Knowledge of Cervical Cancer and Cervical Cancer Screening Uptake Among Sexually Active Women Aged 20-40 Yrs in Umuakashi Village Nsukka, Enugu State
Chapter One
Research Objectives
General Objective
To evaluate the Knowledge of cervical cancer and cervical cancer screening uptake among sexually active women in Nsukka LGA.
Specific Objectives
- To determine the utilization of cervical cancer screening by women.
- To determine the levels of knowledge on cervical cancer screening among women.
- To identify the association between the socio demographic characteristics and utilization of cervical cancer screening.
- To assess women’s attitude towards utilization of cervical cancer screening.
- To identify the barriers to cervical cancer screening utilizations’
CHAPTER TWO
LITERATURE REVIEW
Introduction
Studies have been conducted worldwide on the factors influencing utilization of cervical cancer screening services, but very few studies have been conducted in Nigeria. Literature review for this study focused on published studies and the process of reviewing the literature was done to identify scientific, evidence based literatures that would add value to the study. Scientific studies were searched electronically from HINARI, CINAHL, PubMed, and Science Direct. Other literature sources included international and local publications and books. Literature was selected if it was not older than ten years. The key words used during the search were: “cervical cancer screening utilisation”, “knowledge on cervical cancer screening services”, “social economic factors influencing cervical cancer screening services”, “attitude of women towards cervical cancer screening services”. The selected literature in this chapter is discussed under the following headings: overview of cervical cancer screening utilisation, knowledge, social economic, attitude and finally a conclusion was drawn.
Overview of Cervical Cancer Screening
Cancer of the cervix uteri is a preventable disease and second most common cancer among women in the world and the most common in the developing countries accounting for more than 80% of all cases worldwide (Carrozzi et al., 2013; Ezech et al, 2014). Globally, it is estimated that half a million cases are detected and over a quarter million women die from cervical cancer each year (Carrozzi et al., 2013). Screening programme performance can improve with adequate emphasis on training, quality control, and telemedicine-support for nurse-providers in clinical decision making (Ezech et al, 2014).
Utilization
A world-wide pandemic of underutilizing CCSS especially in developing countries has been established by several studies. (CDC, 2013; WHO, 2010; CIDRZ, 2014). Several studies have shown that developed countries have a better utilization levels than developing countries. Previous study reported that 76% of the women in the study had a Pap smear in the previous 24 months among native (Ezech et al, 2014, CDC, 2013; WHO, 2010). Therefore, a decline in CC incidence and deaths has been observed in the developed world over the past 20 years (Ebu et al., 2014). Recent report has shown that only about 5% of women in developing countries had been screened for cervical cancer compared with 40% to 50% of women in developed countries (Almobarak et al., 2016: Chirenje et al., 2012),
A study among Italian women showed that 77% of the 25-64 year-old women had Pap smear or HPV test in the three years before the interview (Carrozzi et al., 2013). It was further observed that in northern regions, the proportion of women who performed the test within a screening programme was higher than in the southern regions, this variation was attributed to the availability of Cervical Cancer screening awareness, particularly the spontaneous testing that was predominant in the north (Chirenje et al., 2012). This shows that the level and commitment to utilize the CCSS depends mostly on the awareness, availability of screening services and knowledge levels (Chirenje et al., 2012),
Screening rates in sub-Saharan Africa for cervical cancer remain very low despite of the existence of proven simple screen and treat approaches to cervical cancer prevention (Mwanahamuntu et al., 2011). In high resource settings where cervical screening is routine care, early screening prevents about 80% of potential cervical cancer mortalities (Finocchario-Kessler et al., 2016). This suggests that with increased screening, the huge mortalities related to cervical cancer in sub-Saharan Africa are avoidable. A review of published research into cervical cancer screening and treatment in sub-Saharan Africa (Finocchario-Kessler et al., 2016) found that different research from different countries report different levels of efforts towards combating cervical cancer. There is evidence of primary prevention efforts mainly HPV vaccination initiatives, and secondary prevention which is underpinned by early diagnosis, commonly called screen and treat (Khozaim et al., 2014). There are also tertiary prevention efforts which consist of treatment opportunities (Finocchario-Kessler et al., 2016) for those who are diagnosed with cervical cancer early enough and have access to effective treatment.
However, about 267.9 million women above the age of 20 years old living in Africa are at risk of developing cervical cancer if CCSS remain underutilized (Chirenje et al., 2012). Over 80, 000 African women are diagnosed with cervical cancer annually with 75% (60, 000) mortality rate, and mostly of these deaths are found in sub-Sahara Africa that consists of 47 countries including Nigeria (Denny and Anorlu, 2012). However, Zimbabwe has more than 95% of the care institutions with basic infrastructure to conduct CCS but the absence of clear policy framework has affected the utilization of Cervical Cancer screening awareness (Ibu et al., 2020). The incidence of cervical cancer in sub-Sahara Africa is relatively high with an incidence rate of 50 per 100 000, and average age standardized rate (ASR) of 31 per 100 000 women across the whole region due to underutilization (WHO, 2012). In several sub-Sahara African nations such as Kenya, underutilization of Cervical Cancer screening awareness makes cervical cancer the second most frequent cancer after breast cancer and accounts for an average of 2000 deaths per year (WHO, 2011).
CHAPTER THREE
RESEARCH METHODOLOGY
Introduction
This chapter presents the research methodology that were used in this study. The research methodology and methods section focus on the research design, study setting, study population, sample selection, sample size, validity, reliability, data collection tools, data collection techniques, pilot study and ethical and cultural considerations. Data were collected using a semi structured interview schedule. A total of 370 respondents were interviewed and there was a 100% response rate. From July 2016, through July 2017, a total of 370 women were enrolled for CCSS interviews from 4 health facilities in Umuakashi Village Nsukka local government area of Nigeria.
Research Design
The study involved collection of information on the factors influencing utilization of cervical cancer screening services. Therefore, this study was a quantitative study and a cross sectional design. A cross sectional study design was used because the purpose of the study was to describe a population or a subgroup within the population with respect to an outcome or a set of risk factors. Cross sectional study was used to investigate the associations between risk factors and the outcome of interest.
Study Population
Umuakashi Village Nsukka local government area has a population of approximately 2, 330,200 as for the year 2020 of which 51 % (1, 188402) were women (Enugu State health statistics, 2020). The study population included all women aged 18 years and above. The target population for the study were all women aged 18 and above and residents of Umuakashi Village Nsukka local government area.
CHAPTER FOUR
DATA ANALYSIS AND PRESENTATION OF FINDINGS
Introduction
This chapter presents how data and the findings were analysed and presented using bar charts pie charts and tables. Data analysis and presentation of findings section focus on the data processing and analysis, demographic characteristics of the participants, knowledge about cervical cancer screening, utilization of Cervical Cancer screening awareness, social economic factors, distance, service delivery, attitude and the association between the independent and dependent variables.
CHAPTER FIVE
DISCUSSION OF FINDINGS AND THE IMPLICATIONS ON THE HEALTH CARE SYSTEM
Introduction
The discussion of the findings is based on the research analysis of the responses from respondents who accessed care at Mtendere, Kalingalinga, Chawama and Kanyama health facilities. The study purpose was to evaluate the factors influencing utilization of Cervical Cancer screening awareness by women in Umuakashi Village Nsukka local government area. The outline of the discussion consists of the characteristics of the sample, discussion of each objective used in the study, the implications of the findings to the nursing care system, recommendations, dissemination of findings, limitation of the findings and the conclusion.
Socio-Demographic Characteristics of the Sample
According to table 4.1, slightly more than half (51.4% n= 190) of the respondents were between 18 to 28 years old. The explanation for the large number of respondents falling between 18 to 28 years old could be attributed to the fact that most household population in Nigeria has a greater number of young people than older people (CCSO, 2007). This study showed a statistically significant relationship (P<=0.008) between age and utilisation of cervical cancer screening services.
More than half (64.1%, n=237) of the study respondents were married. This could be attributed to the fact that the participants were drawn from women who were available at the health facility during data collection period in various clinics. Therefore, married women have a lot of services they can utilise at the health centre than unmarried women. The study established that marital status was statistically insignificant (P>= 0.969) with CCSS. Majority (94.4% n=353) of the study respondents had some formal education. with a minimal number (4.6% n=17) of respondents having no formal education at all.
The study also reviewed that there was statistical significant relationship (P<=0.005) between education levels and utilisation of cervical cancer screening services. These findings are supported by various authors (Sigh et al 2012; Ezechi et al, 2014; Chang et al, 2007; Cunninghen et al, 2020). These studies revealed that there was a direct relationship between the women’s level of education and their willingness to be screened for cancer of the cervix. Sigh et al, (2012), stated that education is an important determinant in health- seeking behaviour since it is assumed that educated people seek medical attention early more than the uneducated or semi-educated people who would seek unconventional medical attention before going to the hospital.
Ezechi et al, (2014), contended that education played a very important role in women’s assimilation of health education given at the institutions as compared to those with minimal or no formal education at all. Their findings, further, revealed that educated women tend to have more concern about their health and cervical cancer screening in particular. Chang et al, (2007) and Cunning et al, (2020) their studies reviewed that educated people were like likely to use this service as the they have various sources of information such as print media and social media. Education changes the mind set of people where access to health services are concerned as educated people are better placed to understand the importance of using screening services to prevent getting diseased.
On the contrary various studies (Were et al 2011, Morema et al 2014 and UN: habitats, 2009) were done on respondents with tertiary education. A study on primary school teachers (Were et al 2011) revealed a low utilization rate of 5% by primary school teachers. Another study by Morema et al 2014 on health workers found that only about 20% of the respondents utilized the services. UN-habitat (2009), study on health staff managers showed that only 3% of the respondent had utilized the service from study. This low utilization may be attributed to lack of awareness by those who have higher levels of education. One’s education level does not make one to be aware or know everything. It is vital to note that being educated may not be the only factor influencing screening and those educated people sited busy schedule as the biggest reason for non-screening, hence health workers should continuously give health education regardless of one’s educational status.
In regard to religion, more than three quarters (88.4%, n=327), of the respondents were Christians. This could be attributed to the fact that Nigeria is largely a Christian nation with over 80% of the population believing in the Christian faith (Africa safari 2010).
Recommendations
There is need for MOH and other stakeholders like Ministry of Education, churches and NGOs to strengthen reproductive health services for women where cancer of the cervix and CCSS screening issues would be communicated to women by sensitising the importance of Cervical Cancer screening awareness to women between the age of 18-37 in the communities so that they can be able to access the services quickly.
There is need to train health care providers in VIA screening methods in order to improve staffing levels and to make it easier for health workers to give IEC at any point of contact with women. Additionally, they should also introduce the outreach programmes using mobile clinics in order to extend the services to the areas that are not being served. This would enable women in such areas to have access to information on cervical cancer and screening services and could be screened as well.
Information, Education and Communication (IEC) on the importance of Cervical Cancer screening awareness should be given to women during Maternal and Child health care activities and in all departments so that women can access the services at the health facility.
Community Based Agents (CBAs) should be fully equipped with knowledge about cervical cancer and importance of CCS screening services, so that they can in turn sensitize communities on cervical cancer.
Government should fund cervical cancer programs so that health workers can use door to door campaign strategy, radio/television sensitization on the prevention strategies of cervical cancer to the community.
The MOH should lobby for more cooperating partners and international organizations such the Johns Hopkins Program of International Education in Gynaecology and Obstetrics (JHPIEGO) which is implementing visual inspection screening.
There is need for the study to be duplicated in other Provinces to enable generalization of the results.
Male involvement in cervical cancer screening to be encouraged.
Conclusion
This was evaluating the factors influencing utilization of cervical cancer screening services in selected clinics of Umuakashi Village Nsukka local government area of Enugu State. This write up comprised five chapters of which chapter one covered introduction, background information, statement of the problem, theoretical framework, justification of the study, research objectives stating of the hypothesis, definition of terms and identification of variables and their cut off points.
Chapter two covered literature review on cervical cancer screening globally, regionally and locally and on the variables. Chapter three was the methodology, chapter four was presentation of findings and chapter five was discussion of research findings. The study addressed the following specific objectives were to: identify the association between the socio demographic characteristics and utilization of Cervical Cancer screening awareness, determine the levels of knowledge on Cervical Cancer screening awareness among women, assess women’s attitude towards utilization of Cervical Cancer screening awareness and identify the barriers to Cervical Cancer screening awareness. All the objectives were successfully accomplished as the study revealed that slightly below three quarters 259 (70%) of the respondents had low knowledge of cervical cancer and screening services. It also revealed that 219 (60%) of the respondents had never been screened for cervical cancer.
The study further showed that the majority 251 (86%) of the respondents had no interest in cervical cancer screening. The study findings revealed that there was a relationship between some demographic characteristics such as education, employment and age, with utilization of cervical cancer screening Women with lower socioeconomic status were found to be much less likely to undergo the freely available cancer screening services.
The results of this study enable us to understand more thoroughly the characteristics of women who undergo cervical cancer screening. The findings can help formulate related policies that are directed at removing the barriers to accessing medical care and targeting those at-risk groups. This analysis provides new evidence of the factors affecting the utilization of preventive care among women in a Enugu State, Nigeria which are comparable to those of other countries, and may shed further light on the issue of promoting cancer screening and women’s health.
REFERENCES
- Abdullahi, A., Copping, J., Kessel, A., Luck, M. and Bonell, C. (2009). Cervical screening: Perceptions and barriers to uptake among Somali women in Camden. Public Health, 123:680-685.
- Abotchie, P. and Shokar, N. (2009). Cervical cancer screening among college students in Ghana: knowledge and health beliefs. International Journal of Gynecological Cancer, 19:412-416.
- Adanu, A. (2020). Determining the level of knowledge about cancer of the cervix
- African safari (2010). Nigerian Religion. Available on http://www.go2africa.com/Nigeria/africa-safari-guide/religioninNigeria
- Ak M, Canbal M, Turan S, et al (2010). Knowledge of cervical cancer and its risk factors among women residing in two urban slums in Lagos, Nigeria. Nig Med Pract, 61:74-81.
- Akinyemiju, T., Mc Donald, A. and Lant Z, M. (2020). Health care access dimensions and cervical cancer screening in South America; Analysis of the World health survey, BioMed Central Public Health, 20 (1): 382.
- Akinyemiyu, T.F. (2012). Socioeconomic and Health Access Determinants of Breast and Cervical Cancer Screening in Low-income countries; Analysis of the World Health Survey. PLoS Access, 7: e0048834.
- Almobarak, Ayman A Elbadawi, Wadie M Elmadhoun, Mohammed, H Elhoweris and Mohammed H Ahmed (2016) Newly diagnosed without treatment Persistence or recurrence Remission and behavior about Pap smear testing in family medicine practice. Asian Pacific Journal of Cancer Prevention, Vol 17, 2016025.0 50.075.0100.0 and Pap smear, Accra.
- Assoumou, S., Mabika, B., Mbiguino, H., Mouallif, M., Khattabi, A. and Ennaji, M. (2020). Awareness and Knowledge regarding prevention, Pap Smear Screening and human papillomavirus infection in Gabonese women. Bio Med Central Women’s Health, 20: 37.
