Download knowledge and utilization of cervical cancer screening amongst

KNOWLEDGE AND UTILIZATION OF
CERVICAL CANCER SCREENING AMONGST
WOMEN OF CHILD BEARING AGE IN AJAH,
ETIOSA LOCAL GOVERNMENT AREA OF
LAGOS STATE.
BY
ABAH MICHAEL
(109093102)
1
KNOWLEDGE AND UTILIZATION OF CERVICAL CANCER
SCREENING AMONGST WOMEN OF CHILD BEARING AGEIN
AJAH ETIOSA LOCAL GOVT. AREA OF LAGOS STATE.
BY ABAH MICHAEL
(109093102).
SUBMITTED TO THE COLLEGE OF MEDICINE, UNIVERSITY
OF LAGOS, IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE AWARD OF MASTERS OF PUBLIC
HEALTH DEGREE.
OCTOBER, 2012.
2
CERTIFICATION.
This is to certify that the content of this dissertation titled Knowledge and Utilization cervical
cancer screening amongst women of child bearing age in Ajah. Etiosa local government of
Lagos state submitted to the department of community health , University of Lagos is my
original work , done under appropriate supervision.
I hereby declare that this work has not been submitted in part or in full for any other purpose.
SUPERVISOR
ASSOC. PROF. K O.ODEYEMI
SIGNATURE
------------------------------
ASSESSOR
PROF. EKANEM.
SIGNATURE
------------------------------
NAME.
DR. ABAH MICHAEL.
SIGNATURE.
-----------------------------
DATE.
--------------------------
3
DEDICATION.
This work is dedicated to God Almighty, for His love in the ages past and for his sustenance
throughout the study period.
4
ACKNOWLEDGEMENT.
I wish to express my sincere gratitude to my supervisor, Assoc. Prof. K .O. Odeyemi for her
thorough and painstaking supervision of this work.
I also express my heart felt gratitude to my wife, Mrs. Evelyn Abah for her moral support all
through the period of this study.
My gratitude also goes to members of my MPH class for a stimulating session during all our
lectures and presentations.
5
TABLE OF CONTENT.
CONTENT.
PAGES.
TITLE PAGE.
I
CERTIFICATION
II
DEDICATION.
III
ACKNOWLEDGEMENT
IV.
TABLE OF CONTENT.
V.
LIST OF TABLES.
VI
ABREVIATION.
VII.
INTRODUCTION.
1.
LITERATURE REVIEW.
5.
MATERIALS AND METHOD.
25.
RESULTS.
29.
DISCUSSION.
53.
CONCLUTION.
61.
RECOMMENDATION.
62.
REFRENCES.
64.
APPENDIX.
71.
6
TABLE.
TITLE
PAGE.
Table 1
Age distribution of respondents.
29.
Table 2
Distribution of respondents by marital status.
30.
Table 3
Distribution of respondents by academic qualification.
32.
Table 4.
Distribution of respondents by ethnic group.
33.
Table 5.
Distribution of respondents by income level.
34.
Table 6.
Respondents first source of information on cervical cancer.
36.
Table 7.
Respondents awareness of cervical cancer screening methods.
39.
Table 8.
Knowledge of place where cervical cancer screening is done.
40.
Table 9.
Respondents first source of information on cervical cancer.
41.
Table 10.
Respondents awareness of place where screening is done.
42.
Table 11.
Knowledge of risk factors for cervical cancer .
43.
Table 12.
Respondents awareness of signs and symptoms of cervical cancer.
44.
Table 13.
Distribution of sex partners among respondents.
44.
Table 14.
Overall assessment of knowledge of cervical cancer screening.
45.
Table 15.
Respondents willingness to participate in health education.
45.
Table 16.
Utilization of cervical cancer screening among respondents.
46.
Table 17.
Practise of cervical can cancer screening among respondents.
48.
Table 18.
Various reasons given by respondents for not doing test.
49.
Table 19.
Knowledge of cervical cancer screening by age.
50.
Table 20.
Knowledge of cervical cancer screening by academic qualification.
51.
Table 21.
Practise of cervical cancer screening by academic qualification.
7
ABREVIATION.
HPV.
Human papilloma virus.
Pap smear.
Papanicoulaou smear.
WHO.
World health organisation.
VILI
Visual inspection with Lugol’s Iodine.
VIA
Visual inspection with Acetic Acid.
LBC.
Liquid based cytology.
NCI
National cancer institute.
CRCHD.
Center to reduce cancer health disparity.
GOPD.
General out- patient department.
8
SUMMARY.
Cervical cancer is the second most common cancer amongst women world- wide but is the
commonest cancer among women in developing countries including Nigeria. The estimated
incidence in Nigeria is twenty five out of hundred thousand women. In most developing
countries cervical cancer screening is not universally done and the knowledge about cervical
cancer in women is quite poor. The aim of this study was to determine the level of knowledge
and utilization of cervical cancer screening and women attitude towards it in Ajah , Etiosa
Local Government area of Lagos State.
This was a cross – sectional descriptive study carried out among women of reproductive age
in Ajah, to assess knowledge and utilization of cervical cancer screening. The data was
collected using self – administered questionnaire. Four hundred and two respondents were
tested after an informed consent was given. Data was analysed using EPI INFO statistical
package and groups were compared using chi – square test at a level of significance of P <
0.05. The findings showed that forty one point three percent of the respondents had heard
about the term cervical cancer. Thirty nine point three percent of the respondents had heard
about cervical cancer screening and most of the people (79.1%) heard about pap smear
compared to other methods. Utilization of cervical cancer among the respondents to thirty
point three percent which is fair due to the urban nature of the area. The overall knowledge
about cervical is pure in the Ajah area of Eti-Osa Local Government Area.
9
CHAPTER ONE.
INTRODUCTION.
Cervical cancer is a malignant neoplasm of the cervix uteri. The cervix is the narrow portion
of the uterus where it joins with the vagina. Most cervical cancers are squamous cell
carcinomas, arising in the squamous (flattened) cells that line the cervix. Adenocarcinoma
arising in glandular epithelial cells is the second most common type. Very rarely cancer can
arise from other cells.1
Worldwide cervical cancer is the twelfth most common and the fifth most deadly cancer in
women. It affects about 16 per 100,000 women per year and kills about 9 per 100, 000 per
year. Approximately 80 percent of cervical cancers occur in developing countries including
Nigeria. 2,3,4,5.
In Nigeria, statistics available show that cervical cancer accounts for 15% of female cancers
as compared to 3.6% for developed countries.6
It is estimated that less than 0. 1% of Nigerian women have ever undergone any form of
screening for cervical cancer and another less than 1% of women aware of this deadly
disease. Consequently it is said to kill a woman every hour in Nigeria.7
World health organisation, (WHO), projects a twenty five percent increase over the next
decade in the absence of wide spread interventions globally. According to WHO estimates,
Nigeria has a population of 40.4 million women, fifteen (15) years and above who are at risk
of developing cervical cancer. Current estimates indicate that every year 14550 women are
diagnosed and of these 9659 will die of the disease which is greater than half of the number
of new cases seen.3
Cervical cancer ranks as the second most frequent cancer in Nigeria diagnosed in women
between the ages of 15 and 45 years of age, breast cancer is number one.7
10
Cervical cancer is one of the commonest cancers affecting a woman’s reproductive organs
and various strains of Human papilloma virus (HPV), a sexually transmitted infection plays a
role in causing most cases of this cancer.
About 23.7% of women in the general population are believed to harbour cervical HPV
infection at any given time.7When exposed to HPV, a woman’s immune system typically
prevents the virus from doing harm. In a small group of women, however, the virus survives
for years before it finally converts some cells on the cervical epithelium into cancer cells.
Once a woman is infected it can take between five to thirty years for the viral infection to
develop to full cancer, but since it has no early symptoms, it continues to ravage her
unknowingly.
Cervical cancer incidence has been reduced drastically in the developed world largely due to
universal screening. The American cancer society presents the following lists of risk factors
for cervical cancer: human pappilomavirus infection (HPV), smoking, HIV infection,
Chlamydia infection, history of early sexual activity, multiple sexual partners, stress and
stress related disorders, dietary factors , hormonal contraception , multiple pregnancy , family
history of cervical cancer, exposure to the hormonal drug diethylstilbestrol and also early age
at first pregnancy.8
Papanicolaou test (also called Pap test, pap smear, cervical smear or smear test.) is a
screening test used in gynaecology to detect premalignant and malignant (cancerous) changes
in the ectocervix. Significant changes can be treated thus preventing cervical cancer. The test
was invented by a Greek doctor, Georgios Papanikolaou and it was later named after him.
The test aims to detect potentially pre-cancerous changes called cervical intraepithelial
neoplasia. (CIN or cervical dysplasia.) Which are usually caused by sexually transmitted
human papillomavirus. The test remains an effective widely used method for early detection
of precancer and cervical cancer. In general countries where Pap smear screening is routine,
11
it recommended that females age 16 to 65 should have regular Pap smear testing.
Guidelines on frequency of screening vary from annually to every five years. If the results are
abnormal and depending on the nature of the abnormality, the test may need to be repeated in
six to twelve months.9
Screening guidelines also vary; it is usually recommended that screening should start from
the age of twenty and end at the age of sixty. Most women contract HPV soon after becoming
sexually active hence there is little or no benefit screening those without sexual contact ..Pap
smear screening is still recommended for women who have been vaccinated against HPV
since the vaccine does not cover all the HPV types that cause cervical cancer.
This study is considered of public health importance because; in Nigeria cervical cancer is
one of the most important cancers affecting women. There are multiple reasons cervical
cancer is common in Nigeria: There is no effective screening programme and the level of
awareness of the disease is very low. Majority of women who present for treatment usually
do so very late in the advanced stage of the disease.9
In the Ajah area in Etiosa local government area of Lagos state, I shall be carrying out the
study on the knowledge and utilization of cervical cancer screening on women of
reproductive age that is between the ages of fifteen and forty five. This study will go a long
way to help in planning intervention measures with respect to cervical cancer screening and
ultimately reduce morbidity and mortality from cervical cancer.
12
GENERAL AIM.
To assess the knowledge and utilization of Cervical Cancer screening among women of child
bearing age in Ajah.
OBJECTIVES.
1. To determine the level of knowledge about Cervical cancer and its screening methods
among women of child bearing age group in Ajah.
2. To assess the attitude of women of child bearing age group in Ajah towards Cervical
cancer screening.
3. To determine cervical cancer screening practise among women of child bearing age.
13
CHAPTER TWO.
LITERATURE REVIEW.
CANCER OVERVIEW.
Cancer is a class of diseases in which a group of cells display uncontrolled growth, invasion
that intrudes upon and destroys adjacent tissues and sometimes metastasis or spreading to
other locations via blood or lymphatics. These properties differentiate them from benign
tumours which do not invade or metastasize.1
Researchers divide causes of cancer into two groups: those with an environmental cause and
those with a hereditary or genetic cause. Cancer is primarily an environmental disease,
though genetics influence the risk of some cancers. Common environmental factors leading
to cancer includes: tobacco (25 – 30%), diet and obesity (30 – 35%), infections (15 – 20%),
radiations (10%), stress, lack of physical activity and environmental pollutants.[2][3] Cancer
pathogenesis is traceable back to DNA mutations that impact cell growth and metastasis.
Substances that cause DNA mutations are called mutagens, and mutagens that cause cancers
are known as carcinogens. Particular substances have been linked to specific types of cancer.
Tobacco smoking is associated with many forms of cancer.4 and causes 90% of Lung
cancer.5
In 2008 approximately 12.7million cancer cases were diagnosed worldwide and 7.6million
people died of cancer.3 Cancers as a group account for approximately 13% of all deaths each
year with the most common being: Lung cancer (1.3million deaths), Stomach cancer
(803,000 deaths), colorectal cancer (639000 deaths), liver cancer (610,000 deaths), and breast
cancer (519000 deaths).6
14
Cancer of the cervix is the second most common cancer in women worldwide, with about
500,000 new cases and 250,000 deaths each year.7 Almost 80% occur in low income
countries, where cervical cancer is one the most common cancer in women.8
Virtually all cervical cancer cases (99%) are linked to genital infection with human
pappilomavirus (HPV), which is the most common viral infection of the reproductive tract.9
GLOBAL VIEW OF CERVICAL CANCER.
In the USA cervical cancer is a success story in the history of cancer control. Since screening
programmes were implemented about 50 years ago cervical cancer deaths have declined more
than 75% nationwide.10 Yet cervical cancer still takes the life of approximately 4000 women
in US annually. This is particularly disturbing since virtually all cervical cancers should be
avoidable with proper screening, and because effective treatment is available for
precancerous lesions and for invasive cancers detected before they spread.11National cancer
institute (NCI) Centre to reduce cancer health disparity (CRCHD) postulates that cervical
cancer is an indicator of the larger health system concerns such as: infrastructure, access,
culturally
competent
communication,
patient/provider
education
deficits
that
disproportionately affects members of particular racial and ethnic minorities and other
underserved women who also are subject to the negative effects of poverty on health status.
An entrenched pattern of high cervical cancer mortality has existed for decades in distinct
populations and geographic areas. Women’s suffering most from this disparity includes
African-American women from the south, Latina women along exas- Mexico border, white
women in Appalachia, American Indians of the northern plains, Vietnamese American
women, and Alaska natives.12 A more detailed analysis of two geographic areas where
cervical cancer mortality is greatest indicates that, in addition to needing targeted
interventions and additional resources to reduce cervical cancer deaths, these communities
15
also experience high mortality rates for other conditions and diseases for which prevention is
currently available.[13][14] Most cervical cancer cases are Squamous cell carcinomas. Non
squamous cell cancers (Adenocarcinomas) now account for about 30% of cases. The
proportions of all cervical adenocarcinomas have increased while the rate for squamous cell
cancershas declined. Reducing mortality from cervical adenocarcinomas have been less
successful compared to squamous cell cancers. It is not yet known whether there is a
relationship between high mortality geographic areas and the histological type of cancer
found there.15
Cervical cancer is the twelfth most common cancer diagnosed in Canada among women aged
20 to 49 it ranks third in incidence.16 In the year 2002 it was estimated that there was
approximately 1400 new cases and 410 deaths due to the disease. Both incidence and
mortality rate have declined significantly in Canada age standardized incidence rates by 50%
over a period of 25years and mortality rate by 75% over 50 years.(which coincides with the
introduction of the pap smear.)17
In 2007 there were 2, 227 new cases of invasive cervical cancer in England. 18 Cervical cancer
incidence fell by 42 percent between 1988 and 1997 (England and Wales).19
This fall is directly related to the cervical screening programme. There was a 25 percent
decrease in cervical cancer incidence rate in women under the age of 70 from 1990 to 1992.
This has been attributed to a rapid increase in cervical cancer screening which occurred from
1989 onwards.20
In 2007, the age- standardised (European) annual incidence rate for cervical cancer is 8.4 per
100,000 females.1 Cervical cancer is the most common cancer in females under 35, with 702
new cases diagnosed in UK in 2007.1 Cervical cancer screening now saves approximately
4500 lives in England and prevents up to 3500 new cases of cervical cancer per year in the
UK.[21][22] In 2008, 759 women died from cervical cancer in England. Mortality rates
16
generally increases with age with the highest number of deaths occurring between the 75 – 79
age group. Less than 6 percent of cervical cancer occurs in women under 35.23Cervical cancer
rates in 2008 (2.4 per 100,000 females) are nearly 70 percent lower than they were 30 years
earlier (7.1 per 100,000 females in 1979). Cervical cancer is the sixteenth most common
cause of cancer deaths in women in the UK. The latest relative survival figures for England
showed that 66 percent of women diagnosed with cervical cancer between 2000 and 2001
were alive five years later.23
Every ten minutes, a woman dies of cervical cancer in Africa, despite the fact that almost
every case is preventable through a programme of screening, treatment and vaccination
against human papillomavirus (HPV). Sub- Saharan Africa and South America have the
highest incidence of cervical cancer in the world with cervical cancer resulting in 1% of all
adult deaths and 2% of all female deaths. Most of these deaths occur in the middle aged
groups.24 Population dynamics are currently changing and an increase in the middle aged
population in the next fifty years will result in a fourfold increase in deaths due to cervical
cancer in middle aged women. Acting now with screening and vaccination will reduce deaths
in the middle and end of this century and approximately 50,000 deaths will be avoided in sub
Saharan Africa.25
Nigeria has a population 40.43 million women ages 15 years and older who are at risk of
developing cervical cancer. Current estimates indicate that every year 14550 women are
diagnosed with cervical cancer and 9659 die from the disease. Cervical cancer ranks the
second most frequent cancer in women in Nigeria between 15 and 45 years of age. About
23.7% of women in the general population are estimated to harbour HPV infection at any
given time.26
17
HUMAN PAPILLOMA VIRUS.
Human papillomavirus (HPV) is a member of the papillomavirus family of viruses that is
capable of infecting humans, HPV establish productive infections only in the stratified
epithelium of skin and mucous membranes. While the majority of the nearly 200 known
types of HPV cause no symptoms in most people, some types can cause warts, while others
can in a minority of cases – lead to cancer of the cervix.
More than 20 to 40 types currently exist and infect the anogenital region. Some sexually
transmitted types of HPV may cause genital warts.27
Persistent infection with ‘’high risk’’ HPV types – different from the ones that cause skin
warts – may progress to precancerous lesion and invasive cancer. HPV infection is the cause
of nearly all cases of cervical cancer. However most infections with these types do not cause
disease. Most infections with HPV in young females are temporary and do not have long term
significance. 70% of infections are gone in one year and 90% in two years. However when
the infection persists in 5 – 10% of infected women – there is high risk of developing
precancerous lesions of the cervix, which can progress to invasive cancer. This process
usually takes 15 – 20 years. Progression to invasive cancer can be almost always prevented
when standard preventive strategies are applied. Over 120 HPV types have been identified
and are referred to by numbers. Types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59 are ‘’
high risk’’ sexually transmitted HPV’s and may lead to development of cervical
intraepithelial neoplasia. A large increase in the incidence of genital HPV occurs at the age
when individuals begin to engage in sexual activity. The great majority of genital infections
are cleared completely in a matter of months. Some individuals may fail to bring genital HPV
infection under immunological control. Lingering infection with high risk HPV types, such as
types 16, 18, 31, and 45 can lead to development of cervical cancer or other types of cancers.
High risk HPV types 16 and 18 are together responsible for over 65% of cervical cancer
18
cases. Type 16 causes 41 to 54% of cervical cancers, and accounts for even greater majority
of HPV – induced vaginal and vulvar cancers.[28][29][30]
HPV is estimated to be the commonest sexually transmitted infection in the United States.31
Most sexually active men and women will probably acquire HPV at some point in their
lives.32 The American social health association reported estimates tha about 75 to 80% of
Americans will be infected in their lifetime. By the age of 50 more than 80% of American
women would have contracted at least one strain of genital
HPV.[33][34][31]
It was also estimated that in the year 2000, there were approximately 6.2million new HPV
infections among Americans aged 15 – 45 years; of these an estimated 74% occurred in
people between the ages of 15 – 24. Estimates of HPV prevalence vary from 14 to more than
90%. Note that prevalence decreases with age.35 This may be due to HPV infection being
cleared by the immune system, or sinking to undetectable levels while still present in the
body. Recent studies from Albert Einstein College of medicine and from the University of
Washington suggest that HPV may eventually be cleared in most people with wellfunctioning immune systems.36
In Nigeria a study was done to find out how many women have HPV infection (NCI); HPV
prevalence is high (greater than or equal to 15%) at all ages, according to one study
performed in urban Ibadan by Francesci group at IACRC (n = 932 women). This pattern is
very uncommon, one possibly relevant element is the marital structure in Nigeria; a man
often has multiple wives.[37][38]
19
CERVICAL CANCER SCREENING.
Several barriers still impede cancer prevention in Mexican American population .This study
identified sociocultural factors that could be used to improve cervical
Cancer screening in women of reproductive age. A survey conducted in 1991 of 36Mexican
American women aged 18 to 40 in Tucson, Arizona, to assess current compliance with
cervical cancer guidelines and several psychological and social variables. Women who have
never been screened (13 % of sample) had a knowledge deficit, no gynaecological care and
no sexual activity. Women not screened (16%) lacked preventive care , imperfect understood
the pap test had lower self efficacy expectations for understanding physicians, experienced
higher emotional stress about the test, and were older and less acculturated.39Women who
have never been screened require basic education about cancer and cancer screening and
policy changes increasing access to care. For women with less routine screening, preventive
care, supportive attitudes, and health care skills must be encouraged. Successfully organised,
population based screening programmes have not yet been implemented in most developing
countries , despite the greatest burden of cervical cancer in these countries, which is largely
related to poverty , lack of resources and infrastructure and disenfranchisement of women.
[40][41]
BARRIERS TO SCREENING IN DEVELOPING COUNTRIES.
Competing health care priorities posed by the impressive burden of diseases other than
cancers, coupled with a trend of shrinking public health budget is overwhelming in many
developing countries. In sub-Saharan Africa in 1995, for example, communicable diseases
and maternal or perinatal complications caused 70% of all deaths in women ; the equivalent
20
figure in developed countries was 4.9%. Most countries in Africa have high incidences of
cervical cancer coupled with extremely limited facilities for screening or treatment.42 Malawi,
for instance, which has a cervical cancer rate of 47 per 10,000 women has one pathologist,
one colposcope, no cytotechnicians and no facilities for cervical cancer screening or
treatment. A similar or worse situation exists in many other sub Saharan African countries
like Congo, Tanzania, Mozambique and many others. Primary health care facilities, where
preventative health care such as cervical cancer screening should be located, are limited,
under resourced and overburdened in most developing countries. Most low resource countries
have very limited cancer diagnostic, treatment and palliative services. A contributing factor to
limited access to health care in poor countries is urban – rural bias in the distribution of
health facilities.
43
The World development report has cited education as an essential
component of human health , stating that ‘’ households with more education enjoy better
health, both for adults and for children is strikingly consistent in a great number of studies ,
despite differences in research methods , time periods , and population samples’’
KNOWLEDGE OF CERVICAL CANCER SCREENING.
Women widely recognise cervical cancer screening as important health behaviour
44
. In the
US women undergoing cervical cancer screening suggest that they are aware they should be
screened, even though they lack basic understanding of the process ,its limitations and results
of the test. The more knowledgeable the women are about the pap smear the more likely they
are to make a repeat visit
45
and to adhere to recommended follow up. In a study in the US
316 Latino farm workers were surveyed in 1994, 65% of women and 74% of men had not
heard of cervical cancer. Qualitative research showed that women enjoyed learning from
andwith other women in groups or one – on – one. Women seldom receive adequate
21
information about pap tests and cervical cancer at clinics, and they feel shy about asking their
health care provider questions.
[46][47]
Studies of knowledge among women experiencing an
abnormal Pap test results showed insufficient knowledge about abnormal results and follow
up procedures such as colposcopy, and they were dissatisfied with the type and amount of
information they received about the results.48Research on adolescents
49
and college
students50 has suggested that the general knowledge of cervical cancer screening and HPV in
the group is poor. Women belonging to racial or minority groups and those who are poor or
lack health insurance yet undergo cervical cancer screening represent an important and
understudied group; these women are at increased risk for cervical cancer 51 have sought out
health care for routine screening and are accessible for educational efforts. In a study to
evaluate knowledge regarding pap testing among a non-ethnic sample of socioeconomically
disadvantaged women undergoing routine cervical cancer screening and to assess their
specific information needs, data showed considerable knowledge deficits among
socioeconomically disadvantaged women undergoing screening51. In West Virginia, a study
assessing the awareness of breast and cervical cancer among Appalachian women , a focused
group discussion was conducted , overall participants were more knowledgeable about breast
cancer than cervical cancer.
51
However they were able to identify the screening tests
associated with both cancers. A survey conducted in an Indian community undertaken as part
of KAP study prior to initiation of cytological screening , total women interviewed were 1411
selected through a two stage stratified random sampling. Subjects consisted of a group of
women who had reported previous gynaecological problems related to cervical cancer. The
study results that younger women had better awareness and knowledge about cervical cancer;
literacy status and exposure to family planning was influential in creating awareness about
cervical cancer ,treatment seeking behaviour due to other gynaecological problems also leads
to increased awareness.
52
Evidence suggests that women’s knowledge about cervical cancer
22
and preventive strategies are significant to their screening practices. 53 In a study54 conducted
in Ghana 175 respondents between the ages of 18 and 56 years old were interviewed. One
hundred and sixty four (93%) respondents have heard of cervical cancer but only 65 (37%)
had adequate knowledge about the disease, of those with adequate knowledge nurses and
medical students were in the majority. Regarding the aetiological factors for cervical cancer
72 respondents (41%) mentioned multiple sexual partners and 63 (36%) thought that vagina
douching and insertion of substances into the vagina increased the risk of cervical cancer.
Forty (23%) had no idea about the aetiological factors of cervical cancer. In Nigeria a study
done in Ibadan GOPD of University college hospital , 264 women were randomly selected
aged 20 to 65 years , 90% had heard of cancer at one time or the other while only 15% have
heard about cervical cancer. The media (38%) and peers (36%) were their major source of
information on cancer. Fifty Five percent had no knowledge , 30% and 15% had poor to
moderate overall knowledge of cervical cancer. Knowledge about cervical cancer is poor
compared to developed countries and there is need to educate our women on the early
warning signs of cervical cancer.55 Women generally recognise screening for cervical cancer
as an important health behaviour. In the United States women undergoing cervical cancer
screening suggests that they are aware they should be screened , however they may lack basic
understanding of the process, its limitations and interpretation of the results . The more
knowledgeable women are about Pap smear the more likely they are to go for screening56 and
to obey instructions on follow up for an abnormal result.
57
Studies of knowledge and
understanding among women experiencing an abnormal Pap test results have found that
women had insufficient knowledge about abnormal results and follow up procedures such as
colposcopy, and many were dissatisfied with the information they received about their
results. Research on adolescents and college students
60
understanding of cervical cancer
screening and Human papilloma Virus (HPV) among these group is poor. Women belonging
23
to ethnic minority group and those of low socio-economic group who lack health insurance
yet undergo cervical cancer screening, but are largely understudied. These women are at an
increased risk of developing cervical cancer .61In a study to evaluate knowledge to evaluate
knowledge regarding Pap testing among ethnic minority women undergoing routine cervical
cancer screening and to elicit their specific information needs , data showed significant
knowledge deficit s among women of low socioeconomic group undergoing screening.64In a
study assessing the awareness and knowledge of breast and cervical cancer among
Appalachian women (in West Virginia, U.S) a focus group discussion was conducted.
Participants were more knowledgeable about breast cancer than cervical cancer. They
wereable to the screening tests associated with both types of cancer. Younger women were
more uncertain as to the frequency and purpose of testing than older women.65In a study of
310 medical workers in Uganda , knowledge of Pap smear was 83% among responders . Less
than 40% knew the risk factors for cervical cancer.
66
In a study of Rush dysplasia clinic ,
38% were unaware that they had an abnormal pap test as the reason for referral , and 51% did
not know that a pap screening tested for precancer cells.
and Australia
69
67
Surveys both in United states 68
have demonstrated that the accuracy of knowledge of cancer risks is
positively associated with educational level. Studies of knowledge before and after
educational campaigns have shown that multifaceted education efforts can improve screening
rates in low income populations
70
. Along with education comes knowledge of risk factors
and perception of disease severity and health impact for cancer. In a study of knowledge
,attitude and practices of cervical cancer screening among two hundred and ninety female
Lebanese / American women , both educational level and economic status were positively
associated with knowledge about the purpose of cervical cancer screening.71
In Sweden , improvements in public and professional awareness of cervical cancer resulting
in diagnosis at earlier clinical stages has been shown to increase the 10year survival rates
24
from 33% in the 1930s to about 55% in the 1950s.72In the university College Hospital Ibadan
, it was found out that self referrals for pap smear were significantly better among the
educated (66% with post-secondary education.) than those who came on the basis of referral.
Additionally a little over half of the referral cases had no knowledge of cervical cancer
screening although about one third of them had undergone the procedure in the
past.73Awareness of the procedure does not necessarily suggest a clear understanding of its
use. Despite a high level of awareness among Nigerian self – referrals in the University
College Hospital, Ibadan, (79%) who knew the name of the procedure as ‘’Pap smear’’
Knowledge of the objective was poor. Only 25% agreed that cervical cancer screening was
for early detection of the cancer of the ‘’womb ‘’. (67%)
ATTITUDES TOWARDS CERVICAL CANCER SCREENING.
Different attitudes towards cervical cancer screening exist for various populations and
Population subgroups. Pap smear testing is cumbersome, uncomfortable and embarrassing to
the patient. Investigators suggested self testing for Human pappilomavirus as an alternative.
In a study in 1995 knowledge attitude and practise survey of 290 members of the American
Red Cross in Lebanon , a significantly higher number of women with poor and average
perceived economic status , compared with good or very good status , cited embarrassment
and costs as obstacles to seeking screening.
64
It is clear from research into cancer behaviour
in numerous countries, that the core perception of cancer is deeply embedded within the
cultural context.
74
Cultural beliefs also influence cancer prevention behaviour as many
Chinese – Australian women had a fatalistic attitude towards cancer and did not perceive
cancer prevention strategies as useful. (68%) The perception that cancer cannot be avoided or
prevented has been found in studies of groups as diverse as African – American women in the
United states
75
, Vietnamese women in the living in America,
25
76
the Greek community
established in Australia (70) and the Australian indigenous women living in remote regions.77
In a study between August 2000 and July 2002, 148 consecutive women with invasive
cervical cancer were queried about barriers to screening
78
. It was found that fatalistic
attitude, lack of family support, and lack of information about the risk of cervical cancer have
a significant association with lack of screening in women presenting with cervical cancer.
Studies addressing fatalism as a barrier to cervical cancer screening have compared general
Hispanic and Caucasian populations using telephone interviews.
79 , 80, 81)
. Hispanic
populations with suboptimal pap tests screening have consistently stated that they would not
want to know if they had cervical cancer and they were more likely to believe cancer is a
death sentence or God’s punishment and to believe that there is little one can do to prevent
cancer. 81
Financial barriers to screening have been easily identified and have received tremendous
national attention. Lack of family support contributed to non – compliance with cervical
cancer screening. Another study including focus group discussion of cancer prevention
strategies in low income urban women found that these women consistently prioritised care
for their families over care for themselves .
82
A study in Ibadan , Nigeria , revealed that
women attending cervical cancer screening clinic expressed more positive attitude towards
cervical cancer screening than control group. A significantly higher proportion than control
group agreed to attend regularly for screening .The commonest reason given by clinic
attenders for the rather poor patronage of cervical screening service was , the people were
ignorant of the availability and usefulness of the procedure. In another study to evaluate
factors associated with awareness of pap test, intention to do it and its receipt in Vietnamese
– American women in Santa Clara county,in California in which 1,556 women participated .
74% has heard about the test and 76% has had at least one test. Only 42% of those who had
not done the test considered doing the test. Women aged 65 and above had the lowest rate for
26
all three outcomes. For all women younger age , being married ,having requested a pap test
,physician recommendation , and having a female stand by if the doctor was male were
associated with pap test intention.Beign married , having a higher education , having a female
doctor , having a respectful Doctor, having requested the test , physician recommendation
were associated with taking the test.[83][84]A study was carried out among Chinese – American
women to examine beliefs and pap test utilization sixty eight percent reported having a pap
test in the past three years , and eighty four percent reported ever having a pap test. The odds
of pap test use and adherence decreased with increasing age.85
UTILIZATION OF CERVICAL CANCER SCREENING.
There is a significant difference in the extent of screening worldwide and this reflects the
degree to which screening programme have succeeded or failed to reduce mortality from
cervical cancer. Generally it was noted that there is an increase in participation in various
review studies.
83
Cervical cancer screening was introduced into the United States over 60
years ago; pap smear testing has led to a 90% decrease in mortality from cervical cancer. 80
Despite implementation of many state and national screening programmes , cervical cancer
screening rates stabilized in the late 1980s and did not increase significantly in the 1990s
.84Furthermore, approximately half of the women diagnosed with cervical cancer reported
suboptimal screening. A study of 664 Connecticut residents diagnosed with cervical cancer
between 1985 and 1990 also showed a high non-compliance rate with any prior Pap test
screening. Mean age in the non-screened population was 64 years compared with 46 years in
the screened population. 83 A third of Norwegian women aged 25 -69 years invited to have a
pap smear do not attend during the recommended period and thus constitute a population with
high risk of cervical cancer. 84 From 1993 to 2003, there was a steady increase in the number
27
of pap smears in US , with an estimated 66.6 million tests performed in 2003 .84
Socioeconomic status is an important reason for the differential use of the smear test. A study
among socio –economically disadvantaged older women showed income to be closely
correlated with cervical cancer screening participation.83 In South Africa, the rate of previous
screening for cervical cancer among unemployed women compared with that of women
earning an income rose from 8% to 25%.69
Generally people in lower social; class partake less in screening compared to women of
higher social group. In the United States between 1987 and 2000, the proportion of women
aged 25 years and older who had a recent screening test increased by 11% in all racial groups
combined. The lowest rates were found among African –American women(4%) and the
highest rate of increase occurred in Hispanic women.
59
In a KAP (Knowledge, attitude and
practices) study of Nigerian women on cervical cancer, 85 % of the studied population
demonstrated very poor knowledge and a negative attitude to the utilization cervical cancer
screening service. This is associated with strong cultural and religious reasons and the non –
availability and poor information about cervical cancer screening. The poor advocacy and
poor manpower were identified as the cause of the continued high prevalence of the cancer of
the cervix in Nigeria.
72
In a study carried out in Lagos University Teaching Hospital
(LUTH). 884 consecutive women had clinical smears in a clinic in Lagos , Nigeria between
September 1998 and 31 August 1999 , most of the patients were having a cervical smear for
the first time. (84)
28
CHAPTER THREE.
MATERIALS AND METHOD.
BACKGROUND.
Ajah is a suburban settlement located in Etiosa East local council development area of Etiosa
local Government, of Lagos state. It is bounded in the North by Lagos Lagoon , South by
Ikota village adjoining the Atlantic Ocean , east by Sangotedo village and the west by the
Aiyetoro Stream. It comprises of three major settlements ,Ajah- Makarios , Thomas village
and Okera – Addo. The Ajah people are predominantly from the Awori Yoruba subgroup,
interspersed with a large immigrant population from different states of Nigeria. The
cosmopolitan nature of Ajah also attracts immigrants from the West African sub region e.g.
Ghanaians , Liberians , Sierraleonians and others. There is little industrial activity in Ajah,
hence the indigenes are mostly fishermen, farmers and traders. However, non-indigene
settlers are either white collar workers or entrepreneurs running their own business at
different levels. The population of Ajah was estimated to be 1080056 by the Etiosa east local
government area.
STUDY DESIGN.
This was a descriptive cross sectional study.
STUDY POPULATION.
The study population was women of reproductive age group, i.e women between the ages of
15 and 49 years of age. The study population included only residents living in Ajah.
29
SAMPLE SIZE ESTIMATION.
The
sample
size
was
determined
using
the
formula
below
n = z 2 p(1-p)
d2
n = minimum sample size required for study,
Z = standardized deviate at 95% confidence level i.e 1.96.
P = prevalence of cervical cancer screening 39% 56
q = estimated proportion unscreened ( 1 – P ).
d = tolerable error margin (a measure of precision) 5% = 0.05.
n = 1.96 x 1.96 x 0 .61 x 0.39
0.05 x 0.05
Sample size (calculated) was 366.
The sample size used in the study was 402 , additional 10% was added to correct for non response during study.
30
,
SAMPLING METHOD.
A multistage sampling method was used to select the respondents for this research. There are
3 settlements in Ajah with a total of 27 streets. These are Ajah – makarios, Thomas village
and Okera –Addo. The settlements have 9, 10 and 8 streets respectively. Four streets were
selected from each settlement by simple random sampling.The houses in each of the selected
streets were numbered 1 – 269, 1- 270, 1- 272 respectively according to the three settlements.
The starting point on the first street of each area was determined by balloting between the
highest and lowest numbered house; after choosing the first house we continue in ascending
or descending order depending on the number of the first house chosen. Each area was
proportionately allocated 134 respondents because the difference in size of the 3 settlements
was not very much. Only one woman was interviewed in each house . In situations with more
than one woman balloting was done to select one of them. In a house with no woman of
reproductive age, we moved to the next house in our samples.
ETHICAL CONSIDERATIONS.
Permission to carry out study was obtained from the Baale of Ajah before data collection.
Verbal informed consent will be obtained from respondents
before questionnaire was
administered to the respondents and confidentiality was maintained throughout the study.
DATA COLLECTION.
The study was carried out using interviewer administered questionnaire, the questionnaire
was composed of closed and open ended questions. Two interviewers were trained to assist
the researcher in administering the questionnaire . The questionnaire was be administered in
the evenings and on weekends to ensure that the women were at home. Each interview lasted
31
20 minutes. The questionnaire consisted of a total of 37 questions which were divided into 4
sections . The first section dealt with socio-demographic data, second section addresses
knowledge, the third section dealt with attitude while the fourth section involved utilization
of cervical cancer screening. Pretest was carried out in Sangotedo community which is
similar to Ajah and 20 women were interviewed.
ANALYSIS.
The data collected was analysed using the EPI INFO 2000 computer software. In determining
level of knowledge of cervical cancer screening, out of a total of 15 questions each question
was assigned a score of 1 , those who score 4 and below are considered as having poor
knowledge . A score of between 5 and 9 are rated fair knowledge and those who scored
between 10 – 15 were considered good knowledge; 15 marks is scored 100 percent. Attitude
and practice was also analysed to asses response to cervical cancer and its screening methods.
Knowledge attitude and practise was cross tabulated with educational level and level of
income.
Chi-square
test
of
significance
significance.
32
was
carried
out
to
test
CHAPTER FOUR.
RESULTS
TABLE 1. AGE DISTRIBUTION OF RESPONDENTS.
AGE GROUP.(YRS)
FREQUENCY
PERCENTAGE.
15 - 19
64
15.9
20 - 24
37
9.2
71
17.7
25 - 29
30 - 34
79
19.7
35 - 39
61
15.2
40 - 45
53
13.1
37
9.2
402.
100.
46 - 49.
TOTAL.
Nineteen point seven percent of respondents were aged between 30 – 34 years ,while fifteen
point two percent are aged 35 – 39 years. Mean age was thirty one point two years and
standard deviation is 9.4
33
TABLE 2. DISTRIBUTION OF RESPONDENTS BY MARITAL STATUS.
MARITAL STATUS.
FREQUENCY.
PERCENTAGE.
Married.
188
46.8
Single.
171
42.5
Divorced.
19
4.7
Widowed.
22
5.5
Others.
2
0.5
TOTAL.
402
100.
Forty six point eight percent of the respondents were married and forty two point five percent
were single women. Only four point seven of the respondents were divorced.
TABLE 3. DISTRIBUTION OF RESPONDENTS BY RELIGION.
RELIGION.
FREQUENCY.
PERCENTAGE.
Christian.
236
58.7
Islam.
149
37.1
Traditional.
6
1.5
Others.
11
2.7
Total.
402
100.
Majority of respondents were Christians (58.7%) while the Muslims make up 37.1% of the
total.
34
TABLE 4. DISTRIBUTION OF RESPONDENTS BY HIGHEST ACADEMIC
QUALIFICATION.
HIGHEST
ACADEMIC
QUALIFICATION.
FREQUENCY.
PERCENTAGE.
Primary.
61
15.1
Secondary.
148
37
Tertiary.
141
35
Others.
7
1.7
None.
45
11.2
Total.
402.
100.
Thirty seven percent of the respondents have secondary education, while thirty five percent
have had tertiary education. Eleven point two percent of the respondents did not have any
formal education.
TABLE 5. DISTRIBUTION OF RESPONDENTS BY ETHNIC GROUP.
ETHNIC GROUP.
FREQUENCY.
PERCENTAGE (%)
Hausa.
38
9.5
Yoruba.
150
123
37.3
30.6
Others.
91
22.6
Total
402
100.
Ibo
Thirty three point seven of the respondents are of the Yoruba ethnic group, the Ibos constitute
thirty point six percent of the total. The Hausa ethnic group makes up only nine point five.
35
34.
TABLE 6. DISTRIBUTION OF RESPONDENTS BY INCOME LEVEL.
INCOME PER MONTH.
FREQUENCY
PERCENTAGE (%)
Less than 10000
123
30.6
11000 – 50000
142
35.3
51000 - 100000
78
19.4
101000 - 150000.
34
8.5
25
402
6.2
100
Above 150000
Total
Most of the respondents earned between N10000 and N 50000 (62.8%), while 25.6% of the
total earned between N51000 and N100000.
TABLE 7. RESPONDENTS FIRST SOURCE OF INFORMATION ABOUT
CERVICAL CANCER.
SOURCES.
FREQUENCY.
PERCENTAGE (%)
Radio
38
23.
TV
10
6
Newspaper,
11
6.6
Health worker.
91
54.8
School
10
6
Others
6
3.6
TOTAL.
166
100
The major first sources of information with respect to cervical cancer were health
worker(54.8%) and radio (23%).
36
TABLE 8. RESPONDENTS KNOWLEDGE ABOUT CERVICAL CANCER .
STATEMENT.
CERVICAL CANCER IS
COMMON IN NIGERIA
FREQUENCY. (N =166)
96
IT IS POSSIBLE TO
DETECT CERVICAL
CANCER EARLY?
PERCENTAGE(%)
57.8
86.1
140
84.3
CERVICAL CANCER IS
TREATABLE.
143
EARLY DETECTION
INCREASES CERVICAL
CANCER SURVIVAL.
91
54.8
Greater than half (57.8%) of the respondents who had heard of cervical cancer ( N = 166)
were aware that it is common in Nigeria. A majority (86. 1%) of those who were aware of the
ailment knew that it can be detectable early and that early detection will improve chances of
survival.
TABLE 9 AWARENESS OF RESPONDENTS ON CERVICAL CANCER
SCREENING METHODS.
SCREENING METHOD.
FREQUENCY. ( N =158)
PERCENTAGE (%)
Pap Smear.
125
79.1
HPV Test.
80
50.6
VIA
10
6.3
Colposcopy.
14
8.9
Others.
9
5.7
(Multiple responses allowed.) Out of those that have heard about cervical cancer screening,
79.1% of the respondents had heard of Pap smear while 50.6% heard about HPV test .
37
TABLE 10. DISTRIBUTION OF RESPONDENTS BY FIRST SOURCE OF
INFORMATION ON CERVICAL CANCER SCREENING METHODS.
SOURCE.
FREQUENCY. (N=158)
PERCENTAGE(%)
Radio.
28
17.7
TV.
21
13.3
Newspaper.
8
5.1
Health worker.
63
39.9
School
14
8.9
Others
7
4.4
(Multiple responses allowed.)The most common source of information on cervical cancer
screening is the health worker(39.9% ) then the radio (17.7%)
TABLE 11. AWARENESS OF RESPONDENTS ON PLACE WHERE CERVICAL
CANCER SCREENING CAN BE CARRIED OUT.
PLACE
FREQUENCY (N =166)
PERCENTAGE.
Primary health centre
9
5.4%
General hospital
35
21.1%
Teaching hospital
97
58.4%
Private hospital
20
12%
Mission hospital
16
9.6%
Others
5
3.0%
(Multiple responses allowed) The commonest place chosen by respondents where cervical
cancer screening is done is the teaching hospital (58.4%) and general hospital (21.1%)
38
TABLE 12. KNOWLEDGE OF RESPONDENTS ON THE RISK FACTORS FOR
CERVICAL CANCER.
RISK FACTORS.
Early onset sexual activity.
Having multiple sex partners
Having ones first child by
age 30 and above.
Past history of STIs.
Having many children.
Old age above 45.
Smoking
Others
Don’t know
FREQUENCY (N =166)
112
129
45
PERCENTAGE. (%)
67.5
77.7
27.1
39
66
106
115
34
138
23.5
39.8
63.9
69.3
20.5
83.1
(Multiple responses allowed.)
Most of the respondents (77.7%) were aware that having multiple sexual partners is a risk
factor for cervical cancer. Other risk factors respondents selected included early onset of
sexual activity (67.5%). 39.8% respondents chose having many children , while 83.1%
respondents could not identify any risk factor for cervical cancer.
39
TABLE 13. RESPONDENTS AWARENESS OF SIGNS AND SYMPTOMS OF
CERVICAL CANCER.
FREQUENCY
SIGNS AND SYMPTOMS
(N =166 )
PERCENTAGE.(%)
Painful menstruation
88
53
Irregular menstrual flow
99
59.6
Bleeding after intercourse
132
79.5
Foul smelling vaginal
discharge
97
58.4
Weight loss
65
39.2
Others
37
22.3
Don’t know
105
63.2
(Multiple responses allowed.) 79.5% of respondents correctly identified bleeding after sexual
intercourse as a likely symptom of cervical cancer , and 53% mentioned painful menstruation
as a symptom of cervical cancer.
TABLE 14. NUMBER OF SEX PARTNERS AMONG RESPONDENTS.
SEX PARTNERS EVER
HAD.
FREQUENCY.
PERCENTAGE. (%)
1
183
64.7
2
70
24.7
>2
30
10.6
TOTAL
283
100.
Greater than half of the respondents (64.7%) say they have only one sexual partner.
40
TABLE 15. OVERALL ASSESMENT OF KNOWLEDGE ON CERVICAL CANCER
SCREENING.
KNOWLEDGE
FREQUENCY
Good
PERCENTAGE.
84
20.9%
Fair
141
35.1%
Poor
177
44%
TOTAL
402
100%
Forty four percent of respondents had poor knowledge of cervical cancer screening, while
20.9% had a good knowledge of cervical cancer screening.
TABLE 16. WILLINGNESS OF RESPONDENTS TO PATICIPATE IN HEALTH
EDUCATION PROGRAMMES/MASS SCTREENING FOR CERVICAL CANCER.
RESPONSE.
Willingness to participate in
FREQUENCY. (N =166)
PERCENTAGE. (%)
112
96
99
59.6
health education.
Willingness to participate in
mass screening.
About 96% of respondents were willing to participate in health education programme
towards preventing cervical cancer , while more than half of respondents were willing to
participate in mass screening programme for cervical cancer
41
TABLE 17. UTILIZATION OF CERVICAL CANCER SCREENING METHODS
AMONG RESPONDENTS.
SCREENING METHOD
FREQUENCY (N = 122)
PERCENTAGE.(%)
Pap Smear
54
44.3
VIA
34
27.9
HPV
22
18
Others
12
9.8
44.3% of the respondents have been screened by pap smear, 27.9% have had VIA, while
only 18% did HPV screening test.
TABLE 18. VARIOUS REASONS GIVEN BY RESPONDENTS FOR NOT DOING
TEST.
REASONS.
FREQUENCY (N=236)
PERCENTAGE(%)
I have not thought about it.
60
25.4
I will do it when Iam older.
70
29.7
Iam not aware of test for
cervical cancer screening.
115
48.7
Iam afraid I may be
diagnosed for cancer.
75
31.8
I don’t have money for the
test.
38
16.1
Others
65
27.5
(Multiple response allowed.)25.4% of the respondents who have not done the test have not
thought about doing the test , while 29.7% say they will do it when older. 16.1 %
ofrespondents gave finances as reason for not doing the test.
42
TABLE 19. KNOWLEDGE OF CERVICAL CANCER SCREENING BY AGE.
AGE
15 – 19
20 – 24
25 -29
30 – 34
35 – 39
40 – 44
45 – 49
TOTAL.
POOR
40
62.6%
9
24.%
15
21.1%
11
13.9%
23
37.7%
47
88.7%
32
86.5%
177
44%
FAIR
15
23.4%
15
41.%
32
45.1%
GOOD.
9
14%
13
35.%
24
33.8%
TOTAL.
64
15.9%
37
9.2%
71
17.7%
42
53.1%
35
57.3%
1
1.9%
1
2.7%
141
35.1%
26
33%
3
5.%
5
9.4%
4
10.8%
84
20.9%
79
19.7%
61
15.2%
53
13.1%
37
9.2%
402
100%
Chi – Square = 25.28
Degree of freedom = 7
P – Value = 0.00032 . There is no association between knowledge of cervical cancer
screening and age of respondents. ( P <0.05.) The calculated Chi – square value is higher than
the table value.
43
TABLE 20. KNOWLEDGE OF CERVICAL CANCER SCREENING BY HIGHEST
ACADEMIC QUALIFICATION OF RESPONDENTS.
HIGHEST
POOR
ACADEMIC
QUALIFICATION.
FAIR
GOOD
TOTAL
Primary
51
9
1
61
83.6%
14.8%
1.6%
59
61
28
39.9%
41.2%
18.9%
41
60
40
29.1%
42.6%
28.3%
0
2
5
0%
28.6%
71.4%
26
9
10
57.8%
20%
22.2%
177
141
84
44%
35.1%
20.9%
Secondary
Tertiary
Others
None
TOTAL.
Chi – square = 22.28
P – Value =
148
141
7
45
402
Degree of freedom = 7
0.0003
There is an association between knowledge of cervical cancer screening and academic
qualification ( P < 0.05) . Those with secondary(36.8%) and tertiary education(35.1%) had
better scores compared with those with primary education and those with none.(11.2%)
44
TABLE 21. PRACTISE OF CERVICAL CANCER SCREENING BY HIGHEST
ACADEMIC QUALIFICATION.
HIGHEST
YES
ACADEMIC
QUALIFICATION
NO
TOTAL
Primary
11
50
61
18%
82%
49
99
33.1%
66.9%
94
47
66.7%
33.3%
1
6
14.3%
85.7%
9
36
20%
80%
164
238
402
40.8%
59.2%
100%
Secondary
Tertiary
Others
None
Total
Chi – square = 27.24
148
141
7
45
Degree of freedom = 6
P value = 0.0007.There is no association between highest academic qualification and
practise of cervical cancer screening. (P <0.05). Those with secondary(36.8%) and
tertiary(35.1%)education are more likely to go for screening compared to those with primary
education.(15.2%)
45
CHAPTER FIVE.
DISCUSSION.
The objective of this study was to determine the level of knowledge , attitude and practise
towards cervical cancer screening in Ajah community of Etiosa local government area of
Lagos State among women of child bearing age. Mean age of the respondents was 31.2years
and 58.7% of the respondents were Christians with 46.8% are married while 42.5% are
single women.
Thirty seven percent of the respondents have had secondary education
while 35% have had tertiary education. The prevalence rate of cervical cancer is in high in
Nigeria .82 However only Forty one point three percent of the respondents have heard about
cervical cancer .
This is lower than a study in Singapore in which 73.1% of the total
respondents were aware of cervical cancer .
66.
This high level of awareness noticed in
Singapore may not be unconnected with their high literacy level (94.2%)
82
compared to
Nigeria.In a study conducted in University of Lagos it was observed that the level of
awareness of cervical cancer was 63. 9% .87 This higher level of awareness can be attributed
to the fact that these respondents were highly educated women who have an unfettered access
to information.This study contrasts with the low levels noticed among refugees in Oru camp
(22%), market women in Ibadan (40.8%) , general outpatient clinic attendees in Ibadan
(15%), and women in Maiduguri(10%)[88][89][90] [91].
It was also observed in a study in Hong Kong that women educated to a higher level are more
likely to have a better knowledge of cervical cancer screening and are more willing to
participate in cervical cancer screening . Women with a higher level of education are more
likely to gather new information by themselves or have a faster channel to reach up to date
information especially in this era of the internet and the ease of accessing information.
85
In this study 39.8% of respondents have heard about cervical cancer screening, thispercentage
is higher than a study in University College Hospital (UCH) , Ibadan in which only 25%
46
ofthe women agreed that cervical cancer screening is for early detection of cancer of the’’
womb’’73 , while the knowledge of the screening methods varied with more being aware of
the pap smear (78.6%%) compared to any other methods like HPV and VIA. This contrasts
sharply with a high level of awareness found among female university staff and students in
the United Kingdom and Accra , Ghana. (93%)99 Visual inspection with acetic acid is of
particular interest to developing countries like Nigeria because it is inexpensive and a low
tech way of screening for cervical cancer and nly requires supplies usually locally available
and can be competently performed by non – hysicians and lay persons who are trained in the
interpretation of the results observed.52 In this study only 6.3% of respondents have heard of
VIA, this is very low compared to other screening methods (Pap Smear(79.1%) and HPV
tests(50.6%) ). This brings to the fore the need for effective publicity by the government and
other well meaning organisations on the very cost effective method like VIA. Health care
workers need to be trained on the performance and the interpretation of VIA results and this
can be incorporated into our primary health care scheme so that cervical cancer screening can
be carried out at grassroots level.
In this study it was observed that knowledge of cervical cancer screening was higher among
espondents with secondary (18.9%) and tertiary education (28.3%) compared to those with
primary education. Respondents with primary education have the poorest knowledge about
cervical cancer screening , hence level of education and exposure plays an important role in
the knowledge of cervical cancer. The association between knowledge of cervical cancer
screening and academic qualification was also demonstrated in a 1995 survey of knowledge
,attitude and practise of cervical cancer screening among two hundred and ninety female
Lebanese – American women , both educational level and socio-economic status were
positively associated with knowledge of the purpose of cervical cancer screening.71
47
The commonest source of information on cervical cancer and cervical cancer screening is the
health worker(54.8%) similar to a study in Singapore where most of the respondents had
obtained information on cervical cancer screening from a doctor or nurse73 .Promotion
strategies ought to be channelled through media that are appropriate to reach women with less
education. Publicity through different means should be considered such as TV and radio.
Health education through lay personnel has also been used among Vietnamese- American
women .86 It was also observed that women as information seekers are more likely to receive
and act on an information gathered from a health worker they are used to and possibly trust.
Health workers have a very important role in spreading the news about certain ailments like
cervical cancer and interventions that can be used to prevent the disease and stop the spread.
Qualitative research showed that women enjoy learning from and with other women ingroups
or one – on – one . Women seldom receive adequate information about cervical
cancerscreening in clinics.
47
In another study in Gwagwalada , .Nigeria
93
, the sources of
information for cervical cancer includes health worker, television , Next of kin, friends,
magazines, and school in the order of importance in that geopolitical zone , this compares
with our finding which shows that the health worker is the most important source of
information on cervical cancer.There is an association between knowledge of cervical cancer
screening and academic qualification.
42.6% of those with tertiary education had fair
knowledge of cervical cancer compared to those with lower levels of education. This may be
due to the fact that education plays a part in health seeking behaviour of human beings
generally. The more knowledgeable the women are about cervical cancer screening the more
likely they are to go for the test.45
In this study knowledge of risk factors for cervical cancer was identified as follows: ( early
onset sexual activity 45.3 % and multiple sex partners 32.1% ). This level of knowledge
(45.3% and 32.1% ) may be attributed to recent emphasis paid to cervical cancer in
48
themedia and the drive by governments and non – governmental organisations for free
cervical cancer screening.Respondents awareness of signs and symptoms of cervical cancer
was relatively poor with 30.8% mentioning painful menstruation as a symptom and 45.2%
citing irregular menstrual flow; only 32.8% mentioned bleeding after intercourse as a
symptom of cervical cancer. This is said to be one of the commonest manifestations based on
a study in Lagos.
73
Overall knowledge of cervical cancer screening among those who have
heard of cervical cancer was poor ( 44%) . Only 20.9% of respondents had good knowledge
of cervical cancer screening and 35.1% had fair knowledge of cervical cancer screening .
This may be attributed to the fact that a large number of respondents (58.7%) have never
heard about cervical cancer demonstrated in table 7.With respect to attitude towards cervical
cancer screening , various reasons were adduced for not doing the test ; 30.3% had not
thought about it and a 21.7% plan to do it when they are older. Many people who have not
given a thought to doing the test will probably lack adequate education on the importance of
screening for the disease.A study in Ibadan showed that the commonest reason given by
clinic attendees for the rather poor patronage of the cervical screening service was’’ the
probability of people being ignorant of the availability and usefulness of the procedure.’’ .
Along with education comes knowledge of risk factors and perception of disease severity and
the health impact of cervical cancer. A study of knowledge and attitude of GOPD attendance
in UCH Ibadan shows that perception of cancer severity is an important factor in compliance
with screening and overshadowed the impact of income and baseline education.55A number
of women were afraid of being diagnosed with cervical cancer (13.6%), slightly greater than
half (54.8% ) of the respondents believed that early detection will improve chances of
survival . The perception that cancer cannot be cannot be cured or prevented has been found
in studies or of groups as diverse as African – American women in the United States.75
Vietnamese women living in America
76
, Greek community established in Australia
49
70
. and
Australian indigenous women living in remote regions .
77
Opinions on cervical cancer
screening methods vary , although Pap smear test is the most common test done among the
respondents in this study . thirty one point one percent of respondents say they are aware of
Pap smear test. , this is closely followed by HPV test and VIA . This is a bit surprising since
HPV test is slightly expensive compared to the other tests.In a 1995 Knowledge attitude and
practise survey of 290 female members of the American Red cross in Lebanon , a
significantly high number of women cited embarrassment and high costs of test as obstacles
to seeking screening. 64
This study did not deviate much from the results of a KAP ( Knowledge , attitude and
practise ) of Nigerian women on cervical cancer where 85% of the studied population
demonstrated very poor knowledge and a negative attitude to the utilization of of cervical
screening service .82 The poor advocacy and poor manpower training were identified as the
cause of the continued high prevalence of cancer of the cervix in Nigeria.The willingness of
women of child bearing age to participate in the study in a mass screening programme on
cervical cancer is encouraging (52.7% ) . About 76.4% are also willing to participate in a
health education programme towards preventing cervical cancer. This finding is similar to
that found in a study in a study of females in Oshodi /Isolo local government Area where
slightly more than 50% of the respondents indicated a willingness to participate in
a
screening exercise for cervical cancer. In the same study more than half of the respondents
were willing to participate in a health education programme for cervical cancer screening.82
Only about 31.1% of respondents have had pap smear and 17% have had other modes
(HPV/VIA ) .
This level of utilization is very small compared to a study in Minnesota in which 95% of
respondents have had at least a pap smear.
83
This low level of utilization is similar to a
study in Lagos , Nigeria in which out of eight hundred and eighty four (884) consecutive
50
women who had clinical smears in a clinic in Lagos, Nigeria between September 1998 and
31st August 1999, most of the patients were doing the test for the first time .
84
In a study of
screening practise of women in Nicaragua reveals that coverage of the current screening
programme was low . Fifty eight percent of women who were sexually active had had a pap
test , but only 41% had had the test within the last three years and could be considered as
adequately screened, of greater concern is that nearly one third of the target population was
reluctant to attend screening programme in the future. This is particularly so for women who
were inadequately screened , the population most at risk for cervical cancer.92
In another study of cervical cancer screening in Nigeria female market women population in
Ibadan showed that inspite of considerable risk of developing cervical cancer among market
women only 5.2% of them have had a previous Pap smear done.90 Also in the study of
refugees in Oru camp in Ogun state only 6.8% reported that they have had pap test in the
past.91 This figure is very low compared to our study probably because of the low level of
education among respondents.The study also observed that respondents are willing to discuss
with others issues relating to cervical cancer screening, this will also go a long way to spread
the message about cervical cancer to the populace . It has also been observed from the study
that level of education affects performance of cervical cancer screening. This finding
issimilar to a 1995 survey of two hundred and ninety five (295) females of the American red
cross in Lebanon.71. Hence there should be an increased literacy drive by the government and
non – governmental organisations , female education and enrolment in schools should be
encouraged and mass screening programmes needs to be introduced in Nigeria and
adequately strengthened.
51
CONCLUSION.
The level of knowledge of cervical cancer is generally poor among women of reproductive
age group studied in Ajah. Only 20.9% of the respondents have good knowledge , 35.1%
have fair knowledge and 44% have poor knowledge .The level of awareness of respondents
on the different cervical cancer screening methods was also at a low level with 75.3% of
those who have heard about cervical cancer screening, being aware of Pap smear as a
screening method , 48.2% was aware of HPV test while 6% are aware of VIA. Attitude to
screening can be said to be encouraging as 96% of the respondents were willing to participate
in health education programme towards preventing cervical cancer, while slightly more than
half of the respondents are willing to participate in mass screening for cervical
cancer.(59.6%).Thirty four point one percent of respondents have been screened for cervical
cancer, hence the rate of utilization of cervical cancer screening is very low in this
community.
52
RECOMMENDATIONS.
1. An intensive health education programme focusing on lifestyles that predispose to
cervical cancer and other diseases , for example poor personal hygiene , early age of
starting coitus , multiple sexual partners as well as creating awareness on places
where screening can be carried out should be incorporated in the health education
curriculum in our health care centres.
2. Cervical cancer screening should be incorporated into our Primary health care
delivery as is done in other countries in order to improve access to utilization of
cervical cancer screening , since PHC is the nearest health care delivery agency to the
grassroots.
3. Judicious use of mass media should be harnessed in disseminating information on
cervical cancer and its screening to the populace especially the radio since it has been
identified as the second most frequent way people get information on cervical cancer
in the area.
4. Faith based organisations and women associations can also be involved in the fight
against cervical cancer. Churches and Mosques can be used to disseminate
information to their members on the need for women to undergo cervical cancer
screening. Some of these organisations can also be encouraged to organse cervical
5. The government can also collaborate with NGO,s and the private sector to ensure that
cervical cancer screening is is very affordable or done free even in private hospitals,
since a large number of people patronise private hospitals.
53
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62
QUESTIONNAIRE
KNOWLEDGE AND UTILIZATION OF CERVICAL CANCER SCREENING
AMONG WOMEN OF CHILD BEARING AGE IN AJAH, ETIOSA LOCAL GOVT.
AREA OF LAGOS STATE.
Iam a student of college of medicine university of Lagos , undertaking a study on the above
named subject as partial fulfilment of the requirements for a masters degree in public health. I
shall be grateful if you can answer the questions succinctly and correctly. No name is
required and all information will be treated as confidential.
SECTION A.
SOCIO-DEMOGRAPHICDATA.
1. AGE
a) 15 – 19
b) 20 – 24
c) 25 – 29
d) 30 – 34
e) 35 – 39
f) 40 – 44
g) 45 - 49
2. MARITAL STATUS.
a) Single
b) Married
c) Divorced
d) Widowed
e) Others (please specify)
63
3. RELIGION.
a) Christianity
b) Islam
c) Traditional
d) Others (please specify)
4. HIGHEST ACADEMIC QUAIFICATION.
a) Primary
b) Secondary
c) Tertiary
d) Others (please specify)
e) None
5. ETHNIC GROUP.
a) Hausa
b) Yoruba
c) Ibo
d) Others (please specify)
6. MONTHLY INCOME. -----------------------
64
SECTION B.
KNOWLEDGE.
7. HAVE YOU EVER HEARD ABOUT THE TERM CANCER?
a) Yes
b) No
8. HAVE YOU EVER HEARD ABOUT CERVICAL CANCER? (CANCER NECK OF
WOMB.)
a) Yes
b) No
(If no please go to Question 23)
9. WHERE DID YOU FIRST HEAR ABOUT CERVICAL CANCER? ( You may tick
more than one option)
a) Radio.
b) Tv
c) Newspaper
d) Health worker
e) School
f) Others ( Please specify)
10. IS CERVICAL CANCER COMMON IN NIGERIA?
a) Yes
b) No
c) Don’t Know
65
11. IS IT POSSIBLE TO DETECT CERVICAL CANCER EARLY?
a) Yes
b) No
c) Don’t Know
12. IS CERVICAL CANCER TREATABLE?
a) Yes
b) No
c) Don’t Know
13. DOES EARLY DETECTION INCREASE CERVICAL CANCER SURVIVAL?
a) Yes
b) No
c) Don’t Know
14. WHAT FACTORS INCREASE THE RISK /CHANCE OF DEVELOPING
CERVICAL CANCER? (You may tick more than one option.)
a) Drinking alcohol
b) Smoking
c) Having many sex partners
d) Women with many children
e) Using Contraceptive
f) Early marriage
g) Others ( please specify )
h) Don’t know
66
15. HAVE YOU EVER HEARD ABOUT CERVICAL CANCER SCREENING?
a) Yes
b) No
16. IF YES, WHERE DID YOU HEAR ABOUT IT? ( You may tick more than one
option )
a) Radio
b) Tv
c) Newspaper
d) Health worker
e) School
f) Others (Please specify )
17. WHICH METHODS OF CERVICAL CANCER SCREENING HAVE YOU HEARD
OF? (You may tick more than one option.)
a) Pap smear
b) HPV test
c) VIA
d) Colposcopy
e) Others ( please specify)
18. DO YOU KNOW ANY PLACE WHERE YOU CAN BE SCREENED?
a) Yes
b) No
67
19. IF YES, WHERE CAN YOU SCREEN FOR CERVICAL CANCER? (You may tick
more than one option)
a) Primary health centre
b) General hospital
c) Teaching hospital
d) Private hospital
e) Mission hospital
f) Others
20. WHICH FACTORS IS/ARE ASSOCIATED WITH INCREASED CHANCE OF
DEVELOPING CERVICAL CANCER? (You may tick more than one option)
a) Early sexual activity
b) Having multiple sex partners
c) Having ones first child by age 30 and above
d) Past history of sexually transmitted disease
e) Having many children
f) Old age above 45
g) Others (please specify )
h) Don’t Know
68
21. WHAT ARE THE SIGNS/SYMPTOMS OF CERVICAL CANCER? (You may tick
more than one option)
a) Painful menstruation
b) Irregular menstrual flow
c) Bleeding after intercourse
d) Foul smelling vaginal discharge
e) Weight loss
f) Others ( Please specify )
g) Don’t know
PRACTISE OF CERVICAL CANCER SCREENING.
22. AT WHAT AGE DID YOU SEE YOUR FIRST MENSES? ------------23. HAVE YOU HAD SEX BEFORE?
a) Yes
b) No ( If no go to question 27)
24. IF YES, HOW OLD WERE YOU WHEN YOU FIRST HAD SEX? ------------25. HOW MANY SEXUAL PARTNERS DO YOU HAVE NOW?
a) One
b) Two
c) More than two.
26. DO YOU SMOKE?
a) Yes
b) No
69
27. IF YES HOW MANY STICKS A DAY? -------28. DO YOU DRINK ALCOHOL?
a) Yes
b) No
29. IF YES HOW OFTEN DO YOU DRINK ALCOHOL?
a) Daily
b)Weekly
c) Monthly
d) Occasionally
30. HAVE YOU EVER BEEN SCREENED FOR CERVICAL CANCER?
a) Yes
b) No
31. IF NO, WHY HAVE YOU NOT BEEN SCREENED FOR CERVICAL CANCER?
a) I have not thought about it.
b) I will do it when Iam older.
c) Iam not aware of any test for cervical cancer.
d) Iam afraid that I may be diagnosed for cancer.
e) I don’t have money for the test.
f) Others (pls specify )
32. IF YES, WHAT TYPE OF CERVICAL CANCER SCREENING TEST DID YOU
DO?
a)Pap smear
b)VIA
c)HPV
d) Others ( Please specify)
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33 .IF YOU HAVE BEEN SCREENED FOR CERVICAL CANCER WHERE WAS
THE TEST DONE?
a) Primary health centreZ
b) General hospital
c) Teaching hospital
d) Private hospital
e) Mission hospital
f) Others (please specify )
ATTITUDE TOWARDS CERVICAL CANCER SCREENING.
34.
WOULD YOU LIKE TO PARTICIPATE IN A HEALTH EDUCATION
PROGRAMME TOWARD PREVENTING CERVICAL CANCER?
a)Yes
b) No
35. WOULD YOU PARTICIPATE IN A MASS SCREENING PROGRAMME?
a) Yes
b) No
c) Don’t know
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36. DO YOU THINK YOU CAN DEVELOP CANCER OF THE CERVIX?
a) Yes
b) No
c) Don’t know
37. WOULD YOU ENCOURAGE OTHERS TO GO FOR CERVICAL CANCER
SCREENING?
a) Yes
b) No
c) Don’t know
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