that increase her level of vulnerability and prompt her decision to go for fibroid screening or examination and treatment. Environmental factors can add to the threat of the disease. The opinions of others such as husband, friends, immediate and extended family play an important role in influencing the women's behavioural intentions to seek medical help for fibroid. The cultural value placed on children and womb might make a woman not to go hysterectomy. Women who are within childbearing age and have not given birth or had the desired number of children might decide not to have hysterectomy even when it is the best solution to their problem. Another modifying factor is cue to action. Cues are necessary in prompting engagement in health promoting behaviours. It is a modifying variable. Cues to action are divided into two: internal cues and external cues. Internal cues to action could be pains or symptoms while external cues include events or information from significant others, electronic or print media, or health care providers promoting engagement in healthrelated behaviours (Rosenstock, 1974). For example, women who believe they are susceptible to fibroid and who have an established relationship with a doctor may be easily persuaded to get investigated for fibroid due to an encounter with a public enlightenment. Whereas women who deem themselves to have low susceptibility of contracting the disease and do not have easy access to health care services may require more strong external cues in order to get screened.

The third factor in explaining health belief model is likelihood of actions based on perceived benefits and barriers
Health-related behaviours are prompted by the perceived benefits of taking action. Perceived benefits of action refer to an individual's evaluation of the value or efficacy of engaging in a health-enhancing behaviour to reduce the risk of illness. When individual believes that a particular action will reduce vulnerability or reduces severity, the individual is most likely to engage in health behaviour in spite of the efficacy of the action (Witte, 1992). If a woman perceived that going for fibroid screening and general medical check-up will reduce the risk of developing fibroid and reducing the risk associated with prolonged diagnosis, she is more likely to undergo screening even in the absence of fibroid symptoms. The perceived benefits will also make her to adhere to the treatments that are prescribed by the doctors. Perceived barriers, on the other hand, refer to the obstacles an individual's encounter towards behavioural change. Health barriers may thwart engagement in health promoting activities even when a person sees a health situation as threatening and believes that taking a particular action will lessen the threat (Witte, 1992). Perceived inconvenience, expense, danger (side effects of a medical procedure) and discomfort (pain, emotional stress) involved in engaging in the behaviour are some of the perceived barriers in taking action. For example, not having access to affordable health care and perception that a surgery can cause pain along post -surgery effects may act as barriers for the surgery.

Research Design
The study was cross-sectional, descriptive and exploratory. It utilised both qualitative and quantitative methods of data collection. The quantitative method involved the use of questionnaires while the qualitative adopted indepth interviews.

Study Location and Population
Benue is a rich agricultural region called the food basket of Nigeria. The state has a projected population of about 5 million and comprises of twenty-three (23) Local Government areas. The Tiv ethnic group who are predominantly farmers, occupy 14 out of 23 local government areas in Benue state. One of the key cultural values Tiv holds prominent is marriage for procreation (Dzurgba, 2012).
The study population were Tiv women of reproductive age (15-49) that were permanent residents in the selected local government areas who can speak either Tiv or English Language. It also included health experts in obstetrics and gynaecology and practice within the study area. Traditional health practitioners in the study area and indigenous spouses of women living with fibroid in the study area were also included in the study.

Sampling Techniques and Sample Size
The quantitative sample size for the study was 440 women. This sample size was determined using Taro Yamane's formula based on a projected population of 2006 by 6% which is 353,345. Based on the above population, the sample size for the study was determined using Taro Yamane's formula (Udofia, 2011). In order to account for attrition rate, the sample size was increased by 10%. Hence, a total of 440 women from the selected wards were sampled in the survey study to make room for non-response rate and missing instruments. The questionnaires were administered to the women in the selected local government areas in proportionate to their population. Tiv ethnic group occupy fourteen (14) local governments in Benue State. Using the multistage sampling technique, the fourteen (14) local government areas were divided into two (2) clusters using the two senatorial districts that comprises Tiv ethnic group. Two (2) local government areas were selected from each of the senatorial districts using simple random sampling method. After this, two (2) wards including one urban and one rural were purposively selected from each of the four (4) LGAs thus making four (4) urban and four (4) rural wards totally eight (8) wards. Households in each of the 8 wards were systematically selected from both sides of the streets. The 1st house and every 2nd house was selected and in each of the household, the most elderly woman that satisfied the criteria for the study was purposively selected and sampled for the study. Number of respondents/household in each ward was based on the total number of respondents for each local government. The qualitative aspect of the study involved thirty-three (33) in-depth interviews for purposively selected participants. The participants included twenty (20) women who have/had fibroid, nine (9) spouses of women living with fibroid, two (2) medical personnel who are specialists in Obstetrics and Gynaecology and two (2) traditional healers.

Data collection
Data collection was done through the use of questionnaire, interview guides and hospital records. The questionnaire was divided into sections to cover the objectives of the study and were anonymous to ensure confidentiality of the respondents. The names of the interviewees were also not mentioned during the course of the interview to ensure their anonymity.

Ethical considerations
Ethical approval was obtained from UI/UCH Ethics Committee and Benue State Ministry of Health with APPROVAL NUMBERS: UI/EC/15/0158 and MED/261/VOL.1/554 respectively.

Data Analysis
A total of four hundred and forty (440) copies of questionnaire were administered but three hundred and ninety-five (395) were properly filled and used for data analysis. The Statistical Package for Social Sciences (SPSS Version 20) was used to analyse the quantitative data and results were analysed at both univariate (frequency tables) and bivariate (chi-square) levels of analysis. Qualitative data was transcribed and analysed through thematic and content analysis using ATLAS.ti software and it generated patterns of relevant information that threw light on the study phenomenon. Analysed verbatim responses were imported and employed for discussion. Data generated through the quantitative instrument were edited and cleaned to eliminate outliers that could affect the validity of the result.

Socio-Demographic Characteristics of Respondents
This section presents the socio-demographic characteristics of the respondents in the selected Local Government Areas (LGAs) of Benue State. Variables examined are age, marital status, educational level, residential pattern and number of children given birth as shown in Table 1. Although the study is about women in their reproductive age (15-49 years), majority of the women sampled in this study are below 39 years. Eighty-five (85.6%) percent of women in the study responded that they have had marriage experience at one point or the other in their lifetime. Very few women are single or widowed. The selected respondents were capable of giving adequate information on how fibroid affects interaction in marriage as most of them are currently married or had previously been married. Eight out of ten of the respondents have ever given birth to surviving children. Forty-one percent had given birth to 1-2 children while a substantial proportion of 39% percent had also given birth to 3-4 children. There are slightly more urban respondents than rural respondents in this study.

Health seeking behaviour of women living with fibroid
Out of the 395 questionnaires collected from the community survey, 245 reported to have experienced or still living with fibroid. Table 2 presents details of health seeking behaviour among 245 women who had lived or still living with fibroid among selected local governments in Benue State. At least half of the respondent chose medical treatment as option for fibroid and preferred to go to government hospital. This is also highlighted in some of the responses from the in-depth interview that utilization of modern health facilities was because of the availability of specialists and the belief in the efficacy of treatment in the hospital.
I go to government owned hospitals for treatment. I think most people that are battling with fibroid use government hospitals because most of the people that I know are living with fibroid used public health facilities. There is the belief in the quality and affordable treatment in public hospitals. (IDI/24yrs/woman living with fibroid/Single/Vandeikya/ Rural) Although the most preferred place of treatment is government hospital, the proportion of women who actually used it (22%) is lower than those who use private hospital (34%). Twenty-eight percent use traditional centres while 14 % reported pharmacy as their health seeking centre. In describing the treatment, one of the medical practitioners explained that the available medical treatments include drugs, myomectomy, hysterectomy and embolization as follows: Most common treatment of fibroid in our environment here has been a major surgery called myomectomy which is the surgery of removing the fibroid. But we also have the TAH (Total Abdominal Hysterectomy). Drug does not treat fibroid, they only treat the symptoms associated with fibroid and drugs are used to halt/suppress the growth of fibroid for like 6 months. We also have embolization as a treatment option in which some chemicals are injected to stop the blood supply to the fibroid and it dissolves into the body system. (IDI/43/Medical Practitioner/Makurdi/Urban) Likewise, a traditional healer explained the available traditional treatments: Treatment for fibroid is called ikula or Akomboaauyav. It is in form of herbs (mixture of herbs) which is to be taken for 2 weeks. After two weeks, the patient is expected to either urinate it because it dissolves or it is passed out from the vagina.
(IDI/87/Traditional Healer/Ukum/Rural) Furthermore, majority of the women reported that they started treatment immediately the disease was diagnosed. This was because of the need to reduce pains associated with fibroid, beliefs that early treatment will hasten recovery and the fear that fibroid disturbs child bearing. The few women that delayed initiation of treatment a week after diagnosis stated that it was due to inability of the husband to swiftly provide money for treatment. With regards to specific type of treatment, about 56% reported that they used drugs prescribed. The use of drugs might be linked to what is required to treat the symptoms of fibroid to bring immediate relief. Also, 31% of the women opted for myomectomy which is the surgical removal of the fibroid from the womb while a very low percentage (1.2%) of the respondents opted for hysterectomy (complete removal of the uterus) as a treatment option.
The interviews conducted also revealed that the choice of treatment option is dependent on a variety of personal and socio-economic factors. For instance, myomectomy is recommended for women who have need of their womb for childbearing. One of the medical practitioners explained that: Myomectomy is recommended more often because of our own level of technology. And it also depends on if the woman still wants more children. A traditional healer also added another factor influencing treatment options. He opined that treatment for a pregnant woman with fibroid is different from that of the woman that is not pregnant. According to him: Fibroid is known as "Ikula" which is "Akombo aa Tiv". Treatment is called ikula medicine. It is in form of herbs (mixture of herbs) which is to be taken for 2 months. After two months, the ikula is expected to dissolve. The belief in life after death influences some women to also decline hysterectomy. The need to have children when re-incarnated informed their decisions to reject hysterectomy and accept myomectomy. According to one of the interviewees: Some women believe in reincarnation so when you advise them to go for hysterectomy which is the removal of the womb, they feel in their second life they will not be able to have children and Overall, one out of two Tiv women in this community used multiple treatment option for fibroid in Benue State. This is buttressed by the interviewees who mentioned both traditional and medical treatment options for fibroid. The respondents affirmed that they would go for multiple treatment for the treatment of fibroid. One of the women living with fibroid said that: I have gone through many types of treatment for this fibroid.
When it was diagnosed I started with local herbs but when the symptoms did not stop, I decided to go back to my doctor for further treatment. I was given drugs to relieve the symptoms and then I later went for surgery to remove it. Presently, I am still taking herbs to stop it from growing back. (IDI/35/Female/ Married/Gboko/Urban)

Factors Influencing the Health Seeking Behaviour of Women Living with Fibroid
There is significant association (p<0.05) between education, monthly income, age, marital status and residence of Tiv women and preferred treatment option for fibroid in Benue State. All the interviewees noted that the income of the women or household determines the kind of fibroid treatment that she will seek. One of the women opined that: Income has a significant influence on the kind of treatment, whether medical or traditional, that a woman will adopt for fibroid. You know medical treatment is expensive. It is only those that have viable and good income that will be able to afford it. People with low income usually resort to traditional treatments because it is cheap and affordable. (IDI/41yrs/woman living with fibroid/Married/Gboko/Rural) The views that education is important in choosing treatment for fibroid and it plays a vital role in health seeking behaviour of people because of the perception of disease causation and treatment options/outlets are mentioned by majority of the interviewees. Women with at least secondary education are likely to opt for modern treatment option for fibroid than others. According to one of the medical personnel that were interviewed: Most of the women that adopt modern treatment are the ones with formal education that is more than secondary school education. They trust modern treatment than traditional medicine. (IDI/43/ Medical Practitioner/Makurdi/Urban) Furthermore, the type of treatment sought by individuals is a function of their marital status and residence. One of the women narrated that: The people in the city are likely to use modern treatment for fibroid because such facilities abound in their area. Rural dwellers are used to traditional healing system; thus, they will use it for fibroid treatment. It is accessible in terms of availability, affordability and location. (IDI/24yrs/woman living with fibroid/ Single/Vandeikya/Rural) Women were asked to mention perceived factors that influence their Health Seeking Behaviour of Tiv Women with Fibroid as shown in Table 3. Education, Income and proximity to health care facility affect health seeking behaviour of women living with fibroid than influence of relatives, influence of friends, influence of medical professionals affects social media, cost of treatment, belief in treatment efficacy, spiritual/religious beliefs and cultural beliefs. The influence of income and cost of treatment highlight financial capabilities that may limit or expand the health seeking behaviour. Some of the responses from the in-depth interviews also buttressed this finding: Because of lack of adequate finance, I was and am still unable to go for a more serious treatment and that was why I opted for herbal treatment. Once I get the money, I will go for modern medical treatment, most importantly, surgery. Till then I will be managing my condition. ( Proximity of health care is also a significant independent predictor of health seeking behaviour which describes the level of accessibility that patients have to health care facilities. In rural areas, the effect of distance on service use becomes stronger when combined with the lack of transportation and with poor roads, which contribute towards indirect costs of visits to health facilities. In the IDIs conducted, it was also mentioned by one of the respondents that: Proximity of health services is a factor in the treatment of fibroid. In villages where they do not have primary healthcare centre, let alone a big hospital, they will likely not use modern health facilities. When they want to come to urban centres, there is also the issue of poor road networks. All these can discourage their use of health facilities for treatment. My wife is treated in the public hospital in Makurdi because she is knowledgeable about fibroid and she overlooked all odds, others may not be able to make such resolutions. (IDI/50/Spouse of woman living with fibroid/ Gboko/Rural) Belief in treatment efficacy, which emerged as predictor of health seeking behaviour in this study, describes the faith that the patient has in the effectiveness of the treatment option. This component incorporates the individual's belief of efficacy of treatment for the present illness. An individual will not utilize the treatment if they do not believe the treatment will be effective. Findings from in-depth interviews also buttressed this finding: Belief in the efficacy of the medical treatment made me and my wife to decide to use the government hospital in Makurdi. Her friend had such case and it was effectively treated there.
(IDI/50/Spouse of woman living with fibroid/Gboko/Urban) The above assertion also revealed the influence of friends in fibroid treatment. This corroborated the quantitative findings that influence of friends is a significant predictor for health seeking behaviour of women living with fibroid. Medical professionals exert more influence on their health seeking behaviour of women living with fibroid. This might be because women believe in the judgement of the medical professionals especially those who specialise in obstretrics and gynaecology. This was corroborated by one of the women living with fibroid: I believe in the judgement of the medical professionals because they are knowledgeable in the area of fibroid treatment. Hence, when I was told that she needed to have a myomectomy, I consented and I advised my wife to go for it. She will be going for it next week. (IDI/51/Spouse of woman living with fibroid/ Gboko/Urban)

Discussion of Findings
This study examined the health seeking behaviour of women living with fibroid in Tiv Communities of Benue State. All the women sought treatment for their fibroid condition. This might be connected to the discomforting symptoms of fibroid and its causation of infertility in women. The African society places much emphasis of child bearing. Hence, any barrier to giving birth to children is not joked with. The study revealed that treatment was initiated within a year of diagnosis of disease condition. This has been reported elsewhere that over 90% of women who are newly diagnosed with fibroids seek medical intervention for the condition within a year of the diagnosis (Agency for Healthcare Research and Quality (AHRQ), 2007). The early initiation of treatment was because of the discomfort experienced from the symptoms associated with fibroid which include excessive bleeding during menstruation and inability to conceive after marriage. This is consistent with the findings that excessive menstrual bleeding in fibroid patients is often the main reason to seek healthcare (Owiredu and Dapilah, 2015). Although all the women sought for treatment, the treatment options and treatment outlets differ. Both the modern and traditional therapies were sought by the respondents though the former was the most common health seeking source for fibroid treatment. Modern treatments include drugs and surgical procedure. However, surgical procedure (especially hysterectomy) was less used. This was because of the fear of surgical operation and the emphasis placed on womb as a symbol of fertility, femininity and womanhood. A study conducted by Adegbesan-Omilabu, Okunade and Gbadegesin (2014) revealed that majority declined surgery because of the fear of surgical complication for fibroids. Myomectomy was discovered to be the most preferred surgical option than hysterectomy among the women that had surgical treatment of fibroid. Factors such as the need to have more children and preservation of the womb are responsible for this choice. Similar finding from a study conducted in Benin by Osaikhuwuomwan and Osazee (2015) highlighted that, number of children a woman had given birth to affects the treatment option adopted for fibroid because parity demonstrated an independent relationship with choice of surgery, as low parity had more myomectomy as compared to hysterectomy amongst of high parity regardless of fibroid. Similarly, Orazulike, Green and Uzoigwe (2015) also found that the premium placed on childbirth by the society has resulted in a strong aversion to hysterectomy and patients thereby resorting first to "traditional practitioners", who claim to "dissolve" uterine fibroids.
The traditional treatments include herbs and spiritual cleansing. The use of traditional medicine is in line with the assertions of Ogedengbe (2003) that the African continent has a long history with the use of plants for medicinal purposes such as cultural interpretation of health, diseases and illness and also addresses the health-seeking process and healing practices (Ogedengbe, 2003). Similarly, a WHO survey in Nigeria estimated that up to 75% of the population patronize traditional medicine (Bako, Bakfur, John and Bala, 2005) irrespective of the social, educational or religious background of the people, which is indicative of acceptance of herbal medical practice (Ukwuomah and Da Costa, 1997).
The facilities for treatment include government hospitals, private hospitals, traditional health centres and pharmacies. However, government hospitals had the highest patronage while pharmacy has the lowest patronage. The high utilization of government hospitals is not un-connected to the cheaper service charge when compared to the private hospitals. Also, government hospitals have a higher number of specialists in different fields of medicine and surgery. Thus, there is the belief in the efficacy of the services rendered by government hospitals. This is contrary to the findings of Adegbesan-Omilabu, Okunade and Gbadegesin (2014) that majority sought treatment from alternative health care providers such as spiritual homes (churches, mosques), traditional healers and massage parlours. There is a significant relationship between background characteristics and treatment options for fibroid. The study also revealed a significant relationship between some background characteristics (income, educational level and occupation) of the respondents and the adoption of surgery. Hence, income, educational level and occupation influence the decision to go for surgical procedure to remove the fibroid.
Health seeking behaviour is influenced by income, proximity to health care facility, relatives, friends and medical professionals. The ability to pay, or level of poverty, significantly determines when and where a person seeks healthcare has been reported by Abdulraheem (2007). Similarly, the findings of Onwujekwe et al. (2011) revealed that "choice of healthcare is influenced by medical costs and income. This was also corroborated by Grundy and Annear (2010) that poor people are more likely to seek healthcare services if the cost of treatment is low and affordable than when they have to pay high out-of-pocket costs. Direct costs and indirect costs of healthcare play a big role on when and how a client seeks healthcare. Indirect costs include transportation, accommodation, and feeding, whereas direct costs are payments for doctor's visits, drugs, diagnostics, and supplies.
Proximity to health care facility is also a predictor of health seeking behaviour. This is similar to the findings of Nteta, Mokgatle-Nthabu and Oguntibeju (2010) in South Africa that there is a relationship between accessibility and healthcare use. Okeke and Okeibunor (2010) also found that, in rural areas, the effect of distance on service use becomes stronger when combined with the lack of transportation and with poor road network, which contribute towards indirect costs of visits. Onwujekwe et al. (2010) also noted that close proximity to a healthcare facility is an influential factor in the choice and use of a health provider.

Findings and Health Belief Model
The findings from this study generally support previous conclusions in literature on the usefulness of the Health Belief Model in relation to health perceptions and attitude towards fibroid treatment within the context of individual practice towards fibroid treatment based on subjective norms.
Health Belief Model which was developed to give insight to why people use or do not use preventive services identifies individual predisposition towards a given preventive health behaviour which is governed by beliefs and attitudes. Some of the basic features of the health belief model that influence health seeking behaviour and decision making were highlighted in the results of this study. First, the belief about the seriousness of the disease, which may be viewed in terms of physical impairment or intrusion with social performance, projected among majority of the fibroid patients who expressed their perception of the severity of the fibroid condition. Results from the quantitative study show that majority of the respondents viewed fibroid as a relatively severe disease. This was also corroborated by responses from interviewees who acknowledged the severity of fibroid.
Such perceived severity of fibroid has its role to play in individual's health seeking behaviour. The health belief model proposes that individuals who perceive fibroid disease as serious are more likely to engage in behaviours to prevent the health problem from occurring (or reduce its severity). Perceived seriousness encompasses beliefs about fibroid disease being life threatening, causing pain, leading to barrenness, destroying the uterus and its broader effects of the disease on carrying out work and social functions such as social expectations and social stigma. These perceptions motivate fibroid patients to seek treatment for fibroid from various sources.
Respondents' view on the gains associated with activities to lower the level of severity of fibroid disease was also highlighted as an associated factor to health seeking behaviour among respondents. While some of the respondents opted for traditional methods of fibroid treatment due to its perceived benefits over other methods, other respondents preferred orthodox methods due to their perceived benefit from other methods. This variation shows that the preference of treatment options and outlets for fibroid are based on the patients' perceived benefits from treatments.
Furthermore, evaluations of potential obstacles associated with the proposed actions, were also highlighted in this study. In seeking for fibroid treatment, the fibroid patients had to consider a variety of limitations to assessing preferred treatment options and outlets such as the cost and inconveniences involved in seeking a particular health care service. Income and cost of treatment limited some of the participants' access to preferred treatment options and outlets. Proximity to health care centre also emerged as a potential obstacle to health seeking behaviour.
The health belief model stipulates that a cue, is necessary for encouraging engagement in health-promoting behaviours. It is a modifying variable. Cues to action can be either internal or external. As obtained in this study, various physiological cues prompted many of the participants to seek treatment such as the various symptoms associated with fibroid. The amount of cues required to stimulate action varies between persons by perceived vulnerability, severity, gains, and obstacles.

Conclusion
The data collected and analysed in this study have shown that, women living in rural areas have low or no access to quality health care services. The data collected showed that a larger percentage of the respondents sought treatment for fibroid at the orthodox medical centres because of the perceived quality of services at government facilities. But with the abysmal state of public health facilities and services in this, can the health facilities be trusted to provide the kind of services these women required? This study recommends an increase in awareness creation about the prevention and care for fibroid. Furthermore, treatment options must be well explained to the women so that they will be able to make decisions that will enhance their health; thus contributing to the family, community and nation's growth and development.