Prevalence Of Cervical Cancer Among Women Of Child Bearing Age At Orlu Teaching Hospital Imo State
Cervical cancer has been identified as the second most common cancer in women and contributes to the high mortality rate in women. Among all cancers in women, cervical cancer is rated the second most common cancer in women worldwide. In poorly resourced settings, access to services offering cervical screening is still a challenge and it is estimated that more than 50% of women in developing countries have never had a single screening test for cervical abnormalities. The purpose of this study was to assess women’s awareness, attitudes and experiences regarding cervical smear testing and for cervical cancer in Orlu Teaching Hospital, Imo State and to better understand factors influencing access to and utilization of cervical cancer screening services by women of child bearing age. The method employed was a descriptive study using a questionnaire to collect quantitative data. The sample consisted of 69 women aged 30 years and above. The primary outcome measure for the analyses was who has been screened for cervical cancer and this was assessed from the previous history reports of the women. The secondary outcome measure was to investigate knowledge and perceptions regarding cervical cancer and screening. Socio-demographic factors associated with having been screened were also explored. Most of the women in this study had never been screened for cervical cancer in their lifetime as reflected by n=55 (82%) while only n=14 (18%) ever screened for cervical cancer. The results of this study cannot be generalised to the population due to the small sample size. However, there is need to facilitate comprehensive health education and the implementation of cervical screening programmes to target women in rural communities to contribute to the success of the cervical screening programme. The results of this study showed that 60% of respondents were informed by health care professionals on cervical cancer screening. Health care workers also should play a vital role in educating communities on cervical cancer and on the benefits for cervical cancer screening, through reaching all patients who utilise health care services with cervical cancer information and also communities through outreach programmes.
1.1 Background of the Study
Cervical cancer forms in the tissues of the cervix (the organ connecting the uterus and vagina). It is usually a slow-growing cancer that may not have symptoms but can be found with regular Pap tests (a procedure in which cells are scraped from the cervix and looked at under a microscope). Cervical cancer is almost always caused by Human Papillomavirus (HPV) infection. Cervical cancer is malignant neoplasm of the cervix uteri or cervical area. It may present with vaginal bleeding but symptoms may be absent until the cancer is in its advanced stages (WHO/ICO Information Centre on HPV and Cervical Cancer, 2009). Treatment consists of surgery (including local excision) in early stages, and chemotherapy and radiotherapy in advanced stages of the disease.
Pap smear screening can identify potentially precancerous changes. Treatment of high-grade changes can prevent the development of cancer. In developed countries, the widespread use of cervical screening programs has reduced the incidence of invasive cervical cancer by 50% or more (American Cancer Society, 2009:10). Human Papilloma Virus (HPV) infection is a necessary factor in the development of nearly all cases of cervical cancer.
Cervical cancer is a typically slow-growing cancer that may not have symptoms but can be early diagnosed by doing a Pap smear. The burden of disease due to transmissible diseases such as HIV and Human Papilloma Virus (HPV) is increasing especially in developing countries. Research has shown that HPV is the cause of about 70% of all cervical cancers (WHO/ICO, 2010). Leroy, Ladner, De Clercq, Meheus, Nyiraziraje, Karita and Dabis (1999:104), and Tate and Anderson (2002:881) have shown a statistical significant relationship between HIV, HPV and cervical abnormalities. According to the World Health Organization (WHO) Information Centre on HPV and Cervical Cancer, 2009 report, cervical cancer is currently the primary cancer in women in Nigeria with an annual new case incidence of 6 742, in African women. It is estimated that the annual number of new cases worldwide, is as high as 493 243. Deaths due to cervical cancer amount to 273 505 women worldwide and 3 681 in Nigeria (WHO/ICO Information Centre on HPV and Cervical Cancer, 2009).
Knowledge about the disease and risk factors are therefore important in determining appropriate health seeking behaviours with the aim to prevent invasive cancer and reduce mortality rates. Chapter one orientates the reader to the rationale of the problem and an overview of the research methodology on familiarity of women regarding cervical cancer.
This research study will provide insight into the knowledge level and experiences of women of child bearing age to screening and cancer, and also explore the factors influencing access to screening services.
1.2 Statement of the Problem
Cervical cancer is the leading cause of death from cancer among childbearing women (WHO, 2007). Though it is preventable, screening practice of both health workers and clients is limited and little documentation is available. Health workers are important in preventing this disease; however, their knowledge, attitude and practices have been not established (Mmiro et al, 2006). It is important to describe the differences among women and their perceived risk of cervical cancer to determine target groups to increase cervical cancer screening (Sudenga et al 2013). Nigerian women above 15 years are at risk of developing cervical cancer. Currently, cervical cytology reduces cervical cancer incidence, since it allows for early diagnosis and treatment. Studies conducted in African countries, like Nigeria, Botswana and Kenya showed that women have limited knowledge towards cervical cancer, which contribute to their non-participation in screening programs and even though some were screened, they do not present themselves for follow up care (Nganwai, 2008). Central to the success of any screening programme is its ability to identify, reach out and screen the defined target population. Cervical screening coverage in Nigeria is currently at 3.2% (NBS, 2012). Cervical cancer cases normally present at advanced stages forcing health seekers to seek health attention in referral hospitals (Onywany, 2012). Several factors may contribute to the underutilization of screening, including lack of awareness, lack of funds, women’s worry about examination discomfort, fear of finding cancer, and inability to establish effective follow-up treatment. Therefore, this study will identify prevalence of cervical cancer among women of child bearing age at Orlu teaching hospital Imo state
1.3 Research Question
- What is the rate of screening for cervical cancer among women aged 30 years and above in Orlu Teaching Hospital?
- What is the knowledge and perceptions of women on cervical cancer?
- What is the socio-demographic factors associated with accessing cervical cancer
1.4 Purpose of the Study
The purpose of the study is to assess the prevalence of cervical cancer among women of child bearing age at orlu teaching hospital Imo state
1.5 Objectives of the Study
The objectives are to:
- Determine the rate of screening for cervical cancer among women aged 30 years and above in Orlu Teaching Hospital,
- Explore and describe the knowledge and perceptions of women on cervical cancer.
- Identify and characterise socio-demographic factors associated with accessing cervical cancer
1.6 Definitions of Terms
Awareness is described as appreciation, familiarity, knowledge, observation or understanding (Oxford Concise English Dictionary 1995). For this study awareness meant “being familiar and also knowledgeable about cervical cancer and cervical cancer smear screening.” It also relates to the experience and perceptions influencing the uptake of cervical screening services.
The cervix is the lower part or neck of the uterus forming the opening to the vagina. It is divided into 2 parts, namely the endo-cervix, internal part and ecto-cervix, the outer part that is next to the vagina (Pocket Medical Dictionary, 2003: 57).
Cervical cancer relates to the actual neoplasma cancerous cell changes in the cervix commonly referred to as carcinoma in situ (cancerous growth localised) and invasive cancer (cancer spreads to nearby organs).
Cervical screening: For the purpose of this study cervical screening relates to early detection of pre-cancer lesions through a Papanicolau smear (Pap).
1.7 Organization of the Study
This study is organized into five chapters. Chapter one included the background of the study, research problem, research objectives and questions as well as limitation of the study. Chapter two contains the literature review. Chapter three includes the methodology and study area. Chapter Four contains the results and discussion of key findings of the study. Chapter Five finally looks at the summary, conclusions, and recommendations based on the findings.
Discussion and Recommendations
5.2.1 Socio-demographic characteristics of women
The sample for the analyses included n=69 women from age 30 and above. Although this is a small sample size, it is not inconsistent with demographic and socio-economic data that has been previously reported in this rural geographic area. The sample comprised mainly middle aged women since the study exclusively enrolled women from age 30 and above. This age group is consistent with age intervals as laid down in the National cervical screening programme (Moodley, 2009:11). More than half n=51 of the sample had some form of education, though almost half of the sample had only achieved primary education. The greater proportion of women were unemployed, however, this factor could not have hindered women from accessing district health services for screening since the services are provided free of charge.
The employment rate was also very low, with only n=18 (26%) of women being employed either part-time or full-time. However, the analyses included a high sample of unemployed women, although this may be expected given that the microbicide study clinics were primarily open during work hours. This high unemployment rate is a course for concern and reflects a challenge in reaching the millennium target of achieving permanent and decent work for all, including women, and also halving the proportion of people who suffer from hunger by 2015. This could negatively impact on access to health care services (including cervical screening services), especially where women are required to pay transport fees. Contrary to expectations it was encouraging to note that over half of these women (71%) were accessing contraceptives. This high proportion might have been influenced by participation to the Microbicide clinical trial, where women were strongly counselled to use contraceptives. The goal of achieving universal access to reproductive health by 2015 is possible, given the high contraceptive prevalence in this rural population (Orlu Teaching Hospital health website, Millennium Development Goals (MDG) indicators, 2008).
5.2.2 The rate of screening and factors associated with having been screened for cervical cancer
Despite a greater percentage (60.8%) of women perceiving themselves at risk of cervical cancer, a very low percentage (18.8%) had ever been screened in their lifetime. Research conducted in other countries have shown similar results, in most cases women thought one needs to go for a test as a result of a recommendation by a health professional (Adanu, 2002:487-488; Ezem, 2007:95). Moodley (2009) re-iterates that, in reality women in developing countries usually attend health care for cervical smear when the disease is symptomatic and progressed to advanced stages. Both women and health care workers attest to women accepting cervical cancer screening when they are symptomatic as opposed to a health screening test (Wood &Jewkes, 1996:10; Leyden, Manos, Geiger, Weinmann, Mouchawar, Bischoff, Yood, Gilbert and Taplin, 2005:677; and Hoque, Hoque and Kader, 2008:112). The research studies have shown a high HIV incidence in this Orlu Teaching Hospital population 3.4 per 100 person-years from the years 2003-2007 (Bärnighausen, Tanser and Newell, 2009:406), and the risk of cervical cancer is also high. However, the cervical screening frequency does not correlate to the risk. The cervical cancer screening frequency also needs to be revised especially for HIV exposed and infected women since the literature suggests that disease progression to invasive cancer usually occurs ten years earlier in HIV positive women (Health Systems Trust, 2009:1; Franceschi& Jaffe, 2007:511).
There are very few differences between women who had been or had never been screened for cervical cancer. This is possibly indicative of a generalized low utilization of cervical screening in this population especially in relation to low awareness levels on cervical cancer and screening in Orlu Teaching Hospital. There was a greater concordance among the various local studies in the low cervical screening rates in women (Abrahams, Wood &Jewkes, 1996:22; Moodley, 2009:12). A study conducted in Orlu Teaching Hospital did not find any significant predictor for doing a Pap smear among respondents; however this study was conducted among university students (Hoque&Hoque, 2009:22). This may be indicative of a general awareness, knowledge and access problem irrespective of educational background.
Women with lower socio-economic status were less likely to go to clinics for screening for cervical cancer, although this difference was not statistically significant. This raises concerns since government primary health care services are provided free of charge. It is not clear whether this is linked to perceptions in the community about free health services, and addressing this might shed some light on reasons for this relationship. Older women between the ages 35-44 were less likely to screen for cervical cancer compared to younger women. Leyden et al., (2005) found similar results. This is of great concern since at these ages women should at least have received a second Pap smear (according to the National screening programme). According to Abrahams et al., (1996: 8), “early screening services focused on family planning attenders and women using antenatal services”. Even when considering this earlier focus, with more than half n=49 (71%) of the sample reporting using family planning, one would expect that a greater proportion of women were reached with this educational information at some stage. Evidence from prior research indicates that hearing about cervical screening does not always translate to higher usage of the screening service (Adanu, 2002:487; Twinn, Shiu and Holroyd, 2002:382; Abrahams, Wood and Jewkes, 1996:12; Hoque, Hoque and Kader, 2008:113). There should be a considerable amount of packaging messages in line with the target population coupled with re-enforcement of messages. The focus should be on all women receiving comprehensive health services including screening for cervical cancer. This study recruited women who were already utilizing primary health care services, therefore one would expect the utilization for cervical screening to be higher than the result presented.
The odds of cervical screening were less in single women compared to married women. Studies conducted elsewhere have shown a significant difference of cervical screening and marriage, with married women more likely than single women to screen for cervical cancer (Twinn et al., 2002:379; Leyden et al., 2005:677).This could be attributed to differences in risk perceptions by marital status. In other studies women explained the role played by marital partners as vital to the utilizing of screening (Twinn et al., 2002:380; Ezem, 2007:95).
Wong et al., (2009) also reported that married women had a higher recognition of cervical cancer risk factors than unmarried women. The health educational initiatives on cervical cancer should not only target women since male partners have a potential of playing a vital role in increasing utilization of this service.
5.2.3 Knowledge and perceptions of women on cervical cancer and screening
Women who were enrolled in this study were exposed to some education on cervical cancer screening, since this service was provided as standard of care to all Microbicide clinical trial participants. Despite this exposure, the level of knowledge was still low in this group. A greater proportion of women who had never tested cited lack of awareness as the main reason. According to Moodley (2009:11-12), the main barriers to testing in developing countries are a lack of awareness of the disease and screening, women not availing themselves of screening services and lack of political will to provide the service. Dissemination of information should focus on all women especially eligible women (aged 30 years and above in the Nigerian context). Women seem to remember messages re-enforced, this is evidenced by more than two thirds (n=15) of women stating that the Pap smear should be conducted every three months. Women in this cohort were screened for sexually transmitted infections (STIs) every three months through pelvic examination and cervico-vaginal sample collection. There is a possibility that the Pap smear cervical cancer screening test, which was conducted once at enrolment, was confused with the three monthly screening for STIs that were conducted as part of the microbicide clinical trial procedures. This indicates that re-enforcement of positive and correct messages could be helpful to motivate women to screen for cervical cancer. It is of vital importance to carefully package cervical cancer and screening messages and also to ensure that the wider female population is reached. Lyttle and Stadelman (2006:6), also found uncertainty on the frequency of cervical screening tests with women reporting that cervical screening should be performed six monthly. The basic screening test was known by more than half of the sample, however it is worrying to note that despite women having been exposed to the same screening test, still almost 30% did not know the basic cervical cancer screening test. Earlier studies conducted in the same rural population found similar results (Wood &Jewkes, 1996:9). There is a great need to empower women to understand their health care needs and also basic screening procedures so as to increase the uptake of this service.
It was encouraging to learn that a greater proportion of women received cervical cancer information from the clinics or community health workers. Hogue and Hogue, (2009:22); Ezem, (2007:95); Abrahams et al., (1996:29); Lyttle and Stadelman, (2006:3) found similar results. Conversely, Wong, Wong, Low, Khoo and Shuib, (2009) reported that lack of recommendation by health care providers hindered women in screening for cervical cancer. In addition, preventive counselling to reduce the risk of cervical cancer is viewed as of less importance by health professionals in other settings (Tessarro, Herman, Shaw and Giese, 1996:272). Only one woman stated that she got cervical cancer information from the posters. This further intensifies the need for all health care professionals who come into contact with women to include cervical cancer and screening information in the health talks. Women showed lack of understanding of the basic female anatomical parts; they vaguely described cervical cancer as a bad and fatal disease without mentioning the cervix. Wood and Jewkes (1996:16) found similar results in earlier studies conducted in this population. It is important to explore terminology used by women to refer to female parts, adjust and use these in the health educational talks.
Lack of sufficient knowledge was demonstrated by more than half (57%) of women not knowing risk factors for cervical cancer. The danger of not knowing risk factors is that chances of prevention of behavioral risk factors are almost non-existent. This then results in a greater proportion of women at risk of cervical cancer. Literature reports that HPV is a significant risk factor for cervical cancer (Khan, Castle, Lorincz, Wacholder, Sherman, Scott, Rush, Glass and Schiffman, 2005:1073; Chirenje et al., 2002:766). The same premise may apply about ignorance on whether cancer can be prevented or not. This study showed that women knew that cancer could be prevented. Women (60%) of the sample also correctly stated that cervical cancer could be prevented through early screening and management. This would form a basis for motivating women to screen for cervical cancer. Willingness to screen in the future was also a strong factor in this sample. Conversely, in other populations, lack of willingness to test is attributed to perceived lack of personal susceptibility to cervical cancer (Wong et al., 2009:50). Lyttle and Stadelman (2006:4), reported misconceptions for future screening like a previous hysterectomy regardless of the reason. There is need to scale up health education on cervical screening services and also access to such services so as to increase impact in reduction of cervical cancer incidence and mortality due to invasive cancer.
5.3 Conclusion and Recommendations
This study revealed that there is limited information about cervical cancer, risk factors and cervical screening among this population. Also these results suggested poor dissemination of information by health care professionals. Women stated lack of information as the main barrier to screening; most surprisingly these women were recruited from health care services. Cervical screening initiatives should aim to reach women who have never had a Pap smear done and all eligible women.
Information pamphlets or posters should be user friendly i.e. translated to the local language and also distributed to the female population as widely as possible. The health managers should review packaging of information so as to simplify complex terminology when necessary to enhance understanding by all women. The use of audio-visual aids presented in the local language (for example video clips in clinic/hospital waiting rooms) should be reinforced. Cervical cancer and screening messages should form part of the basic health education package offered to all women, irrespective of their health status. Mini surveys should also be periodically conducted to elicit the level of understanding on cervical cancer and the importance of screening. Information obtained would then assist health professionals to further improve the screening services.
The national screening guideline should be revised to include cervical cancer screening in HIV positive women, and also resources should be scaled up in line with the HIV prevalence in this population. This should be coupled with staff training and periodic in-service education, but also revision of basic health programs would also be necessary. Health educational initiatives should also target men since studies suggest that male partners could play a vital role in increasing the awareness of this service. It is recommended that further large scale studies be conducted to focus on exploring health care resources that influence access across the district so as to better understand reasons for the low uptake of the screening service in this rural community.
5.4 Concluding Remark
Most of the women in this study had never been screened for cervical cancer in their lifetime as reflected by n=14 (18%) ever screened and n=55 (82%) never screened for cervical cancer in this study. The results of this study cannot be generalised to the population due to the small sample size. However, there a need to re-inforce a comprehensive health education and cervical screening programme to target women in rural communities and to ensure the success of the cervical screening programme. The results of this study showed that 60% of respondents were informed by health care professionals on cervical cancer screening. Health care workers also should play a vital role in educating communities on cervical cancer and on the benefits for cervical cancer screening, reaching all patients who utilise health care services with this information and also communities through outreach programmes. Attempts should be made to reach women who rarely visit health care services, for example, through increasing health campaigns in partnership with other organizations in the area.
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