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Table of Contents…………………………………………………………………………1
CHAPTER ONE .................................................................................................................................. 5
1.0 INTRODUCTION ......................................................................................................................... 5
1.1 Background to study.............................................................................................................. 5
1.2 Purpose of study .................................................................................................................... 6
1.3 Problem statement................................................................................................................ 6
1.4 Research questions................................................................................................................ 7
AIMS AND OBJECTIVES .................................................................................................................... 7
1.5 Aim......................................................................................................................................... 7
1.6 Objectives .............................................................................................................................. 7
1.7 Significance of Study.................................................................................................................. 7
1.8 COMPELLING REASONS FOR CERVICAL CANCER SCREENING: .............................................. 8
1.9 LEVELS OF PREVENTION OF CERVICAL CANCER: ................................................................... 8
1.10 CRITERIA FOR SCREENING OF DISEASE:............................................................................... 9
CHAPTER TWO: .............................................................................................................................. 10
2.0 LITERATURE REVIEW................................................................................................................ 10
2.1 Value of screening for cancer of the cervix ......................................................................... 10
2.2 Appropriate age for screening:............................................................................................ 10
2.3 Problems associated with conventional method of screening: .......................................... 11
2.4 Alternative screening methods for cervical cancer: ............................................................ 12
2.5 VISUAL INSPECTION (VI): ................................................................................................. 13
2.6 VISUAL INSPECTION USING ACETIC ACID (VIA) ............................................................... 13
2.7 VISUAL INSPECTION AFTER APPLICATION OF LUGOL’S IODINE (VILI): ............................ 13
2.8 HPV SCREENING:.............................................................................................................. 14
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2.9 REASONS FOR POOR SCREENING ATTENDANCE: ................................................................ 14
2.10 THE STANDARD CA CERVIX SCREENING PROGRAM IN BOTSWANA ................................. 15
2.11 THE HEALTH BELIEF MODEL AS THE FRAMEWORK FOR HEALTH PROMOTION
INTERVENTION: ......................................................................................................................... 16
2.12 HEALTH PROMOTION: ....................................................................................................... 18
2.12.1 Definitions of Health promotion: ............................................................................... 19
2.13 THE GOAL OF HEALTH PROMOTION: ................................................................................ 19
2.14 SOURCES OF INFORMATION FOR PROPAGATION OF HEALTH PROMOTION: ................... 20
2.15 CLASSIFICATION OF THE TARGET GROUP OF CERVICAL CANCER SCREENING: ................. 21
2.16 ACTIONS TO IMPROVE UPTAKE RATES OF CERVICAL CANCER SCREENING: ..................... 21
CHAPTER THREE............................................................................................................................. 23
3.0 METHODOLOGY ....................................................................................................................... 23
3.1
INTRODUCTION ............................................................................................................. 23
3.2 THE STUDY DESIGN .............................................................................................................. 23
3.3 The Instruments of Study .................................................................................................... 23
3.3.1 The flyers ...................................................................................................................... 24
3.3.2 The posters ................................................................................................................... 24
3.3.3 Questionnaires ............................................................................................................. 24
3.4 DATA COLLECTION ............................................................................................................... 25
3.5 INTERVENTION .................................................................................................................... 26
3.6 ETHICAL CONSIDERATIONS.................................................................................................. 27
3.7 LIMITATION ......................................................................................................................... 27
3.8 RELIABILITY, VALIDITY, & OBJECTIVITY ................................................................................ 28
CHAPTER FOUR .............................................................................................................................. 29
4.0 RESULTS ................................................................................................................................... 29
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4.1 INTRODUCTION ................................................................................................................... 29
4.2 Distribution of respondents to questionnaire in study site and in control site. ................. 29
4.3 Age Characteristics of Participants in cervical cancer uptake ............................................. 30
4.4 COMPARISM UP TAKE OF PAP SMEAR TEST........................................................................ 31
4.4.1 Pap smear test uptake in Francistown Clinics. ................................................................. 31
4.4.1.2 Pap smear Uptake by each clinic in Francistown ...................................................... 33
4.5 Pap smear test uptake in Nyagabgwe Referral Hospital ..................................................... 34
4.5.1 Uptake of Pap smear test by age in Nyangabgwe Referral Hospital. ............................... 34
4.5.2 Uptake of Pap smear test in Nyangabgwe Referral Hospital by months. .................... 35
4.6 Pap smear Test uptake in Princess Marina Hospital ........................................................... 36
4.6.1 Uptake of Pap smear test by months in Princess Marina Hospital. ............................. 36
4.6. 2 Uptake of Pap smear test by age in Princess Marina Hospital .................................... 37
4.7 Factors influencing cervical cancer screening uptake ......................................................... 38
4.8 TRENDS OF PAP SMEAR TEST IN THE PERIODS BEFORE AND DURIND THE STUDY............. 39
4.9 CERVICAL CANCER SCREENING UPTAKE PERIODS ............................................................... 39
Figure 11: Percentage of cervical cancer screening uptake. ................................................. 40
4.10 Test of Hypothesis ............................................................................................................. 40
4.10.1 The Null Hypothesis .................................................................................................... 40
4.10.2 Alternate hypothesis: ................................................................................................. 40
4.11 Test Statistic: (t –distribution) .......................................................................................... 40
4.11.1 Test of difference between up take in the two periods in Francistown .................... 41
4.11.3 Critical Region ............................................................................................................. 42
CHAPTER FIVE ................................................................................................................................ 43
5.0 INTRODUCTION ....................................................................................................................... 43
5.1 DISCUSSION OF FINDINGS ................................................................................................... 43
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5.3 CONCLUSIONS ..................................................................................................................... 45
5.4 RECOMMENDATIONS .......................................................................................................... 45
REFERENCES .................................................................................................................................. 47
APPENDICES………………………………………………………………………………………………………………………………54
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CHAPTER ONE
1.0 INTRODUCTION
1.1 Background to study
Cervical cancer is one of the most common cancers and the leading cause of cancer
deaths among women in developing countries. It is estimated that 200,000 to 300,000
women die from cervical cancer every year, mostly in poor countries (1). Even more
sobering are findings from studies which suggest that the human immunodeficiency
virus (HIV) positive women are at increased risk for cervical cancer, and HIV rates are
known to be on the increase in many of the same countries in which cervical cancer is a
leading cause of cancer deaths. Cervical cancer is an Acquired Immune Deficiency
Syndrome (AIDS) defining illness. However, there is a growing body of evidence
suggesting that HIV positive women develop the disease at least ten years earlier that
those not infected, and it tends to run a more aggressive course (1, 19).
In Botswana, cervical cancer is the most common cancer (18), and the Southern Africa
regional prevalence rate of cervical cancer is 15.5% (25). In Nyangabgwe Referral
Hospital, cervical cancer is the most common malignancy admitted in the gynecology
ward. In 2007 there were 173 cases of cervical cancer out of 238 cases of malignancy,
while in 2008 there were 195 cases of cervical cancer out of the 250 malignancies cases
admitted in the gynecology ward. Therefore 73% and 78% of all malignancy admissions
were due to cervical cancer in the two successive years respectively. Cervical cancer also
constituted 8.6% of the total number of admission beds in gynecology ward. The age
distribution revealed range for cervical cancer admission was 20 – 69 years. The
contributory factors for this high incidence of Cancer of the cervix for this population are
not known, however, some factors responsible for the high incidence of cervical cancer
in most developing countries may also be applicable to Botswana. In Latin America
many women never get tested because many of the screening programs have not been
effectively or adequately implemented and screening is infrequent (26). Deaths
resulting from cervical cancer are particularly tragic because this type of cancer
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develops slowly and has a detectable precursor condition, known as carcinoma in situ
(CIS), which is treatable and can therefore be prevented through screening (1). Although
there is a government policy directive for screening women for cervical cancer (20),
presently it is only those who have the opportunity to visit the health facilities who
receive this screening. The data on national coverage is yet unavailable or scarce.
Limited knowledge of cancer of the cervix and the importance of early detection and
regular screening are among the areas often addressed through health education efforts
to raise awareness and change behavior (24). In Nyangabgwe Referral Hospital, as in
many other health facilities in the country, screening is mostly targeted to symptomatic
patients and a few who specifically request for it. It is very likely that the majority of
these women may not be aware of Pap smear screening services and so morbidity and
mortality due to cervical cancer will continue to increase in Botswana in the coming
years if no proper screening strategy is put in place. In the presence of this reality there
is the need to create more awareness on the importance cervical cancer screening as a
matter of public health issue in Nyangabgwe Referral Hospital and the catchment areas.
1.2 Purpose of study
The purpose of the study is to improve the uptake of cervical cancer screening by
integrating a health promotion component to the standard program.
1.3 Problem statement
Despite efforts by the Ministry of Health to encourage women to go for screening for
cervical cancer, many only come for treatment when the disease is far advanced,
resulting in poor prognosis. The cervical cancer screening program is therefore not fully
utilized and fails to achieve its objective of enabling early detection of cancer of the
cervix.
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1.4 Research questions
1. Are the women who attend Nyangabgwe hospital aware of the availability of cervical
cancer screening services?
2. How can women be helped to understand the severity of cervical cancer disease?
3. Can health education be used to improve cervical cancer screening in Nyangabgwe
hospital?
AIMS AND OBJECTIVES
1.5 Aim
To promote cervical cancer screening services uptake in Nyangabgwe hospital.
1.6 Objectives
1. To provide a health promotion intervention on cervical cancer to female patients
in health facilities in Francistown
2. To evaluate the effectiveness of the health promotion component on the uptake
of cervical cancer screening in the communities utilizing the identified health
centers
3. To compare the pre- and post test level of uptake of ca cervix screening.
1.7 Significance of Study
Several studies done on cervical cancer screening had revealed different levels of
barriers to cervical cancer screening (37), but only few had boldly delved into the
aspects that will promote adoption of cervical cancer screening behavior by women
(38). This study is therefore, an attempt to boost the information reservoir that will
assist women in forming attitudes, beliefs and values responsible for satisfactory
cervical cancer screening lifestyle. Other studies have also revealed that younger
women aged 25 to 34 tends not to be responding to cervical screening program (35).
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Without regular cervical cancer screening the early changes that could progress to
cervical cancer will not be picked up. This study is aimed to add impetus to the
cultivation of early cervical cancer screening behavior more so in the culture and
environment stimulating earlier sexual lifestyle as Botswana. This study aims to address
this concern by the application of health promotion and with the hope that this younger
group of women will improve in their response to cervical cancer screening. Given the
impact of mass advertising and health promotion campaigns in other areas, such as
smoking cessation, there is clearly a need for a similar strategy to be applied to cervical
screening (39).
1.8 COMPELLING REASONS FOR CERVICAL CANCER SCREENING: Cancer of the cervix is
the third most common malignancy worldwide and the leading cause of cancer death
among women in the developing countries. It was estimated that 466,000 new cases
occur annually worldwide. Eight percent of these occur in developing countries, with the
highest recorded in Sub - Saharan Africa, Central America and Asia. It is now generally
accepted that Human paillomavirus – HPV, a sexually transmitted infection, is a major
cause of cervical cancer. HPV infection is an indolent problem that causes cellular
changes that may lead to cervical cancer after 20 or more years in normal women.
Several risk factors associated with cervical cancer have been studied. Many are thought
to be mere proxies of HPV infection. However, smoking, and parity are independent cofactors in the progression of HPV infection (43).
1.9 LEVELS OF PREVENTION OF CERVICAL CANCER: Prevention comprises of activities
designed to protect patients or other members of the public from actual or potential
health threats and their harmful consequences. Simple and effective ways of preventing
cervical cancer are known and available. Primary prevention is aimed at healthy
individuals to prevent disease from occurring (44). Primary prevention by preventing
HPV infection as in using barrier contraception and reduction of sexual partners but the
effect in the overall reduction of cervical cancer incidence remains unclear. Secondary
prevention is aimed at patients with an existing pathology to reduce the risk of
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recurrence or progression. Secondary prevention had already been shown to be feasible
and cost effective (43, 44). Screening is a secondary level of prevention which involves
testing an otherwise healthy person in order to detect or rule out disorders at an early
stage, or testing for infection or disease in populations of individuals who are not
seeking health care. The numbers needed to treat (NNT) and show benefit in at-risk
populations are smaller as in secondary prevention (44). Screening for cervical cancer is
one of such secondary prevention activities involving screening and treatment of
precancerous lesions (42, 43).
1.10 CRITERIA FOR SCREENING OF DISEASE: There are a number of criteria that must
be fulfilled for a screening procedure to be viable (44). Cervical cancer screening
matches these criteria quite well.

The disease must be sufficiently common within the group to be screened that a
reasonable number of cases can be expected to be detected.

There is a benefit in early detection. This means offering treatment at a more
favorable stage or taking action to prevent or ameliorate the disease.

The screening procedure must be cheap, easy and acceptable.

The screening test is not usually a gold standard for diagnosis.

There must be an acceptable small number of false positive results. Low
specificity will overload the system with further investigation and lead to
unnecessary anxiety.

There must be a very low of false negatives. Low sensitivity with too many false
reassurances will bring the test into disrepute.
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CHAPTER TWO:
2.0 LITERATURE REVIEW
2.1 Value of screening for cancer of the cervix
In developed countries, the United States of America (USA), as an example the Healthy
People 2000 target of 85% coverage of cervical cancer screening of women by the 1990s
had been achieved and this feat was accomplished due to integrated health promotion
adoption (2.). In developed countries cytology-based services utilizing Papanicoalaou
(‘Pap’) smear have been the basis of cervical cancer screening and detection programs
for many years. While the introduction of Pap smear test as national screening program
has contributed in the reduction of the incidence rate of cervical cancer and also to the
marked decline in cervical cancer deaths but data suggest that the finding is not
uniform.
In Finland, a 65% reduction in the incidence rate of cervical was observed between 1970
and 1985. By contrast, in Norway, only 5% of the population was covered by a cervical
cancer screening program. The reduction in cervical cancer incidence was only 20%
during this same 15-year period (2). These findings indicate that the reductions in the
incidence rate of cervical cancer and in cervical cancer deaths do not depend solely on
the introduction of national cervical cancer screening program and that a correlation
between the extent (coverage) of a screening program and the reduced incidence of
invasive cervical cancer (2). In Nigeria, for example, studies done on the utilization of
Pap smear testing facility revealed poor utilization of the test independent of
respondent’s profession, marital status or hospital. The utilization of Pap smear test and
the knowledge of cervical cancer were high among doctors, and surprisingly inadequate
among nurses and poor among hospital maids. 93.2% of respondents had not done Pap
smear test. The study, there recommended intensification of campaign towards
prevention of cervical cancer among health workers (16).
2.2 Appropriate age for screening: Cervical cancer is rare in women under 20 years of
age because teenagers’ body, particularly the cervix, is still developing. Invasive cancer
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below the age of 25years is extremely rare but changes in the cervix are common.
Evidence suggest that screening could start at age 23 or 25 (11, 16), but in the Sub –
Saharan Africa the high burden of HIV and with teenagers being among the sexually
active group, initial screening at age 15 to 18 is recommended (Botswana MoH and
WHO). While in the UK the target age group for cervical cancer screening is 25 - 64
(NHS), for Sub- Saharan Africa the target age group is 18- 65. In the UK protection
offered with 3 - yearly screening by single negative smear is 41% for the age groups 20 39; it is 69% for the age groups of 40 - 54 and 73% for the age groups 55 - 69. While with
5-yearly screening the protection by single negative smear is 30% for age groups 20 –
39. It is 63% for age groups 40 – 54 and 73% for age groups 55 - 69 (7, 13). Regular
participation in screening program is considered to be important for that rate of
detection and protection. Well organized screening programs have substantially
reduced cervical incidence and death (7, 13)
2.3 Problems associated with conventional method of screening: In the conventional
screening method known as Pap smear test or cytology-based screening, a trained
health professional inserts a cervical brush or spatula through the vagina and cells are
wiped from the surface of the cervix and placed on a slide or a vial. The cells are then
examined under a microscope by a trained cytologist for abnormalities that could
indicate pre-cancerous or cancerous conditions (36). Despite the knowledge that the
burden of the disease is high in developing countries and that screening is known to be
cost effective intervention, only 5% of women at any point in time are screened in most
developing countries (13). It is clearly known that Pap smear (cytology based screening
method) is the most common form of screening performed world wide (12, 13, and 26).
This secondary prevention has successfully decreased cervical cancer in high and middle
income countries and reduced cervical cancer mortality in these countries (26), but the
outcome in Botswana is still to be established. Cytology-based screening programs are
complex and can be costly. Although performing Pap smear test seems relatively simple,
a large number of steps are required to take an adequate smear, process and analyze
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the specimen, and inform, patients of the results. If any of these steps are unreliable or
logistically burdensome, the entire screening program could break down (13) and with
it, the potential for any public health benefit. For example, whatever cytology screening
services that do exit in such resource-limited settings are usually in urban settings by
private sector or referral facilities. And, even in these settings, trained cytotechnicians
and cytopathologists are scarce and turnaround times for processing and reading
specimens are slow. Thus patients do not receive their results promptly and follow up
losses (including those lost treatment) are high (13). World Health organization report
has revealed that 80% of cervical cancer cases are in developing countries, and that only
approximately 5% of eligible women actually undergo testing in the developing
countries in a 5 year period (28).
2.4 Alternative screening methods for cervical cancer: Pap smear or cytological test is
still the only available form of screening in Nyangabgwe Referral hospital. This is also the
case for the other referral hospital in the southern region of the country. Hence by
implication one can assert that in Botswana only Pap smear is available for cervical
cancer screening. It has been noted that in order for any screening program to achieve
sufficient coverage to realize a long term impact on morbidity and mortality, coverage
generally to be considered is 70% or higher. England, for an example achieved a
significant decline in national mortality rates only after 80% coverage was exceeded
(27). In the developing world the low screening coverage could be associated to
resource constraint and the complexity of the prevalent cytological screening program.
Resource constraint has been a major hurdle on organizing screening programs. It has
been estimated that in India, even with a major effort to expand cytology services, it will
not be possible to screen even one-fourth of the population once in a lifetime in the
near future. In Mexico, the low quality of cytology services has been a major barrier. In
Colombia a shortage of cytotechnicians has been a key barrier. Hence there is need for
options for the limited resource conditions (3).
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2.5 VISUAL INSPECTION (VI): Visual inspection is a strategy to detect the disease in an
early stage by visually inspecting the cervix and carrying out Pap smear in suspected
cases, also referred as down-staging. It also provides an opportunity to involve
paramedical and nonmedical workers for carrying out visual inspection.
2.6 VISUAL INSPECTION USING ACETIC ACID (VIA) has been described as an alternative
to Pap smears in the identification of cervical cancer lesions. VIA testing is not only
inexpensive and simple, it can be provided at all levels of the health care system by
midwifes, nurses and other health workers with short training. A key advantage of VIA
testing over cytology based services is that the results are immediately available. This
means that management decisions, especially whether to offer outpatient treatment if
the cervix is found to be abnormal, during a woman’s initial visit (28). VIA is a simple
procedure that consists of swabbing the cervix with a dilute solution of acetic acid
(vinegar), waiting for one minute and the viewing the cervix with a light source.
Precancerous lesions are suspected if acetone-white changes appear near the squamocolumnar junction (SCJ). If lesions meet all the established criteria (e. g. occupy less than
75% of the surface area of the cervix), the woman is offered the option of immediate
treatment with cryotherapy (27). Another attractive aspect of VIA is that it is a low-tech
approach with minimum reliance upon infrastructure for performance. The results of
the procedure are available immediately for initiating treatment at the same visit (3).
2.7 VISUAL INSPECTION AFTER APPLICATION OF LUGOL’S IODINE (VILI): VILI is the
visualization of cervix after application of Lugol’s iodine. On liberal application of Lugol’s
iodine over the cervix and vagina, the normal squamous epithelium (that contains
glycogen) will be strongly stained almost black or dark brown. On the other hand,
columnar epithelium lacks glycogen and does not stain with iodine. Likewise immature
mataplasia, dysplastic epithelium or atrophic epithelium also does not stain, but some
invasive cancers do contain some glycogen and may stain. Thus VILI is considered
positive if SCJ or entire cervix or growth turned yellow (non uptake areas). The yellow
13
color changes associated with a positive VILI test result could be recognized with much
greater ease by trained health workers (3).
2.8 HPV SCREENING: Human Papilloma Virus (HPV) infection is recognized as the main
risk factor in the development of cervical cancer, and has been found in 99.7% of cases.
Women who have had many sexual partners or who have had sex with someone who
has had many partners, have a greater risk of contracting HPV. There may also be an
increased risk of HPV infection during puberty, pregnancy or when taking the oral
contraceptive pill because of the enlarged Transformation zone at these times (31).
A sample of cells is taken from the cervix during a pelvic examination, using a brush or
spatula. The sample is placed into a preservative and sent to a laboratory to test for the
presence of HPV DNA. HPV has been implicated in almost 100% of cervical cancer cases
(35). Human Papilloma Virus (HPV) testing provides assessment of current risk as well
the risk of subsequent development of high grade CIN and gives the known natural
history of HPV-induced cervical precursor lesions. The screening interval in a woman
with negative HPV test and a normal cytologic screen could safely be extended to 8-10
years without compromising with the cancer prevention (3). Women with positive HPV
test result would be followed and treated immediately.
2.9 REASONS FOR POOR SCREENING ATTENDANCE: Concerning the awareness to
cervical cancer screening by women several studies mentioned that the reason for non
attendance could be the lack of sufficient information about cancer of the cervix. (6, 12,
14, 15) Studies carried out in Sweden to evaluate women’s experience of screening
showed that only 32% to 60% of Swedish women knew that Pap test was aimed to
detect precursors of cancer or cancer of the cervix (12). In order to have sustained
information sources, some women emphasized the importance of informing young
women, and they still considered midwives and school teachers to be good messengers
of information about cervical cancer (6, 12). The study conducted on the situational
analysis on cervical pre cancerous and cancer lesions in Botswana founded out that
women complained of long waiting interval at the facilities for the test to be carried out
14
and also 5 – 8 weeks intervals for results to be available. It went further to include other
contributory factors as shortages of basic equipment for cytology, and of trained
laboratory staff (5).
Extensive reviews of literature had indentified barriers that had negative impact on the
use of screening services. Accordingly, these barriers had been grouped into two
namely, client barriers and system barriers (25A). Among the client barriers inadequate
knowledge of cervical cancer and the purpose of Pap smear test, embarrassment with
test because of unwelcome exposure of their private (13), fear of frightening findings
(12, 13, 17), cultural belief on both cancer and sexuality associated with test (12, 15, 19).
Other client barriers include distance from health facility and time constraints due to
family and work responsibility. Geographical isolation and role involvement in the farm
or cattle post (6, 14, 19).Other factors are limited English proficiency, the use of
traditional health practices, problems of accessibility of health care, the lack of health
insurance, the lack of female physicians, low income and education levels, marital
status, individual age, and values (16, 21). The system barriers cited include ineffective
health policies, inadequate and in accessible health services, shortage of staff and
financial constraints (6, 19). However, another study related a positive view of women
who recount that they trust the health system; they derive personal benefit from
screening participation because it increases their self value after a healthy report (12).
Any efforts aimed at increasing the uptake of screening for ca cervix needs to take into
account the identified barriers.
2.10 THE STANDARD CA CERVIX SCREENING PROGRAM IN BOTSWANA
Cervical cancer screening became Botswana national strategic plan of the ministry of
health in 2005. The plan was for all women between age 20 to 65 to receive free Pap
smear test in any health facility in Botswana. All the primary hospitals, district hospitals
and the two referral hospitals were required to adopt cervical cancer screening as part
of their (APP) Annual Performance Plan. The target initially was that 35% of all women
coming to the clinics and hospitals for any reason should be screened for cancer of the
15
cervix. But from 2007 the target was scaled up to 50% and the adopted interval of
screening being every six months for those with low grade cervical intra-epithelial
lesion, and yearly for those with normal cervix. However, those women with high grade
intra-epithelial lesion following screening result are given appointment with the
gynecologist. Even Nyangabgwe Hospital, which should be a leader for other hospitals,
had never gone beyond 25% as indicated by the annual report of the Department of
Obstetric and Gynecology (OBGY) responsible for achieving the goal for the hospital.
The department of OBGY opened two screening service centers at the Out patients
Department (OPD) and Infectious Disease Control Center (IDCC) for the purpose of
routine screening. However, majority of those who are screened are the ones consulting
doctors had requested to be screened for cervical cancer for investigation. Those who
volunteer to screen themselves are in the minority. Many women attending the hospital
are ignorant of the existence of this free cervical cancer screening service. In the
peripheral clinics and hospitals the mandatory cervical cancer screening is scantily
preformed. There are only two centers where Pap smear samples are interpreted for all
the health facilities in the country. Facilities in the northern part send to Nyangabgwe
Referral Hospital (NRH) laboratory while those in the southern part send to Princes
Marina Hospital (PMH) laboratory. These laboratories return the reported results back
to the facilities or their sources where the clients go for feedback or review. Women
with abnormal report are referred to gynecologists in the two referral hospitals for
further management.
In summary, the cervical cancer screening is free for all citizens of Botswana but not
fully utilized. This accounts for the increasing incidence rate of cancer of the cervix
nationwide.
2.11 THE HEALTH BELIEF MODEL AS THE FRAMEWORK FOR HEALTH PROMOTION
INTERVENTION: The Health Belief Model (HBM) is one of the oldest templates that
attempts to explain health behavior. It is based on the premise that for a behavior
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change to succeed, individuals must have the incentive to change, feel threatened by
their current behavior, feel that a change will be beneficial and be at acceptable cost.
They must also feel competent to implement that change (6). Tung. et al in their study
(4) had indicated that in this challenge of higher cervical cancer incidence rates,
research using a theory-driven approach to study women’s behavior with regard to Pap
smear testing is limited, and added that there is an immediate need to understand the
Pap smear practices of women through a theory based assessment that would allow
healthcare professionals to develop more effective and cost effective programs.
It has been stated in various studies that there are challenges to working with patients
to change their behaviors to reduce the likelihood of experiencing a condition e.g.
cervical cancer, and that some of the challenges are highlighted in the dimension of the
Health Belief Model. The constructs defined in the Health Belief Model are; perceived
susceptibility (perception of personal vulnerability to cancer of the cervix), perceived
severity - evaluation of medical / clinical consequences (death, disability, pain) and
social consequences (work, family life, social relations); perceived benefits of action perception of feasibility and efficacy of action and perceived barriers- perception of
action as expensive, dangerous, unpleasant, inconvenient, time-consuming (23).
Additional principle of the Health Belief Model include a cue to action such as health
educational materials, mass media campaign, reminder postcards from health workers,
illness of family, members or friends and news paper or magazine. Other factors include
self efficacy (confidence in one’s ability to take action), as well as predisposing, enabling
(values, beliefs, attitudes and perception of disease) and reinforcing factors - availability
and accessibility of health resources (23,24).
The observation that effective behavior change is difficult to initiate and sustain even
when communities are informed well about simple means of health promotion or harm
reduction had been noted (21). Suggestions to the approach in preventive health care
for cervical cancer include, involving community health workers in public awareness
campaigns, peer education, (one teach one), a public health campaign over a short
17
period of time, such as a cervical cancer awareness month or a traveling clinic which
target one village at a time is a good way to reach women who do not seek routine
preventive care (22).
Guided by literature review, which identified barriers to ca cervix screening, the current
study focuses on some client barriers i.e. inadequate knowledge of cervical cancer,
inadequate knowledge on the purpose of Pap smear test and limited English proficiency.
These factors will be addressed by an intervention that increases knowledge on cervical
cancer, increasing knowledge on the purpose of Pap smear and including Setswana as a
language of communication for the intervention.
2.12 HEALTH PROMOTION: The Ottawa Chatter definition captures empowerment as
one of the key elements of health promotion. That is it suggests that health promotion
is fundamentally about ensuring that individuals and communities are able to assume
the power to which they are entitled. Thus the primary criterion for determining
whether a particular initiative should be considered to be health promoting, ought to be
the extent to which it involves the process of enabling or empowering individuals or
communities. The absence of empowering activities should therefore signal that an
intervention does not fall within the rubric of health promotion. Attempts to encourage
public participation are critical to the process of empowerment (41). This study
incorporates the principles of empowerment by encouraging increase in cervical cancer
screening participation.
Health promotion is both a concept and an approach that could be used by
governments, organizations communities and individuals. As an approach health
promotion extends beyond health protection to include among others reducing the
negative impact of a broad range of health determinants associated with social,
political, and economic environment; redistributing power and control over individual
and collective health issues as well as giving attention to domains of health beyond the
physical, including the mental, social and possibly spiritual dimensions (41).
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2.12.1 Definitions of Health promotion:

The process of enabling people increase control over and to improve their health
(WHO; 1984 (24), 1986 (4), and Epp 1986 (25).

The process of enabling people to increase control over the determinants of
health and thereby improve their health ( Nutbeam, 1985 (23).

A strategy “aimed at informing, influencing and assisting both individuals and
organizations so that they will accept more responsibility and be more active in
matters affecting mental and physical health”.

A combination of health education and related organizational, political and
economic program designed to support changes in behavior in the environment
that will improve health (US department of Health, Education and Welfare, 1979
(19).

Any activity or program designed to improve social and environmental living
conditions such that people’s experience of well-being is increased (Labonte &
Little, 1992, 29) (41).
2.13 THE GOAL OF HEALTH PROMOTION: The main objective of health promotion is to
persuade or convince the receiver to adopt a healthier behavior as an easier choice.
The macro and micro activities which lead to this result include; sending a message to a
receiver; the message becomes identified and perceived by the receiver; the receiver
interprets or attributes a meaning to the message; the meaning inside the recipient acts
as a stimulus to generate an effect within; the inward or internal effect of message
motivates a behavior (action or inaction) that can be related to the goal of the health
promoter. The main important of these goal directed activities is the meaning aroused
in the recipient (29).
Health promotion is an instrument used to create a meaning
among recipients that the probability of an undesirable event (occurrence of cervical
cancer) does exist, and so use the information to adopt healthier life styles. Health
promotion can also be put into use as a strategy to diminish the risk of cervical cancer in
the population by communicating that cervical cancer prevention and early dictation
can lead to preventive behavior (29). To reduce the impact of cervical cancer in
19
Botswana, it is first necessary to reduce the prevalence of behavioral and environmental
factors that increase its risk. Information regarding the contribution of a risk factor to
global rates of cervical cancer in populations, and not only in exposed individuals, is
useful to decide which risk factors are important, and which are not so important for
global community health. A relatively weak risk factor, but highly prevalent in the
community, can be responsible for a higher incidence of the disease than a stronger
factor of lower prevalence level (29). Women with multiple sexual partners have an
increased risk of contracting HPV and HIV and other sexually transmitted infections. HPV
infection is recognized as the main risk factor in the development of cervical cancer, and
been found in 99.7% of cases. Human immunodeficiency virus (HIV) has been shown to
increase the risk of cervical cancer (31).
There are many compelling reasons to use health promotion to propagate the
importance of cervical cancer screening. These include that cancer of the cervix is
known to be fuelled by HIV infection and does not remain confined to HIV–infected
individuals only. People Living with HIV/AIDs (PLWHA) are at greater risk for cervical
cancer. Women infected by Human papilloma virus (HPV), which is a sexually
transmitted infection, although without HIV infection is at risk for cervical cancer.
Women indulging in multiple sexual partnerships have greater risk for both HIV and HPV
infections. Cervical cancer screening helps to alleviate anxiety of HIV patients because
many are aware of the link between HIV and cervical cancer. Regular cervical cancer
screening will motivates HIV negative patients to adopt life-saving skills (29).
2.14 SOURCES OF INFORMATION FOR PROPAGATION OF HEALTH PROMOTION:
Majority of the reviewed studies indicates that program documentation and Pap
consultation represent the main sources of information, although a sizable proportion
relies on other sources. Cervical cancer and screening feature frequently in the mass
media, which include news papers, magazines, television and the internet. It can be
speculated that the objective quality of the information provided by the different
sources could be variable, as could women’s subjective perception of each source’s
20
reliability (32). In some developed countries e. g. England, regional / recall systems
invite each eligible woman, at intervals of three to five years, to make an appointment
for a Pap smear test (32). Mass media has been used not only as cues to screening but
also as avenue that can uncover or highlight perceived susceptibility. For example it was
observed in England that the usual persuasion by health promotion massages, and
invitations sent out for cervical cancer screening did less to increase cervical cancer
screening uptake than the media coverage of the death of Jade Goody did in increasing
cervical cancer screening uptake (30).
2.15 CLASSIFICATION OF THE TARGET GROUP OF CERVICAL CANCER SCREENING:
Women who are targeted for cervical cancer screening have been placed into three
broad groups (45). The first group represents women who respond to screening if they
are made aware of its importance and benefits and if it is made reasonably accessible
whether through a formal program or regular contact with primary care physician.
Women in the second group respond to a more proactive approach such as call or recall
system. The third group is the hard to reach with health promotion messages (45).
2.16 ACTIONS TO IMPROVE UPTAKE RATES OF CERVICAL CANCER SCREENING: Various
suggestions have been made about how to increase the uptake of cervical cancer
screening as in other preventive health care. These include peer education (each one
teach one), a simple and cost-effective method for reaching a diffuse population of
women. A public health campaign over a short period of time, such as cervical cancer
awareness month or a traveling clinic which targets one village at a time, is a good way
to reach women who do not seek routine preventive care, the hard –to-reach and
under-screened (22,45). Broader suggestions for improving cervical cancer screening
uptake involve increasing women’s access to education, involving poor women in
decisions about how to guarantee they have access to health care (22). Registration of
females will facilitate an up-to- practice database which is an essential tool for primary
prevention. Even the simplest list will have patient’s name, age and sex so that they can
be for an over 70s’ check. More advanced databases will allow searching by disease so
21
that at- risk patients can be identified. For example patients for annual cervical cancer
screening appointment could be recalled using the database (45). Countries which have
recorded success in program coverage with sustained increase in uptake rate had used
standard call and recall schedule to achieve this feat. For example, first invitation for
screening is at age 20 in United Kingdom, and routine call is as follows: England-3 yearly
between ages 25-49, then 5yearly recall until age 65. For Scotland; it is 3 yearly recall
from age 20 until aged 60. In Wales it is 3 yearly recall from age 20 until aged 65, while
in Northern Ireland it is 5 yearly recall from age 20 until aged 65 and many general
practitioners run their own recall at an interval of three years. Patients above the upper
age limit, who have not been screened since age 50 or have had recent abnormal tests,
are offered a smear test (46)
22
CHAPTER THREE
3.0 METHODOLOGY
3.1 INTRODUCTION
The purpose of the study was to improve the uptake of cervical cancer screening by
integrating a health promotion component to the standard program of cervical cancer
screening in Nyangabgwe Referral Hospital. Nyangabgwe Referral Hospital serves as a
referral hospital for the northern part of Botswana and more especially to the
surrounding clinics or health facilities in Francistown. The focal site of the health
promotion activities was in Nyangabgwe Referral Hospital and the clinics that are in
Francistown. This chapter explains the method employed in the study to arrive at the
findings. These include the research design, the instruments, data collection methods,
the intervention and data analysis as well as the limitations and ethical considerations.
3.2 THE STUDY DESIGN
The study was a cohort study. Two populations were selected for the study namely
women attending Nyangabgwe Referral Hospital and the clinics in Francistown (the
research group) and women attending Princess Marina Hospital (the control group).
The population of women attending Nyangabgwe Referral Hospital was exposed to
health promotion. The second population of women attending Princess Marina Hospital
was not exposed to the health promotion intervention. A pre-test quantitative trend of
cervical cancer screening patterns was collected in the health facilities before the
intervention. Intervention by health promotion was conducted in the study sites and
was followed by a post - test quantitative measure of cervical cancer screening trends in
the research group. Also quantitative trend of cervical cancer screening patterns was
collected in the control groups for the two periods corresponding to pre-intervention
and intervention.
3.3 The Instruments of Study
The instruments employed in the study were flyers, posters and questionnaires.
23
3.3.1 The flyers contained information concerning cervical cancer. It explained why
cervical cancer is the disease of women and that women have the capability to prevent
the disease by taking actions that can help protect them from cervical cancer disease.
The front of the flyer contained a picture of a normal cervix and that of a cancerous
cervix being supported respectively on the right hand and on the left hand of smiling
lady with the exclamation that women have the power to choose the cervix of their
preference by their action to the message contained in the flyer. It advises women to
take immediate action to protect themselves and their loved ones. Inside the flyer is the
information on the reason for screening for cervical cancer, the symptoms and signs of
cervical cancer, and the risk factors of cervical cancer. Other contents in the flyer
include good news associated with regular cervical cancer screening, the harm in not
screening for cervical cancer as well as the way forward action for all who had received
the message. The translation in each flyer was English and Setswana. Each participant
was given two pamphlets, one for herself and another to give to one other person, e.g.
sister, neighbor, friend etc. A record of the number of people exposed to the health
education intervention, as well as the number of pamphlets given out, was kept. Sample
of the flyer is found in Appendix 1.
3.3.2 The posters were large sized clearly and boldly written information on cervical
cancer screening with messages and actions that women should take to prevent cervical
cancer. It also had a true photograph of a volunteered beautiful local woman with a
semi stretched arms holding pictures of normal cervix and a cancerous cervix on her
right and left hands respectively. The right hand picture was indicated as good while the
left hand picture was indicated as wrong sight of a woman’s cervix. The posters were
posted at various strategic positions in the hospital and each clinic as well as in female
wards. It was also posted at strategic locations in all the participating clinics. Sample of
the poster is found in Appendix 2.
3.3.3 Questionnaires were administered to respondents who were screened for cervical
cancer by the research assistants. The questionnaire contained socio demographic
24
characteristics such as the age of clients and location of the health facility where
screening occurred, the date and period of test and factors that influenced the decision
to screen for cancer of the cervix. The questionnaires which had Setswana translation
were distributed to all the participating clinics in Francistown and all the units or
department that participated in the health education in Nyangabgwe Referral Hospital.
Some of the questionnaires were administered by the research assistants while some
were self administered. About 120 questionnaires were distributed to the clinics and
200 distributed in Nyangabgwe Referral Hospital. Fifty questionnaires were distributed
in Princess Marina Hospital. The number of questionnaire all together retrieved was
188. Sample of the questionnaire is found in Appendix 3.
3.4 DATA COLLECTION
Pre–test cervical cancer screening trend for four months prior to intervention was
collected from the kept records of clients who participated in cervical screening in all
the screening centers of the respective health facilities namely Nyangabgwe Referral
Hospital and the surrounding clinics in Francistown (the study site) and Princess Marina
Hospital (the control study site).The records of each of the centers were used to extract
the number of cervical cancer screening tests conducted in the centers from the month
of June 2009 to September 2009 prior to the onset of the intervention on October 2009.
This was to measure the normal trend of cervical cancer screening in these health
facilities. The data is the number and pattern of Pap smear tests done in the different
health facilities. The data collection was partly done by the research assistants and
partly by the principal researcher. Post–intervention data collection involved reviewing
the documented sources of the number and trends of cervical cancer screening done in
those health facilities during the four months of intervention. These data which were
collected from the months of October 2009 to January 2010 are the intervention data.
The post intervention data could not be used because of the time constraint for the
project to be submitted.
25
3.5 INTERVENTION
Each department in Nyangabgwe Referral Hospital had an allocated days and time for
the health education talk in the week days. Each session lasts for 45 minutes. The period
of intervention was four months. Apart from Infectious Disease Care Center (IDCC) and
the Accident and Emergency (A&E) departments, all the other departments had their
sessions at a central place – the General outpatient Department (GOPD) where the
different departments had their allocated clinic days. Below is a table indicating the
schedules in Nyangabgwe Referral Hospital.
Table 1: Schedules for health education in Nyangabgwe Referral Hospital.
Departments
Allocated week Days
Medicine & Surgical out patients.
Allocated Time
0730- 0815HR.
Monday
Antenatal
/
Gynecology
and Tuesday
Maternal Child Health
Accident and Emergency (A & E)
0730- 0815HR
Wednesday
Infectious Disease Care Center ( Thursday
0730- 0815HR
0730- 0815HR
IDCC)
The Clinics also had scheduled days and time for the same message but was usually on
appointment. All the females who attended outpatient clinics on the selected days for
that department or clinic were recruited for the intervention. The recruitment was done
during the time when the patients have collected their files and are waiting to be
attended by the doctors. The research assistants, who were trained by (me) the
principal researcher, used the guideline for the presentation to explain the message in
26
the flyers to the clients. The training was done with a workshop held for the research
assistants, during which the contents of the flyers and posters were fully explained to
them and how to convey the information in the flyer to the clients using the prepared
guideline. The guide line was based on the Health Belief Model (HBM) constructs for
cervical cancer screening behavior change. Demonstration of health education talks was
done in three clinics. Here each research assistant took a turn while others observed
how he imparted the message. Followed were inputs from the observer members.
Consequently there was uniformity in the research assistants’ method of imparting the
message to the recipients before the commencement of the health education in the
study sites. The detail of how the health belief model was applied in the guide line
during the health education was explained in Appendix 4.
3.6 ETHICAL CONSIDERATIONS
Participation of the patients was voluntary. However, there was no need for
participatory informed consent because the intervention falls within normal health
information given to patients at a health centers and it was not invasive. However, for
the purpose of establishing whether the impact of the health promotion did contribute
to voluntarily cervical cancer screening by participants, there was the need for informed
consent in order to collect individual data from them. The informed consent was
translated in both English and Setswana. Appendix 5 is the copy of the consent form.
Those who accepted to participate in completing the questionnaire signed the consent
form. The questionnaires in most instances were self-administered and in few instances
administered with the help of research assistants who took time to explain the contents
to the clients and also informed them that it was not obligatory for anyone to answer
the questions. Permission to conduct the study was sought from Nyangabgwe Referral
Hospital, City of Francistown Research and Ethics Committee for all participating clinics
in Francistown. Clearance from the Ethical Committee of the University of Limpopo was
obtained as well as from Botswana Health research unit. The health facilities advised to
prepare for the potential influx of patients who may avail themselves for cancer of the
cervix screening.
3.7 LIMITATION
This study met some unforeseen challenges that limited its scope in the area of health
promotion. Among such challenges are financial and administrative. Nyangabgwe
27
Referral Hospital experienced a reduction in budgetary allocation following the country
wide economic down turn. As a result the production of the Hospital bulletin was
stopped. So the health promotion using the bulletin was not possible. Publishers of the
‘Northern Advertiser’ decided not to publish articles in that magazine again but rather
accepted the article on “cervical cancer and preventive behavior” for publication in a
new journal called ‘Inner City’ which was yet to be launched as news media. Time
constraints also limited the post-intervention period and as such the data measuring
effect of the intervention was collected immediately after the intervention period
contrary to the proposed collection of data four months post-intervention. It took much
longer time for Botswana Research and Ethical Committee to approve the study
following the approval by MREC of the University of Limpopo Medunsa Campus. This
was order to meet the time of submission of report.
3.8 RELIABILITY, VALIDITY, & OBJECTIVITY
Intervention reliability was ensured by the training of the research assistants on the
content of the material, as well as the presentation skills. The training reduced intertrainer differences. The translated educational materials into Setswana, which is the
local language, ensured accuracy of information given. The questionnaire was also
translated into Setswana in order to ensure accuracy of information. The research
assistants who participated in assisting clients in the completion of the questionnaires
were chosen based on their fluency in Setswana. The questionnaire was pilot tested to
ensure content validity. Content validity of the tool was ensured by the supervisor and
other professionals at the School of Public Health. The clinic and hospital records on the
uptake patterns were used to support the objectivity of the outcome evaluation results.
28
CHAPTER FOUR
4.0 RESULTS
4.1 INTRODUCTION
This chapter is devoted to the results of the analysis of the data of Pap smear screening
uptake from Nyangabgwe Referral Hospital, the clinics in Francistown (these are the
study sites) as well as from Princess Marina Hospital (the control group). The excel
spread sheath and the Statistical Package for Social sciences (SPSS) were the
instruments used for the analysis and capturing the data.
4.2 Distribution of respondents to questionnaire in study site and in control site.
A total number of 188 women responded to the study questionnaire. Out of these
respondents, 165 were from the study sites while 23 from the control site. The
distribution of the study questionnaire in the facilities is shown in Figure 1. The figure
shows that 28.2% were from Nyangabgwe Referral Hospital and 12.2% from Princes
Marina Hospital. From the clinics in within Francistown, 11.7% were from Gerald clinic.
10.6% from Area W clinic while 3.2% was from Masego clinic.
29
Figure 1 Health facilities in where study questionnaire were distributed.
4.3 Age Characteristics of Participants in cervical cancer uptake
The age distributions of the participants in intervention and control areas in the uptake
of cervical cancer is shown in Figure 2. The figure reveals that 3% were below age 21
years, 34 % were in the age range of 21- 30 years, and 35% were between 31-40 years.
Also 18% of the women sampled were in the age range of 41-50 years and 10% were in
the age range of 51-60years. It can also be noted that 86.2% of the participants were in
the reproductive age 15-49 years.
30
Figure 2: Age Characteristics of intervention participants in the uptake of cervical
cancer screening.
4.4 COMPARISM UP TAKE OF PAP SMEAR TEST
This section examines the trends of Pap smear test up take in Francistown clinics and in
Nyangabgwe Referral Hospital (NRH), (the study sites) and in Princess Marina Hospital
(the control site). Data for the period June to September (Pre-intervention period) and
the period October to January (during intervention period) were collected and analyzed
graphically.
4.4.1 Pap smear test uptake in Francistown Clinics.
The result of the Pap smear uptake by women in the clinics within Francistown is shown
in Figure 3. The result compares the uptakes in the pre-intervention and during
intervention periods by age range of women. The ratio of the number of uptake for each
31
age group to the total in both periods was expressed as percentage. The denominators
were the respective total uptake in the pre-intervention and in the intervention periods.
Age 21 to 40 years responded more than any other age group to the need for cervical
cancer screening (40% during the intervention period, and 32% for the pre-intervention
period). The trend of response falls with increasing age. Females in the advanced age 61
to 80 rarely came out to the call for regular cervical cancer screening. In both the preintervention and during intervention the uptake the pattern is similar. Also of note is
that the total uptake of Pap smear test was higher during the period of intervention
(1370) than in the pre-intervention period (1069) in the clinics within Francistown.
Figure 3 illustrates the percentage of cervical cancer screening uptake by age in
Francistown clinics.
Figure 3: Percentage Pap smear Up Take in Francistown Clinics by Age
32
4.4.1.2 Pap smear Uptake by each clinic in Francistown
The result of Pap smear test uptakes of women by the clinics in Francistown is shown in
Figure 4. This result represents the percentage Pap smear uptake by each clinic. The
ratio of the number of uptake by each clinic to the total uptake was expressed as
percentage. The denominators were the respective total uptake in the pre-intervention
and in the intervention periods. It reveals also that there was greater uptake in most of
the clinics during the intervention period than in the pre-intervention period. Area W
clinic registered 11% uptake during intervention period and 9% at pre-intervention. Nine
out of the twelve clinics studied attest to this finding. Comparative percentages indicate
higher values for the intervention periods than for the pre-intervention period. Also the
net uptake was higher (1365) for the intervention period than for the pr-intervention
period (969).
Figure 4: Percentage Pap smear test Uptake in the Pre- intervention and during
intervention in the Clinics.
33
4.5 Pap smear test uptake in Nyagabgwe Referral Hospital
4.5.1 Uptake of Pap smear test by age in Nyangabgwe Referral Hospital.
The result of Pap smear uptake in percentage by the age of women from Nyangabgwe
Referral Hospital is shown in Figure 5. The figure compares the pre-intervention uptake
with the intervention uptake of cervical cancer screening. The ratio of the number of
uptake for each age group to the total was expressed as percentage. The denominators
were the respective total uptake (741) in the pre-intervention and the total uptake
(1069) in the intervention periods. It is shown that 59% uptake was during the
intervention period as opposed 41% occurring in the pre-intervention period. There was
greater percentage uptake during the intervention period for all the age groups than in
the pre-intervention period.
Figure 5: Percentage uptake of Pap smear test in NRH (Pre- and during intervention
periods) by Age groups.
34
4.5.2 Uptake of Pap smear test in Nyangabgwe Referral Hospital by months.
The result of Pap smear test uptake by months in Nyangabgwe Referral Hospital is
shown in Figure 6. The trend of Pap smear uptake in Nyagabgwe Referral Hospital over
the months indicates sustained increases in uptake in the intervention months more
than in the pre-intervention months. The ratio of the number of uptake for each month
to the total was expressed as percentage. The nominator was the respective monthly
total uptake while the denominator was total uptake (1810) for the whole period.
Beginning from the onset of intervention there was a steady sustained rise from 11% in
October to 18% in January. This pattern of steady rise in uptake differs from the
fluctuating uptake pattern experienced in the pre-intervention months (June to
September). This is illustrated in figure 5.
Figure 6 Uptake of Pap smear test by months in Nyangabgwe Referral Hospital
35
4.6 Pap smear Test uptake in Princess Marina Hospital
4.6.1 Uptake of Pap smear test by months in Princess Marina Hospital.
The percentage of Pap smear test uptake by months in Princess Marina Hospital (control
site) is shown in Figure 7.
The ratio of the number of uptake for each month to the
total was expressed as percentage. The nominator was the respective monthly total
uptake while the denominator was total uptake (2442) for the whole period. The
percentage uptake of Pap smear test in PMH showed a declining trend during the
months which correspond to the pre- intervention period in the study site. The uptake
percentage was 19% in June, 16% in July, 13% in August and 12% in September of 2009.
The result also shows a fluctuating percentage uptake of Pap smear test from the
months of October 2009 to January 2010 which correspond to the intervention period in
the study site. The uptakes were 9% in October, 11% in November, 9% in December and
12% in January 2010. This is illustrated in Figure 7.
Figure 7: Uptake of Pap smear tests by months in Princess Marina Hospital.
36
4.6. 2 Uptake of Pap smear test by age in Princess Marina Hospital
The result in Figure 8 compares the uptake of Pap smear test in percentages by age of
women from Princess Marina Hospital, where there was no intervention. This result
reveals that in the period corresponding to the pre-intervention period in study site
(June to September2009), there was a higher uptake than during the period equivalent
to the intervention period in the study site (October 2009 to January 2010), for all the
age groups. The percentages of women who took the Pap smear test during preintervention period were 15% and 10% during the intervention period for the women
aged 21-30 years. For the age group 31-40 years, the percentage uptakes were 23% for
the pre- intervention and 16% for the intervention period. The percentage of women in
the ages 41-50 years that took the Pap smear test were 14% for the pre-intervention
period and 9% for the intervention period.
Figure 8 Uptake of Pap smear tests by age in Princess Marina Hospital
37
4.7 Factors influencing cervical cancer screening uptake
The result in Figure 9 highlights the factors which influenced cervical cancer uptake
among the women who participated in the study. Amongst these factors in their order
of contributions were; health education talks in hospitals and clinics-67%, interaction
with one suffering from cervical cancer-55%, pamphlet from someone who attended the
talk at clinics-35%, and posters at the hospital-17%. Other factors were pamphlet from
someone who attended the talk at the hospital-13%, consultation in the Infectious
Disease Center (IDCC)-10%, and posters at clinics-9% as well as health worker
consultation advice-8% and routine Maternal Child Health Care (MCH) visit-2%. These
findings are illustrated in Figure nine.
Figure 9 Factors influencing cervical cancer screening uptake.
38
4.8 TRENDS OF PAP SMEAR TEST IN THE PERIODS BEFORE AND DURIND THE STUDY
The result in Figure 10 shows the periods in which the respondents Pap smear test.
From the figure, it can be observed that the majority of the respondents (46%) indicated
being screened for cervical cancer during the intervention period as against 25% who
were screened in the pre-intervention period between January and September 2009.
Figure 10: Pap smear test before and during study in both the study and control sites.
4.9 CERVICAL CANCER SCREENING UPTAKE PERIODS
The result in Figure 11 shows the active period of cervical cancer screening uptake. The
figure indicates that 96% of cervical cancer screening activities occurred during the
intervention period (October 2009-January 2010).
39
Figure 11: Percentage of cervical cancer screening uptake.
4.10 Test of Hypothesis
4.10.1 The Null Hypothesis: (Ho: µ during intervention=µ pre-intervention). There is no
difference in the Pap smear test uptakes in the two periods (Pre-intervention and during
intervention periods) in the study sites on one hand and the study site with the control
site on the other hand.
Ho: µ during intervention=µ pre-intervention.
4.10.2 Alternate hypothesis: (H1: µduring >µ pre-intervention). There has been a
significant increase in the uptake of Pap smear test between the periods before
intervention and during the intervention in the study sites and the control sites.
4.11 Test Statistic: (t –distribution)
40
4.11.1 Test of difference between up take in the two periods in Francistown
June -September
October-January
Nyangabgwe
Referral Hospital
(NRH)
163
208
151
249
193
285
234
327
226
339
247
372
168
386
328
268
uptake
213.75
304.25
Standard deviation
58.25498
58.09421
Francistown
Clinics
Mean monthly
p-value
0.004718
Critical Region: Reject (Ho) Null hypothesis if p-value is < 0.05.
But P-value is < 0.05.
Null hypothesis is rejected and alternate hypothesis accepted. There was a significant
difference in the uptake of Pap smear test comparing the pre-intervention period and
during the intervention.
41
4.11.2 Comparison of uptake in Pap smear test Nyangabgwe Referral Hospital with
Princess Marina.
PMH
NRH
224
208
267
249
214
285
281
327
Mean
246.5
267.25
STDEV
28.16469 43.95665
p-value
0.25845
4.11.3 Critical Region: Reject Null hypothesis if P-value is < o.o5.
But P-value 0.25 is > 0.05. There Null Hypothesis is accepted in this case. The difference
in the two means is not statistically different.
42
CHAPTER FIVE
5.0 INTRODUCTION
This chapter is devoted to discussing the findings of this study. It also includes the
conclusions and some recommendations.
5.1 DISCUSSION OF FINDINGS
The study has shown that there was a higher uptake of cervical cancer screening during
the period of health promotion in the study site (59% in Francistown Clinics, and 57% in
Nyangabgwe Referral Hospital) than in the preceding period (41% in Francistown Clinics
and 43% in Nyangabgwe Referral Hospital). The difference in mean uptake between the
pre-intervention period and the intervention period in the study site was shown to be
significant, emphasizing the importance of the health promotion in boosting uptake of
cervical cancer screening.
The study also revealed that 67% of the women responded to screening following health
education talk as against 20% of the women that responded because of the routine
health professional advice. From questionnaire responses it is evident that health
promotion increased the awareness of women to the availability of cervical cancer
screening services more than the routine advice provided by health professional to
patients during consultation sessions, hence the higher response. There was 95%
screening uptake following health promotion intervention and 79% respondents had
Pap smear test at the same period. These results are supported by Pollack et. al. [22]
and Eva Grunfeld [45], who suggested regular public health campaigns over a short
period of time, such as cervical cancer awareness month or a traveling clinic which
targets one village at a time, as a good way to reach women who do not seek routine
preventive care, and the hard-to-reach and under-screened [22,45]. Such initiative
would promote community participation by mobilizing women organizations and
groups, and community information dissemination structures. Empowering women
within the facilities with information concerning the availability of cervical cancer
screening services in those facilities contributed to improve the uptake of Pap smear
test. Attempt to encourage public participation are critical to the process of
empowerment [41].This agrees with [25B] that limited knowledge of cancer of the
cervix and the importance of early detection and regular screening are among the areas
often addressed through health promotion efforts to raise awareness and change
behavior. The reason for non attendance could be the lack of sufficient information
43
about cancer of the cervix [6, 12, 14, 15], and was contributory to inadequate utilization
of Pap smear test among nurses and hospital maids [16].
The response to cervical cancer screening following health promotion was higher with
women in the reproductive age 20- 40 years, than those outside the reproductive age,
below age 20 and above age 40 respectively. Carruth et al [14] found out that the risk of
failing to obtain Pap testing increased with age and decreased with education and is in
line with the finding in this study which showed that 66% of women within age group,
20- 40 years, were motivated to respond to the screening by the health promotion
intervention while 38% of the older women accessed cervical cancer screening services.
Contact and interaction with someone living with cervical cancer had great motivating
influence in cervical cancer uptake response. In this study 55% uptake was due to
respondents’ interaction with someone affected by cervical cancer disease. Therefore,
women who had contact with someone affected by cervical cancer disease responded
positively to health promotion behavior change. This falls in line with the study of Hamid
and Azita [48] who found that 68.8% of participants in Pap smear test did so after they
had access to knowledge about cervical cancer and screening from letters of invitation
to participate in the test. This finding elaborates the perceived threats construct of the
Health Believe Model which proposes that perceived vulnerability to disease and
disease severity combine to form ‘threat’, and that threat perception motivates action.
Also supportive is the findings of Brewer et al [49], that woman who received false–
positive results conducted more frequent breast self-examination than did those with
normal results. The health promotion did arouse meaning in the recipients [29] that the
probability of an undesirable event (occurrence of cervical cancer) does exist, and so use
the information to adopt healthier life styles by responding to cervical cancer screening
test.
The study revealed an upward trend in the uptake of cervical cancer screening in the
study site and some fluctuation in the control site. However, there was no significant
difference in the mean uptake between the control and study sites. This result, which
appears contradictory to expected results, can be explained by the fact that the control
site is a referral hospital at the national capital city of Botswana. The women and their
families are likely to be more educated and respond to information about their health
needs easily. This view is further supported by Carruth et al [14], who have shown that
the risk of failing to obtain Pap testing decreased with education.
44
5.3 CONCLUSIONS
This study is timely; in that it occurred at a time when the momentum of government
instituted cervical cancer screening program is relaxing. It has provided an insight into
the situation of cervical cancer screening in Nyangabgwe Referral Hospital, Francistown
clinics as well as in Princess Marina Hospital. It is now obvious that the routine
opportunistic cervical cancer screening conducted by health care workers is not enough
because many women who do not come in contact with them are left out. Therefore,
there is a necessity to encourage more women to seek for cervical cancer screening
services in the health facilities as part of normal healthy behavior.
The information from this study although limited in terms of scope of the study has
provided insight into the uptake of cervical cancer screening. This information will be
useful for planners interested in interventions to increase uptake of cervical cancer
screening nationwide.
The discrepancy noticed between the uptake of cervical cancer screening by the very
elderly women and the rest of the eligible women is a cause of concern and that should
be a focus for planning an intervention to encourage this group to fully access the
cervical cancer screening services.
5.4 RECOMMENDATIONS
Based on the finding that health promotion had positive impact in the uptake of cervical
cancer screening in Nyangabgwe Referral Hospital, I recommend that the ministry of
health should mandate all clinics, primary and district hospitals as well as the two
referral hospitals in the country to include cervical cancer screening health promotion
within their catchment areas as part of their yearly annual development plan.
This study should be extended to include all the hospitals in the country so as to
establish the trend of cervical cancer and cervical cancer screening uptake in all the
45
districts. Not only should this study be undertaken in other locations to establish its
replicability but also it could be directed to target specific groups or classes of women.
Studies could also be done to establish the turn around time of the cytology based
cervical cancer screening so as to identify its benefit in reducing the cervical cancer
morbidity and mortality in the country. This is more desirable as many clients
complained that they are discouraged by not getting a feedback on their follow up
review visits.
46
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