Uptake of Cervical Cancer Screening Among Female Staff at the University College Hospital, Ibadan

Among the 375 participants recruited into this study, 360 returned a completed questionnaire giving a response rate of 96%.

Result from Table 1 below shows the distribution of the study participants into 48 (13.3%) clinical and 312 (86.7%) non-clinical staff members and the socio-demographic characteristics of the respondents. The largest proportion of the respondents 177 (49.2%) were within the age group 30-39 years while the lowest proportion 39 (10.8%) were within 20-29 years. The mean age of all respondents was 38.2±0.43 years, with age range of between 20 and 58 years. All the respondents were females, the highest educational status was first degree, (43.3%) while 21.4% had postgraduate degrees, the majority were married (87.2%), while the remaining 25.3% had no child and included those that were single and those that were married but with no children yet.

A larger proportion, 351 (97.5%) of the respondents had heard of cervical cancer while 9 (2.5%) were ignorant of the disease. Most of respondents got their information from the health workers, 182 (50.6%); other sources included Teachers (59, 16.4%), media (53, 14.7%), printed materials (32, 8.9%), family and friends (22, 6.1%) and religious leaders (2, 0.6%). There were others (10, 2.8%) who claimed to have been informed at work and at school.

Majority of the respondents reported vaginal bleeding (69.4%) and vaginal foul smelling discharges (67.8%) as the common symptoms of cervical cancer, while others (27.5%) considered abdominal pain, headache as a symptom. Some reported other symptoms including painful sexual intercourse, post coital bleeding and weight loss.

Concerning the knowledge of the respondents on the risk factors of cervical cancer, majority rightly indicated that multiple sexual partners (72.2%) and early sexual debut (63.6%) were the two most important risk factors among others.

Majority (86.1%) also displayed a good knowledge of the cured of cervical cancer in its earliest stage following screening. Most of the respondents indicated that radiotherapy (64.2%), specific cancer drugs (56.1) and surgery (52.5%) were mode of treatment while about 4.7% reported herbal remedies as a treatment modality. The cost of cervical cancer treatment was said to be very expensive in 57.8%, 20.8% said that the cost is moderately expensive, while 0.8% thought it’s free of charge.

Among the respondents, 77.8% stated that there were screening procedures to detect premalignant cervical lesion, and 53.3% rightly said that screening should be yearly but only 38.3% responded that sexually active women should be screened while 61.7% had poor knowledge on eligible persons for cervical cancer screening. Majority of the respondents (82.8%) identified Pap smear as the main procedure used in screening cervical cancer, while others also identified Visual Inspection with Lugol's Iodine (VILI) (35.6%) and Visual Inspection with Acetic Acid (VIA) (18.3%) as shown in Table 3. Most of the respondents (61.7%) agreed that cancer of the cervix is highly prevalent in Nigeria and is a leading cause of death amongst all malignancies. On overall, the average score on the knowledge of the respondents on cervical cancer identified 65.5% having good knowledge of the cervical cancer while 34.5% had poor knowledge.

(Table 2) below gives a summary of responses of respondents on their attitude to cervical screening. Fewer number of respondents 171 (47.5%) displayed positive attitude to cervical cancer screening.

As shown in Table 3, majority of the respondents (65.9%) had never been screened for cervical cancer, and out of the 34.1% screened, 60.2% of them had it once, while 39.8% had screened more than once with most having their last screening done less than a year ago. The major barriers to non-uptake included undecided (21.9%), ignorance of the available screening methods (16.1%) and cost (9.2%), while others included feeling of good health and may be painful. Other factors affecting their uptake of screening services are shown in Table 3 below. Only 32.8% claimed to have utilized the available facility based screening services before while most respondents had not. The major reasons for not using the services varied among the respondents and included Staff hostility (28.6%), cost (20%), and pain (8.9%), others as shown in Table 3 below. Pap smear was reported as the main available screening test in their centre in 68.6%.

There is a higher proportion of the respondents, (56.6%) who have had information on cervical cancer but did not take up its screening services. This difference though, was not statistically significant (p =0.190). There was a negative significance relationship between the knowledge of locally available cervical cancer screening services and the utilization of the services (p <0.001), for instance, majority of the respondents, (76.7%) were aware of the availability of Pap smear services, but only (30.2%) utilized the service.

The majority of the respondents, 72.5% had positive attitude toward cervical cancer screening out of which only about a half of them, (52.9%) have been screened while majority of those with negative attitude (83.5%) also failed to uptake the screening programme (p< 0.001).

(Table 5) shows the result of the logistic regression performed to ascertain the effects of socio-demographic factors, attitude, and awareness of cervical cancer on the likelihood that respondents will go for cervical cancer screening. The model explained 53.2% (NagelkerkeR²) of the variance in cervical cancer screening uptake and correctly classified 83.0% of cases.

We observed from Table 5 that attitude and number of children added significantly to the model at p=≤0.005. That of age, education, barriers, and awareness was not statistically significant at p=≤0.05. This implies that females with negative attitude and those with children (no matter the number of children they have), are less likely to take up cervical cancer screening services (co-efficient is negative).

The findings from this study highlight the major factors affecting the uptake of cervical cancer screening by the respondents. The study clearly demonstrated a high level of awareness on cervical cancer (93.1%), knowledge on symptoms and the risk factors of acquiring cervical cancer and the availability of a screening programme (85%). These high percentages may be because the respondents were hospital staffs with majority of them having basic medical or paramedical training and exposures. This cannot be compare with poor awareness, (20%) among tertiary school female students in Ibadan and among women in a local community in Ibadan(40%) and Lagos⁶,⁷,⁸. However, in the United Kingdom, USA (California) and other developed countries, awareness was found to be high among the entire populace as over three quarters of the respondents were aware of carcinoma of the cervix⁹,¹⁰.

Fewer than half of the respondents (47%) identified health workers as the main sources of information on cancers screening, these may reflect the low drive for information dissemination among the health workers on cancer screening despite high knowledge. This is unlike in the developed areas where the health workers have a mandate to ensure provision of more effective health education and information about preventive and screening in order to be able to elicit the fears, prejudices and priorities of patients that may serve as barriers to uptake of the programmes¹¹.

This study also shows a good attitude of the respondents to the screening programmes. On overall, more than half of the respondent had a positive attitude towards the screening which was similar to the finding in the study in Tunisia¹². Perception of susceptibility to the cancer development also affect screening behaviour. Less than one quarter of the respondents wrongly expressed lack of personal susceptibility to cancer and therefore believed it was unnecessary for them to have any screening done. Unlike in the Tunisia study which showed more women expressing lack of susceptibility to cervical cancer preventing them from uptaking the screening programmes¹².

In this study, only one third of the respondents had undergone cervical cancer screening. This pattern of low uptake of pap smear is usually observed across African countries including among the health workers in spite of their good knowledge and among Vietnamese women¹⁰,¹³. The situation was worse in the study by Udigwe in 2006 that showed that only 5.7% of respondents had undergone a Pap smear test.

In this study, the majority of women in age group 30-39 years uptake the screening more whereas in developed countries, the younger women in the age group 20–29 years tend to be screened earlier based on the high level of awareness and standard national programmes on screening available.

The relationship between level of knowledge of cervical cancer screening, attitude towards the screening programmes and uptake of the screening programmes by respondents in this study is very worrisome because the respondents had good knowledge of the disease, associated risk factors and the available screening programmes, they also had positive attitude toward the screening programmes but uptake was still very poor. This is alarming because their knowledge and attitude did not translate to actual utilization of the programme. This result can partly explain the reason why there are poor uptake among women in this part of the world, the health workers who supposed to flag-off the campaign for proper and regular screening and advocate for the establishment of a national screening programme, are careless about their own screening and this will lead to poor sensitization of their patients and clients on the locally available screening programmes and hence resulting in poor or non-uptake. Surprisingly similar pattern is seen in some studies done among the health workers especially in Africa¹¹,¹⁴,¹⁵.

A significant relationship is observed between age of respondents and uptake of cervical cancer screening. The practice of cervical cancer screening is higher among the married respondents, despite their relatively poor attitude, although still more than half of the married are yet to be screened.

The greatest barriers identified against the screening in this study was indecision of respondents, and believe of being healthy. Other factors include shyness in being screened by a male doctor, disagreement of their husband, fear of positive result, high cost of the screening, fear of infection from equipment used for the procedure, busy schedule at work, delay in conception and logistic reasons. Similar barriers are common to several local and hospital based studies even in this environment⁶,¹⁶,¹⁷.

It is therefore obvious from these findings that a concerted effort is needed to actively remove these barriers by repeated education, training and re-training strategies to improve their uptake and level of advocacy in campaigning for screening among their patients and clients.