Keywords

Cancer; Cervical; Perspective; Providers; Screening

Introduction

Cervical cancer is the 3rd most common cancer among women worldwide. According to [1]. The estimated cervical cancer mortality rate across all 78 low-income and lower-middleincome countries was 13.2 (range 12.9–14.1) per 100 000 women. It is the most frequently diagnosed in women between the ages of 35 and 44 with the average age at diagnosis being 50. The primary causative agent is the Human Papillomavirus (HPV) with the high-risk genotypes (HR- HPV) being responsible for the development of invasive cancer. Over 70% of all cases of cervical cancer are directly due to infection with HPV-16 and 18 strains thus making it the only human cancer whose cause is known [2]. In the early stage of the disease, no symptoms are seen. Later symptoms may include abnormal vaginal bleeding, pelvic pain, or pain during sexual intercourse [3]. It`s incidence and mortality rates remain high in developing countries due to low levels of awareness on preventive measures. It is the second leading cause of female cancer aged 15 to 44 years with 14,943 new cases in Nigeria diagnosed annually [4]. Women at risk for cervical cancer (female population aged above 15 years) in Nigeria is 53.1 million [5]. The annual number of deaths in Nigeria is 8,757 with a death rate (deaths per 100,0000 population) of 21.16. It is postulated that by the year 2025, there will be 22,914 new cervical cancer cases and 15,251 deaths in Nigeria [6]. In Nigeria, cervical cancer is the most common gynecological cancer and a leading cause of cancer death in women. It kills one woman every hour and over 9000 women every year [7]. Morbidity and mortality statistics for cancer are high in Nigeria, due to the ‘late presentation syndrome’ involving 83-87 percent of cancer patients [8]. This is because the awareness level of Nigerian women about cervical cancer is very low.

In Nigeria, services for dealing with cervical cancer are predominantly curative and have minimal effect on the incidence and mortality of the disease. Reviewed literatures have showed low knowledge and utilization of screening among women in the study area. A method known as Visual Inspection using Acetic Acid which is suitable for use in low resource settings has also recorded low knowledge and utilization by women.

There are currently vaccines that protect against common cancer-causing types of human papilloma virus (HPV) and can significantly reduce the risk of cervical cancer [9]. In Nigeria, the vaccine for preventing cervical cancer is not readily available due to its high cost.

Cervical cancer is the commonest malignancy among women in Kaduna State, Northwestern Nigeria [10,11]. Many of the women who die are breadwinners and caretakers of both children and the elderly.

Screening and treatment of pre-cancer lesions in women of 30 years and more is a cost-effective way to prevent cervical cancer [9]. Despite sensitization and availability of the screening services in this area, only a few women are attending the screening [12]. The researchers observed at several visits to the antenatal, Gynecological and oncology units of the hospital that, most patients with cervical cancer arrived late after receiving different kinds of treatment at home and eventually died. Further investigations revealed that, about 60-70% of patients managed at the hospital were cases of advanced stage cervical cancer [13]. It is interesting to note that cancer of the cervix is about the only human cancer that is almost entirely preventable. It is also 100 per cent curable if detected at very early stage. Treatment is cheap and simple in early stages requiring minimal manpower to achieve the high cure rate.

The role of the health care provider in cervical cancer screening is crucial and far-ranging. The provider's role as "gatekeeper" can profoundly affect how and when clients receive services or even whether clients receive services at all [14]. Despite the availability of screening services in the hospital, most women do not go for the service. Study by Oguntayo et al. [11] in Zaria, among women attending the hospital showed low levels of utilization of cervical cancer screening. No study has been carried out in the State to understand provider`s perspective on the subject matter. Provider`s perspective could provide more information and improve the utilization of screening for cervical cancer by women. Thus, the need for this study.

Methods and Materials

Objectives of the study

• To identify factors affecting women’s participation in cervical cancer screening.

• To examine the strategies put in place for cervical cancer screening.

• To examine the effectiveness of strategies for cervical cancer screening.

• To identify ways towards improving cervical cancer screening women.

Area of study

The study setting is Ahmadu Bello University Teaching Hospital (ABUTH) Shika, Zaria, Kaduna Statelocated along the Funtua road about five Kilometers away from the Ahmadu Bello University Zaria main Campus Samaru. As an institute of health, Ahmadu Bello University Teaching Hospital was established in 1967 under the ABU Zaria law commanding Act enacted by the former Northern Nigerian Government. The Federal Government took over the affairs of all Teaching Hospitals in the country in 1976 with ABUTH Zaria not an exception which was later regulated under the control of the Federal Ministry of Health. The aim of the hospital is to provide a variety of tertiary health care services to meet the health care need of people from the region and the country at large. ABUTH Zaria as a health care institution comprises of various departments and staff with different specialties among which the antenatal unit, oncology unit, Obstetrics and gynecology unit. This institution serves as a referral hospital for cases of cervical cancer.

Population of study

The study population consists of nurses and doctors working in the antenatal, gynecological and oncology units of the hospital.

Sample Size: Nurses and doctors (8) working in the antenatal, Oncology and reproductive health units who were willing to participate in the study were purposively selected for the study.

An in-depth-interview (IDI) guide was used to collect data from the informants.

In-depth-Interview Guide

• Age

• Religion

• Tribe

• Occupation

• Sex

• Factors affecting women’s participation for screening

Probe

Why do you think so?

Have the women been utilizing the services as expected?

*Strategies put in place for effective cervical cancer screening.

Probe

Services available

Duration

*Effectiveness of the services

Probe

Training of staff

Availability of equipment

*How cervical cancer screening can be improved

Interviews were in English language. The interviews were conducted by the principal investigator and one trained research assistant who was a nurse in the antenatal unit of the hospital. Individual interviews lasted for about 45 minutes and took place at the doctors’ and nurses’ offices. Interviews were audio recorded.

Ethical consideration

Permission to conduct the study was obtained from the ethical committee of the hospital. An informed consent form was sent to participants providing information on the essence of the study and seeking the respondents’ consent to participate in the study. The researchers adhered to the ethical principles that guided the study which were the principles of informed consent, respect for persons, beneficence, non-maleficence, and justice. These ensued voluntary participation by respondents and ensured that respondents were aware of confidentiality and anonymity. Confidentiality was maintained by not giving out participant’s information obtained during the study. Participants were made to know that they were free to withdraw their consent at any time and end their participation in the research without any fear of retribution.

Analysis

The audio recordings were transcribed verbatim. These were listened repeatedly to be familiar with the responses. Significant statements were grouped to form a unit. Clustering of units of meaning formed themes. Each interview was summarized and validated. Validity check was done by asking the informants if their responses were correctly captured, developing a textural description of “what happened”, and a structural description of “how” the phenomenon was experienced and then develops the essence. This was further reviewed by the interviewers for accuracy of information. Codes were formed after careful scrutiny.

Results

Table 1 shows the socio-demographic data of the respondents. The results showed that, majority (62.5%) of the respondents were females, less than half (37.5%) were between the ages of 51-60 years, most (87.5%) were Christians and a significant proportion (37.6%) were Yoruba and Edo and nurses were the majority (62.5%).

Table 1: Socio-demographic characteristics of  informants N=8.

Factors affecting women going for cervical cancer screening

In-depth interviews with key informants revealed lot of factors affecting women going for cervical cancer screening. Majority of the informants mentioned the following factors affecting women going for cervical cancer screening; “Ignorance, poverty, religion, superstitious belief, attitude of health care providers, cost of materials or equipments, long distance to screening centres, samples take a long time for results to be out and fear of opposite sex screening the women”. This was exemplified by some interviewees as stated below.

A 39 years old doctor from the antenatal unit stated that “These factor can be divided into two: Patient related factors such as; Ignorance, poverty, religion, unemployment, superstitions believe etc and care provider factors such as cost of materials or equipment, assessment of screening, samples take a long time, fear of opposite sex screening the women”.

Another doctor in the oncology unit said “awareness, superstition, belief, lack of beneficial information, low income, lack of free will of women to make medical decision, especially in the Northern part of Nigeria and influence of peer group, multiple sex partners etc, are the common factors affecting women going for cervical cancer screening.

Similarly a nurse from the antenatal unit said that “From my own understanding, it’s all about fear and ignorance that affect women coming for cervical cancer screening to the hospital”.

Probe: Why do you think so Majority of them said that from their own experiences, most of the women are not educated, not empowered to take care of themselves and depend on their husbands for money before they can do anything. They therefore lack money to autonomously take care of their health. This was exemplified by one of the nurses who said that “some women cannot afford to pay for the screening and also lack of awareness about the screening which makes them not to come for the screening services.” Another interview with the informants on whether they think that if the women are screened free for the first time, this will encourage them to go for subsequent screenings revealed, “That action may encourage them to go for subsequent screening”. Women in this environment like free services. One of the nurses in the reproductive health unit said that: “after the first screening, subsequent screenings are usually after 3 years until the patient reaches the age of 65 years. So I do not think that this will be a problem because they will have enough time to prepare towards attending the next screening”.

Strategies put in place for cervical cancer screening

Most informants said that “There are facilities on ground for screening women for cervical cancer. This includes both material and human resources. The nurses and doctors in the hospital have been trained to carry out cervical cancer screening especially Pap smear which is the main screening being carried out in the hospital. There are always enough equipment for the test and the doctors and nurses are willing to screen women for the disease.

Probe: Since when had these services been going on in the hospital?

Majority of the informants said that, the services have been going on for the past thirteen (13) years in the hospital. One of the nurses had this to say the services had been on for long now and women have been coming for the screening since the inception of the screening in the hospital.

Probe: Have the women been utilizing the services as expected? All the interviewees said “The women have not been utilizing the services as expected, but they avail themselves for other gynecological issues”. One of the informants, 57years old from antenatal unit said, “in a month we screen about 5 to 7 women for cervical cancer”. Our records will give us specific figures weekly, monthly and yearly.

Probe: If the few who avail themselves for screening have been consistent with their scheduled appointment dates.

Findings revealed that “the women have not been consistent with their appointment dates. When asked why, they usually complain of no money to come to the hospital which is also based on the husbands` approval”.

Effectiveness of strategies put in place for cervical cancer screening

The results revealed that all the respondents said that the services for cervical cancer screening are very effective. One of the nurses reiterated that “the services are very effective because we usually send the women to gynecologists who are well trained to take their specimen. We also health educate them on the need for cervical cancer screening. This is the reason why a few even come for the screening together with those that the doctors recommend as an investigative procedure.

Ways towards improving cervical cancer screening among women

Majority of the informants were of the opinion that, to improve cervical cancer screening, there is need to create more awareness about the disease to the general populace through health education. Incentives should be given to women who avail themselves for the screening and this should be made free. One of the medical doctors said ‘cervical cancer screening can be improved if the policy making process include some salient issues in the medical curriculum towards improving health care. There should be general sensitization of the women and cordial relationship among providers and the women towards encouraging the patients to go for screening. A nurse also said that “cervical cancer screening can be improved by creating awareness to women using pamphlets, distributing hand bills for women to be more educated about the disease and the importance of screening for the disease. There should also be proper remuneration for the health care providers to encourage them to screen the patients”.

Discussion

Results from the study highlighted the main themes that describe provider’s perspective regarding women participation for Cervical Cancer Screening.

The findings on factors affecting women’s participation in cervical cancer screening showed that; lack of awareness, cost of screening, attitude of health care providers, were some major factors affecting cervical cancer screening among women. This is in cognizance with the findings from other studies on the subject matter in Nigeria. Despite sensitization and availability of screening services in the area of study, only a few women are attending the screening [11]. Several studies such as Ogunbode et al, Feyi-Waboso et al, Ojiyiet et al, and Ezem [15-18]. In Nigeria have shown that, most women lack the required information about cervical cancer screening, in addition to some barriers leading to poor attitude and utilization of screening services for the disease. According to the main reasons for low utilization of Pap smear test are lack of awareness and cost of transportation to the hospitals [7]. A study by Ying et al. [19] among refugee women in King County, Washington showed that the women were unfamiliar with preventive care and cancer screening.

Findings regarding the strategies put in place for cervical cancer screening revealed that; there are adequate and effective services for cervical cancer screening. There is an equipped laboratory for Pap test screening. There are trained medical Doctors and nurses working in the screening unit of the hospital where pregnant women usually visit. The Pap smear is the main screening service in the centre. This is not surprising as the hospital is a tertiary hospital and serves as a referral centre for patients from other hospitals in Northern Nigeria.

The results on identifying ways towards improving cervical cancer screening for women revealed thus; some informants emphasized the need to improve health education for women using pamphlets and distributing handbills to complement the health education given to mothers about cervical cancer screening during antennal care. Other measures include; provision of incentives for women, making the services free and only females health workers should be doing the screening. This is because majority of the women are not educated, mainly full time housewives with no income to take care of their health as they totally depend on their husbands for finance. They will also prefer females screening them since the reproductive area are considered private and they will not want the male health personals to screen them. A study by [10] among refugee women in King County, Washington also showed that the women were in need of health education on cervical cancer screening and health education videos may be effective for providing simple, low literacy messages in women's native languages. A study by also revealed that women in the environment prefer the male health personnel’s to screen them [7].

Conclusion

Findings from this study showed that improving knowledge about cervical cancer screening would improve utilization of the services. There are appropriate strategies put in place for screening the women. Emphasis on health promotion and prevention should be considered when designing education programs. Interventions designed to improve screening can be more effective when the women/community members are involved in each phase, ensuring cultural relevance. Improving knowledge through handbills, pamphlets may also help improve knowledge among the women.

This study was merely the tip of the iceberg in regards to exploring provider’s experiences of Cervical Cancer Screening; however, it informs the potential and future emphasis for research and nursing interventions.

Recommendation

There is need for more research focusing on the ways in which culture influences how women perceive screening practice. Specific interventions for health care providers can be developed based on the findings from this study.

Limitations

Although the findings from this study add to the current knowledge base of the experiences of health care providers on cervical cancer screening for women in a referral hospital in Northern Nigeria, there is need for a wider coverage in Nigeria. There were other factors that this study did not look at and may be interesting to include in future studies like the intention for use of cervical cancer vaccine and the effects of cervical cancer fatalities and survival in the area of study.

References

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