MASTERS IN PUBLIC HEALTH THESIS ASSISTED

BY VINCENT ENE
FOR

IWARA, PROMISE EYO

1
UTILIZATION OF CERVICAL CANCER SCREENING SERVICES AND TRENDS IN
OCCURRENCE AMONG WOMEN OF REPRODUCTIVE AGE IN CALABAR
MUNICIPALITY, CROSS RIVER STATE, NIGERIA

THESIS

WRITTEN BY

IWARA, PROMISE EYO

PUH/MPH/16/005

SUBMITTED TO

DEPARTMENT OF PUBLIC HEALTH

FACULTY OF ALLIED MEDICAL SCIENCES

UNIVERSITY OF CALABAR

IN PARTIAL FULFILMENT FOR THE AWARD OF MASTERS IN

PUBLIC HEALTH (MPH) DEGREE

APRIL, 2021.

2
 CERTIFICATION

I certify that this thesis is original and has been written by me. It is a record of my research work

and has not been presented before in any previous publication.

Iwara, Promise Eyo Signature………………….………

(Student/candidate)

Date………………………………

Dr. Bernadine N. Ekpenyong Signature:………………….……….

(Supervisor)

OD, MPH, PhD, FNCO Date…………………….………….

3
 DECLARATION

We declare that this thesis entitled “Utilization of cervical cancer screening services and trends
in occurrence among women of reproductive age in Calabar Municipality, Cross
River State, Nigeria” by Iwara, Promise Eyo with registration number
PUH/MPH/16/005, carried out under supervision has been examined and found to have
met the regulations of the University of Calabar. We therefore recommend the work for the
award of Masters in Public Health Degree.

Dr. Bernadine N. Ekpenyong Signature:………………………..

(Supervisor)

OD, MPH, PhD, FNCO Date……………………………...

Senior Lecturer

Prof. Nelson C. Osuchukwu Signature……………….………..

(Head of Department)

OD, MPH, PhD Date……………………………...

Professor

…………………..……... Signature…………………..……...

(External Examiner)

Ph.D, MPH Date………………………….……

Professor

4
 ACKNOWLEDEMENTS

The successful completion of this thesis is as a result of the grace and mercy of the

Almighty God and the assistance of several individuals. I express my profound gratitude

to my thesis supervisor, Dr. Bernadine N. Ekpenyong for her patience, tolerance and

supportive suggestions which contributed immensely to the successful completion of this

work. I am grateful to the Head of Department, Prof. Nelson C. Osuchukwu for his

fatherly advice, support and encouragement towards the successful completion of the

programme. I am also grateful to all other lecturers in the Department of Public Health for

the profound influence they have had on my career. As my lecturers, they were a source

of inspiration to me and gave me every necessary encouragement. These lecturers deserve

more gratitude from me than I can express.

My special loving thanks to my family; Engr. Michael Eteng, Engr. and Mrs. A. Iwara

and all my siblings; Glory, Samuel and Arch. Efa for their unconditional love, delights

and even financial support during the thesis time. I may not have reach this far without

them.

With encouragement and love from my friends and colleagues, especially, Victor Ene,

Jimmy Eko, Justine Apebende, Margaret Inde, Love Inyang, Grace Okure among others.

Who stood by me and gave me support in diverse ways to make this thesis completed

within the stipulated time. I will not forget Dr Margaret Akpan whose work in cervical

cancer served as an inspiration to me in choosing this research topic. Above all I am most

thankful to the Almighty God for his grace to start and complete this work.

5
 ABSTRACT

Cervical cancer is the second-most common cancer among women in developing countries. In
2012, an estimated 266,000 deaths from cervical cancer was reported worldwide which
accounts for 7.5% of all female deaths from cancer and a larger proportion of these deaths
(87%) occur in developing countries. Although screening is a known cost-effective strategy
used in reducing the burden of cervical cancer worldwide, its uptake particularly in
developing countries is still abysmal. Therefore, it is essential to determine the utilization
of cervical cancer screening services and trends in occurrence among women of
reproductive age in Calabar Municipality, Cross River State, Nigeria. A descriptive cross-
sectional study design was adopted and used for the study. Semi-structured questionnaire
was used to generate primary data from 450 women of reproductive age who were selected
using multi-stage sampling technique. Secondary data was also generated from University
of Calabar Teaching Hospital to assess the trend in occurrence of cervical cancer among
women of reproductive age. Results computed were expressed in simple percentages and
presented in tables and charts. Secondary data were analyzed using descriptive statistics
and results were presented in graphs. Chi-square and logistic regression test were used to
test for association between the dependent and independent variables at 0.05 level of
significance using SPSS (version 20). The major finding of this study is that most
respondents 262(58.2%) had only a fair knowledge about cervical cancer screening test
and 277(61.6%) demonstrated negative perception about cervical cancer screening. Only
28(6.2%) of respondents utilized available cancer screening services. Furthermore, lack of
awareness about the availability of cervical cancer screening services 242(45.3%), low risk
perception about cervical cancer 34(6.0%) and no knowledge of where to access cervical
cancer screening services (18.5%) were the major factors affecting utilization of cervical
cancer screening services. The chi-square test revealed an association between
occupational status (P=0.013), age of respondent (P=0.001) knowledge of cervical cancer
(P=0.001), perception about cervical cancer (P=0.001) and utilization of cervical cancer
screening services among women. Logistic regression analysis revealed that age as a factor
is 1.6times likely to increase one’s chances of utilizing cervical cancer screening services
(crude odds ratio [COR] 1.861; adjusted odds ratio [AOR] 1.662, P =0.001). Young women
between the ages of 20-24 and 25-29 were more likely to utilize cervical cancer screening
services than older women (COR 0.032, AOR 0.048, P =0.020) and (COR 0.083, AOR
0.109, P = 0.034) respectively. Trend in occurrence of cervical cancer analysis indicated
an increase in cervical cancer among married women and women aged 41-60years. In
conclusion, respondents lack knowledge about cervical cancer, exhibit negative perception
towards cervical cancer and recorded low uptake of cervical cancer screening services. The
study recommends advocacy and sensitization campaigns to educate the populace on the
need to utilize available cervical cancer screening services.

Word count: 455

6
TABLE OF CONTENTS
PAGE

TITLE PAGE i

CERTIFICATION ii

DECLARATION iii

ACKNOWLEDEMENTS iv

ABSTRACT v

TABLE OF CONTENTS vi

LIST OF TABLES ix

LIST OF FIGURES x

LIST OF ABBREVIATIONS xi

CHAPTER ONE: INTRODUCTION

1.1 Background of the study 1

1.2 Statement of the problem 4

1.3 Objectives of the study 5

1.4 Research hypotheses 6

1.5 Significance of the study 7

7
1.6 Scope of the study 7

1.7 Limitation of the study 8

1.8 Operational definition of terms 8

2.0 CHAPTER TWO: LITERATURE REVIEW

2.1 Overview of cervical cancer 10

2.2 Burden, trend and risk factors of cervical cancer 11

2.3. Knowledge about cervical cancer and cervical cancer

screening among women 13

2.4 Perception of women about cervical cancer 15

2.5 Utilization of cervical cancer screening services among women 17

2.6 Factors affecting the use of cervical cancer screening among women 19

2.7 Strategies to promote the use of cervical cancer screening among women 27

2.8 Theoretical framework 33

3.0 CHAPTER THREE: METHODOLOGY

3.1 Study setting 37

3.2 Study design 37

3.3 Study population 38

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3.4 Sample size determination 38

3.5 Sampling procedure 39

3.6 Instruments for data collection 40

3.7 Pre-testing of the instrument 40

3.8 Procedure for data collection 41

3.9 Method of data analysis 42

3.10 Ethical consideration 43

4.0 CHAPTER FOUR: RESULTS

4.1 Socio-demographic characteristics of respondents 44

4.2 Knowledge of cervical cancer among respondents 44

4.3 Perception of women about cervical cancer 49

4.4 Trend in cervical cancer among women 52

4.5 Utilization of cervical cancer screening services among respondents 52

4.6 Factors affecting the use of cervical cancer screening services

among women 52

4.7 Hypotheses Testing 59

4.8 Logistic regression analysis of the relationship between age, education,

marital status, occupation and utilization of cervical cancer screening

9
 services 64

CHAPTER FIVE: DISCUSSION, SUMMARY, CONCLUSION AND

RECOMMENDATIONS

5.1 Discussion 66

5.2 Summary 73

5.3 Conclusion 75

5.4 Recommendations 75

5.5 Contributions to body of knowledge

REFERENCES

APPENDICES

10
 LIST OF TABLES

TABLE 1: Socio-demographic characteristics of respondents 45

TABLE 2: Knowledge of cervical cancer among respondents 46

TABLE 3: Knowledge of cervical cancer among respondents 47

TABLE 4: Perception of women about cervical cancer 50

TABLE 5: Utilization of cervical cancer screening services among respondents 57

TABLE 6: Factors affecting the use of cervical cancer screening services among

women 58

TABLE 7: Test of association between educational, marital status and utilization of cervical

cancer screening services among women 60

TABLE 8: Test of association between occupational status, knowledge and perception about

cervical cancer and utilization of its screening services 63

TABLE 9: Logistic regression analysis of the relationship between age, education, marital

status, occupation and utilization of cervical cancer screening services

65

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12
 LIST OF FIGURES

FIG. 1: Andersen’s Behavioral Model 36

FIG. 2: Perception of women about cervical cancer 51

FIG. 3: Trend in occurrence of cervical cancer among women from 2013 to 2017

at University of Calabar Teaching Hospital (UCTH) 53

FIG. 4: Trend in occurrence of cervical cancer among women according to age

from 2013 to 2017 at UCTH 54

FIG. 5: Trend in occurrence of cervical cancer among women according to

marital status from 2013 to 2017 at UCTH 55

FIG. 6: Trend in occurrence of cervical cancer among women according to occupational

status from 2013 to 2017 at UCTH 56

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 LIST OF ABBREVIATIONS

ACCP - Alliance for Cervical Cancer Prevention

ART - Antiretroviral Drugs

CDC - Centre for Disease Control

FMOH - Federal Ministry of Health

GAVI - Global Alliance for Vaccines and Immunizations

HIV - Human Immunodeficiency Virus

HPV - Human Papilloma Virus

LGA - Local Government Area

LMICs - Low Middle Income Countries

NGOs - Non-Governmental Organizations

PATH - Program for Appropriate Technology in Health

SDGs - Sustainable Development Goals

SES - Socio-economic Status

SSA - Sub-Sahara Africa

SPSS - Statistical Package for Social Sciences

UCTH - University of Calabar Teaching Hospital

VIA - Visual Inspection with Acetic Acid

VILI - Visual Inspection with Lugol’s Iodine

WHA - World Health Assembly

WHO - World Health Organization

14
 CHAPTER ONE

INTRODUCTION

1.1 Background of the study

Cervical cancer is the second commonest cancer among women in developing

countries (WHO, 2015). It is caused by human papilloma virus (HPV) during sexual

intercourse. Many HPV strains do not show any symptoms initially and diminishes readily,

but a few infect the cervix and cause pre-cancerous lesions that can advance to cancer

(WHO, 2015). About 500,000 cervical cancer cases are reported yearly and more than

half of them result in mortality (WHO, 2015). In poor communities, cervical cancer causes

a lot of morbidity and mortality because most cases are detected very late. Almost 19%

and 63% of women in developing countries and developed countries had been screened in

the last three years, respectively and there is an evidently wide gap between developing

and developed countries (Gakidou, Nordhagen & Obermayer 2008). Some women who

are able to have right to use screening may never have their results or be lost to follow up

for lifesaving treatment (WHO, 2012).

In Nigeria, cervical cancer is the second most common female cancer, with an age-

standardised incidence rate of 34.5 per 100 000 and incidence/mortality ratio of 0.6 (Jedy-

Agba, Curado, Ogunbiyi, Oga, Fabowale, Igbinoba et al., 2014). The global burden of

cervical cancer is unevenly distributed throughout the world, with developing countries

accounting for over 80% of all new cases (Ferlay et al., 2014). Evidence have shown that

about 10,000 and 8000 new cases and deaths respectively are reported yearly (Airede,

Onakewhor, Aziken, Ande & Aligbe, 2008). Also, Nigeria has had the prevalence of

15
21.6% for cervical cancer for up to 5 years as at 2012 (GLOBOCAN, 2012). A study

carried out in Ilorin reported a 5% prevalence of cervical cancer among women.

(Durowade, Osagbemi, Salaudeen, Musa, Akande, Babatunde, Raji, Okesina, Fowowe,

Ibrahim & Kolawole, 2012)

According to Satyanarayana, Asthana, Bhambani, Sodhani & Gupta, (2008),Pap

smear (Papanicolaou ) cytology screening method used to recognize precancerous lesions

has helped in attaining massive decrease in the burden of cancer of the cervix especially in

the developed countries (WHO, 2006). Again other less intrusive methods have been

established for rapid screening of cancer of the cervix. Example of such techniques include

Visual Inspection with Acetic Acid (VIA) and Visual Inspection with Lugol’s Iodine

(VILI). Although these methods are faster and less cumbersome, they have been discovered

to be less sensitive compared to cytologic examination through Pap smear. VIA in

particular has been associated with high false positive results leading to immense emotional

problems and wrong treatment of affected women.

As a result of the emergent burden of the disease, the World Health Assembly

(WHA) in 2005, adopted resolution 58.22 to reassure nations to increase action against

the rise of cancer scourge through creation of National Cancer Control Programmes

(WHO, 2005). The National Cancer Control Programme was developed in nigeria in the

year 2008 with a target of reducing the disease spread and death caused by cancer and its

socioeconomic effects. The Federal Ministry of Health (FMOH) formed a cervical cancer

control plan within the background of the National Cancer Control Plan . Screening was

approved for the early disease detection of cervical cancer and also (HPV) human

papilloma virus.

16
immunization for girls of age 9–15 years as a means of primary prevention (FMOH,

2008). The application of this plan is highly debatable in Nigeria.

Even though screening is seen as a cheap way for reducing the commonness of

cervical cancer in the world, the use in developing countries like Nigeria is still poor

(Jeronimo, Bansil, Peck, Paul, Amador, Mirembe, Byamugisha, Poli, Satyanarayana,

Asthana, & Start-up Study Group, 2014). One of the hindrances to utilization of cervical

cancer screening services is that many cervical cancer screening services provided by the

government and NGOs had been poorly coordinated and not frequent. The location is

usually in urban centres and the rural and semi-urban dwellers are not included. Another

area is that women lack information about cancer of the cervix and about screening

services available to them (Ndikom & Ofi, 2012). Doctors see these cases late, by then they

can do nothing. In Some part of Nigeria, access to many cervical cancer screening services

is usually a big challenge. Accessible services are usually located in secondary and tertiary

health facilities with aides from few non-governmental organizations. In some settings, the

cost of screening for cervical cancer is as high as 25USD (Idowu, Olowookere, Fagbemi,

& Ogunlaja, 2016). According to Idowu et al., (2016), the population of Nigerians living

below the poverty line and with a healthcare system that is principally reliant on out-of-

pocket expenditure, such cost of service could be unaffordable. moreover, cytological

screening is the most acceptable method of screening in these facilities

Despite efforts from the government and NGOs to increase accessibility to

screening services, utilization of services is vey poor. Therefore, it is essential to identify

and understand how these influences affect

17
 the use of cervical cancer screening among women in nigeria. This expected that this study

would provide knowledge capable of being helpful to decision makers to influence the

advancement of cervical cancer screening programmes in Nigeria.

1.2 Statement of the problem

The leading cause of cancer deaths among women in the world especially in

developing countries is cervical cancer (WHO, 2015). Also ranking as the second most

common cancer among women in the world (WHO, 2015). About 530,000 new cases of

the disease and 275,000 deaths were noted in the whole world in 2012 alone where it is

responsible for almost 12% of all female cancers and most of the deaths which were about

90% were recorded in developing countries (WHO, 2015). Also about 75,000 new cases

were reported in the WHO African region (WHO, 2015). The highest incidence of cervical

cancer is recorded in countries such as Eastern Africa (42.7%), Melanesia (33.3%),

Southern (31.5%) and Middle (30.6%) Africa. Cervical cancer cases remain low for regions

such as West Asia (4.4%) and Australia & New Zealand (5.5%) (WHO, 2015). In Eastern

and Middle Africa, it has been observed that cervical cancer remains a highly predorminant

cancer in women (Ferlay, Soerjomataram, Dikshit, Eser, Mathers, Rebelo, Parkin, Forman,

& Bray, 2014; WHO, 2015).

About 266,000 deaths from cervical cancer was reported in the whole world in

2012 alone which accounts for 7.6% of all womens deaths from cancer and a larger

proportion of these deaths (87%) occur in developing countries (Ferlay et al., 2014; WHO,

2015). The mortality from cervical cancer differ among the diffent area of the world, with

rates going from less than 2 per 100,000 in West Asia, West Europe and Australia/New

18
 Zealand to over 20 per 100,000 in Melanesia (20.6%), Eastern (27.6%) and Middle

(22.2%) Africa (WHO, 2015).

more than 100,000 women die every year from the disease in nigeria (Ferlay et al.,

2014). Evidence-based Nigerian studies has also confirmed that the use of screening

services is very appaling despite the growing threat it pose to the health of women (Ndikom

& Ofi, 2012; Ahmed, Sabitu, Idris & Ahmed, 2013; Utoo, Ngwan & Anzaku, 2013). In

Cross River State, it has been observed that poor access and use of health care services

contributes significantly to the dismal health indices of Nigeria as a whole

(Edu, Agan, Monjok & Makowiecka, 2017). In Calabar municipality, there is little or no

current empirical evidence on the awareness level and cervical cancer screening use which

signifies a dearth of data in the current research. Hence, identifying these factors are crucial

in promoting the use of the screening services. It is against this backdrop that this study

was conceptualized.

1.3 Objectives of the study

1.3.1 General objective

The general objective of this study is to identify the determinants of utilization of

cervical cancer screening services and trends in occurrence among women of reproductive

age in Calabar Municipality, Cross River State, Nigeria.

1.3.2 Specific objectives

The specific objectives of this study are to;

1. determine women’s knowledge level about cervical cancer and its screening services,

19
 2. describe women’s perception about cervical cancer,

3. examine the trends in cervical cancer from 2013 to 2017,

4. determine the proportion of women utilizing cervical cancer screening services in the study

area,

5. identify the factors influencing the use of cervical cancer screening services among women

in the study area,

6. establish the relationship between utilization of cervical cancer screening services and

socio- demographic characteristics (level of education, occupation and marital status) of

the women.

1.4 Research hypotheses

The null hypotheses was formulated and tested as follows;

Ho1: There is no statistically significant association between educational status (literate and

illiterate) and utilization of cervical cancer screening services among women in Calabar

Municipality.

Ho2: There is no statistically significant association between marital status (single and

married) and utilization of cervical cancer screening services among women in Calabar

Municipality.

Ho3: There is no statistically significant association between occupational status (skilled

and unskilled labour) and utilization of cervical cancer screening services among women

in Calabar Municipality.

Ho4: There is no statistically significant association between knowledge of cervical cancer

and utilization of cervical cancer screening services among women in Calabar

Municipality.

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 Ho5: There is no statistically significant association between women’s perception about

cervical cancer and their utilization of cervical cancer screening services in Calabar

Municipality.

1.5 Significance of the study

This academic researchwork provided baseline data for more research on cervical

cancer and the use of its available services. This study also raised the consciousness and

awareness level of the growing incidence of cervical cancer among women of reproductive

age and the need to utilize the accessible screening services for prompt identification and

treatment of cases. Data generated would aid health planners and policy makers to enact

effective policies that would boost the patronage of cervical screening services among

women as well as address barriers identified. With the view to improve women health as

one of the cardinal points of the Sustainable Development Goal (SDGs), the findings from

this study would also be beneficial to the public health system, government at all levels

and non-governmental organizations to set out modalities that would increase the uptake

of cervical cancer screening service for women via planning and implementation of

intervention programmes. The results of this study would add to the existing literature and

contribute substantially to the body of knowledge.

1.6 Scope of the study

This study covered only women aged (15-49 years) in Calabar Municipality, Cross

River State, Nigeria. This study also covered variables which include; knowledge level

about cervical cancer and its screening services, perception of women about cervical

cancer, patronage of screening for cancer and factors affecting direct use of cervical cancer

diagnostic services in the study area.

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1.7 Limitation of the study

Data generated in this study primarily rely on information that was provided by the

study participants. In this case, unreliable answers were difficult to detect and as such affect

the quality of inferences and conclusions that was drawn in the study. Secondly, secondary

data are often not without errors/mistakes especially during data entry into a suitable

database system. This may also affect the quality of inferences and conclusions drawn.

However, effort was made to convince the participants to be truthful by giving them more

information on the benefit of the research. Also care was taken to reduce mistakes that may

arose from data entry.

1.8 Operational definition of terms

1. Cervical cancer: This refers to cancer arising from the cervix. It is due to the improper

increase of cells that can raid or spread to other parts of the body.

2. Cervical cancer screening services: This refers to services provided for women of all

ages to screen for cervical cancer and so as to treat identified cases.

3. Women of reproductive age: This refers to women who are between 15 to 49 years of

age in Calabar municipality.

4. Knowledge: This refers to the level of awareness and knowledge of women about the signs

and symptoms, risks factors, methods of screening and effects of cervical cancer on their

health.

5. Perception: This refers to the way in which cervical cancer is interpreted, understood or

regarded by women of reproductive age.

22
6. Determinants: These are causes that blocks the use of cervical cancer screening services.

These factors may be individual, socio-economic, socio-cultural or health system factors.

7. Trends: A pattern of gradual change or occurrence of cervical cancer over a period a time

and its usually represented by a line or curve on a graph.

8. Literate: A person who is able to read and write.

9. Illiterate: A person who is unable to read and write.

10. Skilled labour: These are workers who have specialized training or skills and mostly have

a college degree. For example: doctors, nurses, sales representatives, electricians.

11. Unskilled labour: These are workers who possess no particular skills and likely have no

formal education. For example: fast food workers, grocery clerks, maids, janitors.

12. Single: These refers to being unmarried or not having a serious romantic relationship with

someone.

13. Married: These refers to having a husband or wife.

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 CHAPTER TWO
LITERATURE REVIEW

2.1 Overview of cervical cancer

Cancer is a disease in which cells in the body grow out of control. Cancer is always

named for the part of the body where it starts, even if it spreads to other body parts later.

When cancer starts in the cervix, it is called cervical cancer. The cervix is the lower, narrow

end of the uterus. The cervix connects the vagina (the birth canal) to the upper part of the

uterus. Cervical cancer is the easiest gynecologic cancer to prevent with regular screening

tests and follow-up. It is also highly curable when found and treated early (CDC, 2016).

All women are at risk of cervical cancer and largely occurs most often in women

over age 30 (CDC, 2016). Each year, approximately 12,000 women in the United States

get cervical cancer. The human papillomavirus (HPV) is the main cause of cervical cancer.

HPV is a common virus that is passed from one person to another during sex. Most sexually

active people will have HPV at some point in their lives, but few women will get cervical

cancer. During the early stage, cervical cancer may not cause signs and symptoms.

Advanced cervical cancer may cause abnormal vaginal bleeding, vaginal discomfort,

malodorous discharge and dysuria (CDC, 2016).

World Health Organization recommends two tests that can either help prevent

cervical cancer or early detection. The Pap test (or Pap smear) diagnoses for pre-cancers,

cell changes, on the cervix that can be treated, so that cervical cancer is prevented. The Pap

test also can find cervical cancer early, when treatment is most effective. The Pap test is

recommended for women aged 21-65 years old. The Pap test only screens for cervical

cancer. It does not screen for any other gynecologic cancer. The HPV test looks for HPV—

the virus that can cause precancerous cell changes and cervical cancer.
24
2.2 Burden, trend and risk factors of cervical cancer

2.2.1 Burden

Cervical cancer was the fourth most frequently diagnosed cancer with an estimated

527,600 cases and the fourth leading cause of cancer death with 265,700 deaths among

women worldwide in 2012 (WHO, 2015). However, in developing countries, it is the

second most commonly diagnosed cancer after breast cancer and the third leading cause of

cancer death after breast and lung cancers (Ferlay et al., 2014). In fact, almost 90% of

cervical deaths in the world occur in developing countries (Ferlay et al., 2014). Cervical

cancer incidence and mortality rates are highest in sub-Saharan Africa (34.2%), Central

and South America (19.3%), South-eastern Asia (12.4%), and Central and Eastern Europe

(5%) (WHO, 2015).

Geographic variation in cervical cancer rates are due to differences in the

availability of screening, which can prevent the development of cancer through the

detection and removal of precancerous lesions and the prevalence of human papillomavirus

(HPV) infection (Bruni, Diaz, Castellsague, Ferrer, Bosch & de Sanjose, 2010; Forman, de

Martel, Lacey, Soerjomataram, Lortet-Tieulent, Bruni, Vignat, Ferlay, Bray, Plummer &

Franceschi, 2012; Vaccarella, Lortet-Tieulent, Plummer, Franceschi & Bray, 2013).

Infection with Human Immunodeficiency Virus (HIV) can promote progression of

precancerous lesions, contributing to a higher burden of cervical cancer in regions with a

greater prevalence of HIV infection, particularly in sub-Saharan Africa (De Vuyst,

Alemany, Lacey, Chibwesha, Sahasrabuddhe, Banura, Denny & Parham, 2013).

25
2.2.2 Trends

In several high-income countries with available screening, cervical cancer

incidence rates have decreased by as much as 80% over the past four decades (Forman et

al., 2012). Rates have also decreased in some LMICs such as Colombia, the Philippines,

and India, likely due to screening activities and improved socio-economic conditions

(Forman et al., 2012). However, cervical cancer rates have increased in Uganda,

Zimbabwe, and some countries of Central and Eastern Europe, as well as among younger

women in many countries of Europe, Japan, and China, likely due to increased HPV

prevalence associated with changing sexual practices in combination with inadequate

screening (Vaccarella et al., 2013).

2.2.3 Risk factors

The main risk factor of cervical cancer is infection with HPV, which is believed to

have a causal role in all cases of cervical cancer (Villain, Gonzalez, Almonte, Franceschi,

Dillner, Anttila, Park, De Vuyst & Herrero, 2015). Over a hundred types of HPV have

been identified, but some of HPV types have shown to cause cervical cancer. Based on

available evidence, the International Agency for Research on Cancer has so far classified

12 types of HPV which are definitively carcinogenic to humans, these include: HPV 16,

18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 (Villain et al., 2015). HPV 16 and 18 are the most

common subtypes identified in cervical cancer; together they are responsible for 70% of

cervical cancer worldwide (Li, Franceschi, Howell-Jones, Snijders & Clifford, 2011).

Sexual intercourse is the main route of acquiring cervical HPV infections. Nearly

80%- 90% of the infections are cleared by the body within a few years; women with

persistent infections will be at a higher risk of cervical cancer (Moscicki, Schiffman,

26
 Burchell, Albero, Giuliano, Goodman, Kjaer, Palefsky, 2012). It has been estimated that

approximately 291 million women (10.4%) worldwide at a given time have cervical HPV

infection (De Sanjose, Diaz, Castellsague, Clifford, Bruni, Munoz & Bosch, 2007). The

proportion of infected women is higher in younger, more sexually active age groups (De

Sanjose et al., 2007). HPV infection prevalence varies worldwide. The estimated

prevalence of cervical HPV 16 and/or 18 infection in women with normal cervical cytology

is approximately 3.9% globally, and although it varies across populations, there is little

difference in overall prevalence between developed and less developed regions (Bruni,

Barrionuevo-Rosas, Albero, Aldea, Serrano, Valencia, Brotons, Mena, Cosano, Muñoz,

Bosch, de Sanjosé, & ICO Information Centre on HPV and Cancer, 2015). The prevalence

of HPV in cervical tumors and precancerous lesions is substantially higher. For example,

prevalence of HPV 16 and/or 18 globally is 25.5% in low-grade cervical lesions, 51.5% in

high-grade lesions, and 70.0% in cervical cancer (Bruni et al., 2015).

Factors that increase the risk of cervical HPV infection includes; early sexual

initiation and having multiple sexual partners (Martin-Hirsch & Wood, 2011). Other

factors that increase cervical cancer risk in women infected with high-risk HPV subtypes,

includes; higher parity, oral contraceptive use, HIV infection and smoking (Martin-Hirsch

et al, 2011; Crosbie, Einstein, Franceschi & Kitchener, 2013).

2.3. Knowledge about cervical cancer and cervical cancer screening among women

The use of cervical cancer screening services could exert a significant improvement

if women and young girls are adequately aware of cervical cancer, its risk factors, effect

and its prevention and control strategies. It is believed that when women have knowledge

27
or are increasingly aware of the intricacies of cervical cancer as well as where to obtain the

required care, the rate of incidence, morbidity and mortality from cervical cancer would be

reduced. Ample evidence has shown that the level of awareness and knowledge of cervical

cancer among women is very low. For instance, a qualitative study carried out among

Malaysian women reported absolute lack of knowledge of cervical cancer (Wong, Wong,

Khoo & Shub, 2009). Another qualitative study in Uganda also reported that women’s

knowledge of cervical cancer was very poor (Ndejjo, Makama, Kiguli & Musoke, 2017).

An Ethiopian cross-sectional study found out that knowledge about cervical cancer among

HIV-infected women was reportedly poor (Shiferaw, Brooks, Salvador-Davila, Lonsako,

Kassahun, Ansel, Osakwe, Weldegebreal, Ahmed, Asnake & Blumenthal, 2016).

A recent study carried out among African female students based in the UK found

out that less than half of the study participants had low level of knowledge about cervical

cancer (Ogbonna, 2017). A Gabonian study confirmed a high level of awareness and low

knowledge about cervical cancer among women (Assoumou, Mabika, Mabika, Mbigumo,

Mouallif, Khattabi & Ennaji, 2015). Two Indian studies reported inadequate knowledge

and awareness about cervical cancer among the study participants (Arunadevi & Prasad,

2015; Jain, Bagde & Bagde, 2016). A study carried out in Zaria, Nigeria also documented

that only 43.5% had knowledge of cervical cancer but knowledge of cervical cancer risk

factors was poorly reported (Ahmed et al., 2013). Idowu et al. (2016) in their study found

out that about 92% of the study participants had poor knowledge of cervical cancer.

Akinlaja & Anorlu (2014) observed that only 26% had knowledge about cervical cancer.

A study carried out in Owerri reported that greater than half of the respondents were

adequately aware of cervical cancer screening (Ezem, 2007).

28
 A high level of awareness of cervical cancer and cervical cancer screening was also

reported in a study carried out among market women in Adamawa State, Nigeria (Jacob,

2014). Bakari, Takai & Bukar (2015) in their study also recorded that 141 study

participants out of 150 knew about Papanicolaou smear and showed high level of

willingness to undergo the test. A study in Enugu State documented poor knowledge of

cervical cancer among pregnant women and only 8.1% knew that human Papilloma virus

was the main cause of cervical cancer (Ingwu, 2016). Adetule & Jolaoye (2016) in their

study observed that cervical cancer knowledge level among the study participants was fair

but poor knowledge was documented about the Pap smear. Owoeye & Ibrahim (2013)

observed that the study participants had high level of awareness about cervical cancer and

cervical cancer screening.

2.4 Perception of women about cervical cancer

Having a clear understanding of the attitude and perception about cervical cancer

screening among women is a gateway in identifying existing gaps, people’s belief system

about cervical cancer and prioritize areas of interventions. Evidence-based studies have

shown that individual’s attitude and perception may influence their level of utilization of

cervical cancer screening services. A study carried out among Kenyan women reported

that over 65% considered themselves at risk of developing cervical cancer (Sudenga,

Rositch, Otieno & Smith, 2013). Likewise a Uganda study reported that two-third of the

women perceived themselves to be at risk of cervical cancer (Mukama, Ndejjo,

Musabyimana, Halage & Musoke, 2017). Ahmed, Sabitu, Idris & Ahmed (2013)

documented that 80.4% of the study participants had good attitude towards cervical cancer

29
screening. Kaggwa (2013) documented that while 12% believed that cervical cancer is an

STD, 5% of nurses felt that cervical cancer is associated with witchcraft.

An Ethopian study also reported that 63.1% of women had positive attitude towards

cervical cancer screening (Gebreegziabhar, Asefa & Berhe, 2016). A South African study

reported that most study participants exhibited a high level of positivity towards the use of

cervical cancer screening services (Ramathuba, Ngambi, Khoza & Ramakuola, 2016). A

Nigerian-based study found out that women felt that wizardry, multiple sexual partners and

inserting herbs into the vagina causes cervical cancer (Modibbo, Dareng, Barnisaye, Jedy-

Agba, Adewole, Oyeneyin, Olaniyan & Adebamowo, 2016). Owoeye and Ibrahim (2013)

observed that the study participants perceived that blood test is used for cervical cancer

screening. Abiodun, Fatungase & Olu-Abiodun (2014) in their study found out that 94%

of the study participants had poor perception about cervical cancer. A study carried out in

Yola Metropolis among market women confirmed that most respondents displayed good

attitude towards cervical cancer since 86.2% admitted that cervical cancer screening is

important for every woman (Jacob, 2014).

Ogbonna (2017) documented that more than half (58.6%) of the study participants

exhibited negative perception as they view cervical cancer as a forbidden disease based on

cultural differences. In the same study, one-third of the respondents (34.9%) opined that

sex with an uncircumcised partner increases one’s risk of developing cervical cancer. Other

Nigerian empirical studies also reported high level of negative perception towards cervical

cancer and cervical cancer screening (Arulogun & Maxwell, 2012; Frank, 2014; Ehiemere,

Frank & Robinson-Bassey, 2015).

30
2.5 Utilization of cervical cancer screening services among women

The use of cervical cancer screening services is highly indispensable to mitigate the

incidence and mortality of cervical cancer. The central essence of regular or routine

screening for cervical cancer is primarily for early detection, diagnosis and treatment.

However, evidence-based studies have confirmed that even with the high level of

awareness of cervical cancer in some developed regions of the world, utilization of cervical

cancer screening services remain very low especially in poor-resource settings. For

instance, a 2015 analysis of population-based World Health Surveys measured coverage of

cervical cancer screening as the proportion of women aged 25-64 who report having had a

pelvic exam and Pap smear in the past three years. The analysis indicates that coverage in

developing countries is on average 19%, compared to 63% in developed countries, and

ranges from 1% in Bangladesh to 73% in Brazil (Gakidou, Nordhagen, & Obermayer,

2008). Women aged 45-65 are least likely to be screened despite their increased risk of

cervical cancer. The decline in coverage among older women correlates with the increased

incidence and mortality of cervical cancer, suggesting that the lack of screening leads pre-

cancerous cells to progress undetected (Gakidou et al., 2008).

There is a stark difference in coverage between income levels (the equity analysis

also includes developed countries). Globally, only 31% of women in the poorest wealth

quintiles have ever had a pelvic examination compared to 91% of women in the wealthiest

quintile. The wealthiest women are seven times more likely to have been screened within

the past three years than the poor quintile women (Gakidou et al., 2008). A study carried

out among Jamaican women observed that 66% had a Papanicolaou and only 16% had a

pap test within the past year (Ncube, Bey, Knight, Bessier & Jolly, 2015). A qualitative

study in Ethiopia also found out that women had low awareness level and poor utilization

31
of cervical cancer screening services (Gebru, Gerbaba & Dirar, 2016). Oladepo, Ricketts

& John-Akinola (2009) in their study found out that though participants had high awareness

level but their perception of being susceptible to develop cervical cancer and utilization of

screening services were extremely low. Eze, Umeora, Obuna, Egwuatu & Ejikeme (2012)

in their study also observed that only 0.6% females utilized cervical cancer screening

services which is abysmally low. A study carried out in Sokoto State, Nigeria carried out

among female health workers documented that most participants had good knowledge

about cervical cancer but only 22 (10%) had undergone the screening test (Oche, Kaoje,

Gana & Ango, 2013). Idowu et al. (2015), also documented poor use of screening services

as only 8% had undergone the Pap smear test at least once.

A qualitative study carried out in Ibadan, Nigeria showed that women reported poor

knowledge of cervical cancer and poor use of the screening services (Ndikom et al., 2012).

A Zambian study conducted between January 2006 to April 2011, observed that cervical

cancer prevention programme were utilized by 56,247 women which was effective in the

mitigation of cervical cancer especially among HIV positive women (Mwanahamuntu et

al., 2013). A study carried out among market women reported that only 15% use cervical

cancer screening services (Ahmed et al., 2013). A study carried out in Makurdi, Nigeria

also confirmed that 65% were aware of cervical cancer, 51% were aware of cervical cancer

screening services and as low as 13.6% utilized the services (Utoo, Ngwan & Anzaku,

2013). Akinyemi, Adeniji, Oyelade, Akintude & Ladi-Akinyemi (2015) observed that

women had high level of awareness and knowledge about cervical cancer screening

services but their uptake was as low as 15%. A Tanzanian study carried out among primary

school teachers observed that only 21% reported using cervical cancer screening services

32
 (Kilco, Michael, Neke & Moshiro, 2015). Arulogun & Maxwell (2012) found out that less

than half of the female nurses (34.6%) had utilized cervical cancer screening services.

2.6 Factors affecting the use of cervical cancer screening among women

The uptake of cervical cancer screening services have been poorly reported in most

empirical studies as earlier highlighted. Certain factors are shown to inhibit the regular use

of cervical cancer screening services among women. These factors are categorized into

individual and behavioural factors, socio-economic factors, socio-cultural factors and

health system factors.

2.6.1 Individual and behavioural factors

These are intra-personal and inter-personal factors that limits women’s access to

cervical cancer screening services. These factors may include; age, marital status, income

level, educational status, level of awareness about cervical cancer and knowledge about the

benefits of using cervical cancer screening. Age is a significant determinant of using

cervical cancer screening services among women. Wangi and Lin (2003) found out that

women aged 65 years and above were 13 times more likely not to undergo a pap smear test

as compared to their younger counterparts (less than 30 years). Hayward and Swan (2012)

also reported that the use of Pap smear was higher among middle age group (40-60 years).

Other studies have also confirmed that age is a predictor of cervical cancer screening uptake

(Mingo, et al., 2012; Bayu, Berha, Mulat & Alemu, 2016). A Jamaican study documented

that older women (>50 years) were 4.5 times more likely to have ever had a pap smear

compared to their younger counterparts (Ncube et al., 2015). Contrarily, Nene et al. (2007),

found out that younger women were more likely to use cervical cancer screening services

than their older counterparts.

33
 Marital status was also identified as a major determinant of utilization of cervical

cancer screening services. For instance, an Indian study found out that women who were

married, widowed and divorced were more likely to use cervical cancer screening services

than their single counterparts (Nene et al., 2007). This was also supported by Chidyaonga-

Maseko, Chirwa & Mulla (2015) where marital status was identified as a factor affecting

the use of cervical cancer screening services. Wong et al. (2008), in their study observed

that married women were more likely to recognize cervical cancer risk factors than their

younger counterparts

Ample evidence have also confirmed that higher income earners were more likely

to undergo a pap smear test than women who are low income earners (Chidyaonga-

Maseko, et al., 2015). Mingo et al. (2012), in their study observed that women earning high

income have had a Pap smear test than the low income women. Income level of women is

subsumed as a socio-economic factor affecting the uptake of cervical cancer screening

services. This is because, finance is key in cost consideration in terms of transport fare to

and from the screening center and cost of undergoing the screening itself except for centers

that offer free screening services. People prioritize other pressing need above the risk of

cervical cancer and its screening, out-of-pocket payment for cervical screening service

when it is not regarded as emergency by client is a major barrier faced by women

(Mutyaba et al., 2007; Ngugi et al., 2012; Ndikom et al., 2012). Fort et al. (2011) there was

also the report of fear of hidden charges that discouraged uptake of screening for cervical

cancer.cost of transportation also discouraged people from utilizing services

(Mutyaba et al., 2007).

34
 Lack of awareness and knowledge about cervical cancer and cervical cancer

screening was equally identified as a major barrier to the use of cervical cancer screening

services among women. Gatune & Nyamongo (2005) and Ndikom et al. (2012) found out

that a significant proportion of the study participants exhibited absolute lack of knowledge

about cervical cancer and where to access the screening services. Other empirical evidence

have confirmed that lack of awareness and knowledge of cervical cancer, its risk factor and

its screening services limits women’s uptake of cervical cancer screening services (Fort et

al., 2011; Ngugi et al., 2012; Williams et al., 2013; Chidyaonga-Maseko et al., 2015;

Modibbo et al., 2016; Ndejjo et al., 2016).

Other individual-related factors such as ignorance, illiteracy, low risk perception,

having many contending issues, non-chalant attitude to their health, fear of having a

positive result, fear of pain of the procedure and screening not important because there is

no symptoms were highlighted as barriers to the use of cervical cancer screening services

(Fort et al., 2011; Gatune, et al., 2005; Mutyaba et al., 2007; Ngugi et al., 2012; Ndikom,

et al., 2012; Whilte et al., 2012; Teng et al., 2014; Kibicho, 2014). According to Lim &

Ojo (2016), fatalism was identified as a factor affecting the use of cervical cancer

screening. Most persons do not want to utilize screening service for fear of discovering

they have positive status (Fort et al., 2011). Some respondents saw no need to screen to

know their status if they will not get any remedy if they are diagnosed as positive (Ndikom

& Ofi 2012; Ngugi et al., 2012). This is not in agreement with the findings outside Africa

where perceived severity of the disease caused more women to want to undergo screening

(Watts et al., 2009).

35
2.6.2 Socio-economic factors

Women with low socio-economic status such as illiterate, unemployed or in part-

time employment are more likely to have less perceived severity of the diseases and

therefore less likely to utilize preventive services (Kahesa et al., 2012; Lyimo &

Beran, 2012). Women with low socio-economic status as well as those living in rural areas

have low perception of risk of cervical cancer. Some are of the view that screening is only

meant for the rich and educated (Teng et al., 2014). A study conducted in Serbia, showed

that women with lower economic status were less likely to undergo cervical cancer

screening even when the screening services were freely available (Matejic, Vukovic,

Pekmezovic, Kesic & Markovic, 2011). It was reported that social economic factors inhibit

women from utilizing cervical cancer prevention services, thereby resulting in increased

cervical cancer morbidity and mortality (Sauvageau, Duval, Gilca, Lavoie & Ouakki,

2007). In the Wofeng study, women with higher education and income had higher levels

of knowledge about cervical cancer and were much more willing to go for cervical cancer

screening than those who had less education and income (Jia, Li, Yang, Zhou, Xiang, Hu,

Zhang, Chen, Ma & Feng, 2013). Women with poor socioeconomic status are not

financially buoyant to pay for cervical screening service. In a region where many live on

less than $2 a day, daily and pressing needs are given more importance than preventive

services like cervical cancer screening (Mutyaba et al., 2007; World Bank, 2014). Fort et al.

(2011) & Mutyaba et al. (2007) noted that screening services in most government hospitals

in the region is free; however, when women pay for ancillary services like, consultation

fee, other laboratory tests and for treatment of any identified infection, utilization of

services reduces.

36
2.6.3 Socio-cultural factors

Sexuality is identified as a taboo topic for parents who want to protect family

reputation and encourage modesty, particularly among daughters. This results in young

women not having the necessary sexual health education (Markovic, Kesic, Topic &

Matejic, 2005). In a study conducted by Markovic et al. (2005) in central Serbia that

explored women's cervical cancer-screening behaviours, participants viewed a lack of

informal sexual education to be a barrier to cervical cancer screening. Participants also

mentioned that there is stigma attached to discussing reproductive health issues in their

communities which contributes to the women having little knowledge about cervical cancer

and its prevention (Markovic et al., 2005). Among black and minority ethnic communities,

it was also reported that African communities never talked about some cancers, especially

cancer of the cervix as it is regarded to be taboo (Thomas, Saleem & Abraham, 2005).

Gender roles and their overall subordinate position in the family and society influence

women's poor ability to access cervical cancer screening (Markovic et al., 2005). In a study

conducted in Mexico, which aimed at attempting to analyze the role of several social and

cultural factors in relation to the early detection of cervical cancer, it was reported that

women feared abandonment by their partners when faced with confirmation of diagnosis

of cervical cancer. The study mainly focused on the influence of partner and the social

networks regarding utilization of the Pap test (Pelcastre-Villafuerte, Tirado-Gomez,

Mohar-Betancourt & Lopez-Cervantes, 2007). Such fear would make women not to go for

cervical cancer screening.

37
 Lack of autonomy was identified as a barrier to cervical cancer screening uptake

(Lim, et al., 2016). Men control the economy of the household and even when women work

they are dependent on men. Most financial decision in the family are usually taken by the

husband. As a result most women are usually reluctant to request for money for screening

purpose. Similar findings were observed elsewhere too (Alemayehu & Mariam 2013).

However, in Uganda, respondent generally agreed that cervical cancer screening is

important irrespective of spousal consent (Teng et al., 2014). Another aspect of partrichial

practices affecting the uptake of cervical cancer screening services is lack of partner’s

support (Lim et al, 2016). Mutyaba et al. (2007) noted that women desiring to go for cervical

cancer screen might be perceived by their spouse to have been unfaithful. Another reason

for lack of support from spouse is the issue of the part of the body involved as most men

view the screening as a violation of the pride and privacy of their woman (Williams et al.,

2013). Kileo et al. (2015) found out that women who did not involve their partner in

decision making concerning their health were more likely to use cervical cancer screening

services. Teng et al. (2014) observed that majority of women does not see this as a barrier

as they believe their health is more important with or without their spouse consent.

Women in Sub-Saharan Africa face stigmatization and some feel embarrassed

whenever they discuss or attempt to access cervical screening services because it involves

pelvic examination and may be combined with treatment for reproductive or sexually

transmitted infection, it can give a wrong inference about a woman (Fort et al., 2011). Most

women noted that the association or relationships a woman keeps can be a barrier to

screening utilisation (Williams et al., 2013). Promiscuity, unsanitary life style and evil

curses were seen as some of the reasons women refuse to go for cervical screening

(White et al., 2012). fear of societal rejection was another reason affecting disclosure of

38
 early symptoms and utilization of cervical cancer screening services. Societal ostracisation

upon positive diagnosis of cervical cancer was a reason some women refuse to go for

screening.(Ndejjo et al., 2016).

2.6.4 Health system factors

Certain health system factors such as screening facilities, long distance, navigation

issues, transport cost, services not easily accessible and attitude of health worker (Gatune

& Nyamongo, 2005; Mutyaba et al., 2007; Fort et al., 2011; Ngugi et al., 2012; Ndikom,

et al., 2012). It was also observed that the negative attitude of health workers goes a long

way affect utilisation of cervical screening services in four studies (Mutyaba et al., 2007;

Fort et al., 2011; Ngugi et al., 2012; Ndikom, et al., 2012). According to Gatune and

Nyamongo (2005), healthcare professional's attitude does not encourage utilisation of

screening services. This factor was reiterated by respondents in another study where health

care workers didn’t provide adequate information or services (even when this was required

as part of the service) and did not make an effort to make the procedure comfortable

(Ngugi et al., 2012). From the study that was conducted in Peru, Mexico, Kenya and South

Africa, it was noted that women would not patronize cervical cancer prevention services

that were delivered by a provider who does not take time to converse with them, answer

their questions, explain procedures, and give them encouragement (Bingham, Bishop,

Coffey, Winkler, Bradley, Dzuba & Agurto, 2003).

Most African women are very conservative about exposing their private part

especially to members of the opposite sex. It is therefore difficult for most women to go

for cervical cancer screening especially if the test is going to be performed by a male health

care giver. White et al. (2012) revealed25that the gender of the care giver can be a hindrance

to screening. The authors further revealed that having to undress for the procedure was a
39
 major barrier to utilization. One study reported a contrasting view where women preferred

male health workers on the premises because they are more polite than their female health

workers (Mutyaba et al., 2007). In another study, modesty or embarrassment was not seen

as a barrier to service utilization (Teng et al., 2014).

Geographic inaccessibility remains a central barrier in most resource-poor settings,

because a significant portion of the population at risk for cervical cancer might be located

in areas where little or no coverage currently exists (Bingham, et al., 2003). In Peru, for

instance, the researcher representing the Alliance for Cervical Cancer Prevention (ACCP)

found that screening rates were much lower in districts where services were distant or

difficult to access. The ACCP program researcher also noted that regional coverage rates

were much higher where static services were more accessible to major population centres

or where mobile campaigns brought services to women (Bingham, et al., 2003).

Distance to fully equipped hospital with laboratory facilities and personnel to carry

out cytology for Pap smear was observed as a factor hindering accessibility and utilisation

of cervical cancer screening. Challenges in navigating health care facility and services was

observed as another barrier; lack of information pertaining to direction of where and when

to obtain service has limited some women from accessing available services

(Fort et al., 2011). Long waiting time for screening in the hospital was identified by nursing

mothers as an obstacle to access cervical cancer screening programme (Ngugi et al., 2012).

In health care centers, where health care is not free at a point of delivery, accessing

cervical cancer prevention services is not easy for some women due to the prohibitive costs

of the services for both the woman and her family (Fort et al., 2011). User fees and the lack

40
 of reasonable health care insurance have led women not to utilize cervical cancer prevention

services in low- and middle-income countries, (Tsu & Levin, 2008).

2.7 Strategies to promote the use of cervical cancer screening among women

To improve the uptake of cervical cancer screening among women, several

strategies have been adopted which primarily includes; health education, Integrating

cervical cancer screening in other sexual and reproductive health programmes and scaling-

up HPV vaccination.

2.7.1 Health education

Increasing awareness through education can encourage the demand for preventive

health services. For any health intervention to be successful, adequate awareness about the

project can encouragee utilization (Sabates & Feinstein, 2006). Several Studies has

affirmed the effect of women's knowledge as an important factor of perception of risk and

subsequent health seeking behavior (Ndejjo et al., 2017; Ogbonna, 2017). The general

agreement from the included studies was that awareness about cervical cancer and

available screening services among women in SSA is seriously lacking or very low.

Perkins et al. (2007) found out that that inexpensive educational programmes utilizing

existing community resources can successfully improve cervical cancer knowledge and

screening behaviour. Abiodun et al. (2014) opined that health education should be used as

a tool to improve the perception of women about cervical cancer and screening. This imply

that providing correct and factual information to women would correct any widely held

misconceptions, beliefs and perception. Improved level of education and awareness of

cervical cancer could abrogate certain cultural practices that inhibits women from

accessing screening services. Effective dissemination of information can be achieved

through symposia, seminar,

41
 workshops, outreach programmes, print and electronic media advertisement, conferences

(Fang et al., 2011).

2.7.2 Merging cervical cancer screening with other sexual and reproductive health programmes

Primary and secondary cervical cancer prevention should be integrated into

Existing sexual and reproductive health programmes particularly those providing HIV and

family planning. sexual and reproductive health services can be used to integrate primary

prevention, especially for girls out of school; HIV and family planning services can

integrate secondary prevention for women and girls. Case studies in Low- and middle-

income countries offer some examples of programmatic cooperation through the

concurrent delivery of programmes targeting adolescence with HPV vaccination. Rwanda

introduced a national cervical cancer prevention programme as part of school health days

in 2011. This campaign resulted in high coverage rates and three-dose HPV vaccine

coverage rates of 93.2% and 96.6% in 2011 and 2012, respectively. These successes were

made possible by recruiting teachers and village leaders in sensitization efforts, and by

mobilizing the country’s 45 000 community health workers to make the vaccine available

to out-of-school girls in the community.(Binagwaho, et al., 2013).

HIV infection makes women five times as susceptible to cervical cancer, and

antiretroviral therapy has not yet shown to improve chances of survival – in fact, the

effectiveness of ART can actually put women at increased risk by extending life

expectancy and therefore increases the risk of developing cancer (Barot et al., 2012;

Mbizvo et al., 2013; Huchko, et al., 2015). Screening programmes are necessary to detect

pre-cancerous cells as early as possible and also provide women with information about

42
how to avoid HPV infection in the first place. There have been few studies on the

effectiveness of integration for increasing uptake of screening. A qualitative study in

Uganda found that many HIV-positive women seek services because they desire to

maintain overall good health. Like other women, however, many are discouraged by

misperceptions about pain and concerns about privacy, and most face logistical barriers

like competing needs for money and time, long waits at the clinics, or forgetting to schedule

a visit (Bukirwa et al., 2015). Designing integrated interventions to inform women living

with HIV about the value and realities of screening will overcome their practical barriers

and increase their uptake. A looming challenge for HIV and cervical cancer service

integration is the availability of human resources. Providers must have expertise in both

health areas and be able to effectively respond to complications that often arise in immune-

compromised patients. Providers with these qualifications are often scarce in low-resource

settings, particularly in rural areas (Mbizvo et al., 2013).

The introduction of cervical cancer screening into family planning clinics may be

relatively easy, as family planning providers are familiar with conducting pelvic exams and

are generally comfortable talking to women about sexual health (Huchko et al., 2015). This

setting may also be appropriate for the delivery of the HPV vaccine to adolescent girls who

are not yet sexually active. During the same visit, they can receive information on the

various risks of sex and learn how the HPV vaccine and family planning methods can

reduce their risk. Treatment for cervical cancer can make it more difficult for a woman to

conceive and carry a child, so it is important that providers inform women of this risk when

discussing family planning options. In cultures where the pressure to bear children is high,

this information may be especially salient (Singhrao et al., 2013). While this type of

43
 integration can drastically improve access for women using contraception, it will miss

women who do not use family planning but are still sexually active and at risk, especially

those who have reached menopause. In some contexts, the clientele at family planning

clinics underrepresents the poor; there is a need to ensure that service delivery remains

equitable (Claeys, et al., 2003).

2.7.3 Scaling-up HPV vaccination

While screening and treatment offer secondary and tertiary means of prevention

against cervical cancer, effort is mounting behind primary prevention through

administration of the HPV vaccine. The vaccine is now recommended for young women,

preferably before the onset of sexual activity. Opportunities for primary prevention occur

early in life (before exposure), and the best chance to prevent infection with HPV is during

adolescence, prior to sexual debut. Scaling up HPV vaccinations for adolescent girls aged

9 to 13 years therefore should be a priority. In resource constrained settings, the two-dose

schedule—which has been shown to be as effective as the current three-dose schedule—

may be easier and more cost-effective to administer (WHO, 2014). Two prophylactic

vaccines are currently available and marketed in many countries worldwide for the

prevention of HPV-related disease: a quadrivalent vaccine and a bivalent vaccine, both of

which are directed against oncogenic genotypes. The HPV4 vaccine is currently approved

in 129 countries, and over 183 million doses have been distributed. The safety of these

vaccines is being closely monitored, and thus far, the results are very reassuring

(Markowitz et al., 2014). A detailed analysis of post Licensure data, accumulated between

2006 and 2015, shows that the HPV4 vaccine continues to have a favourable safety profile

(Vichnin et al., 2015). Both vaccines exhibit excellent safety and immunogenicity profiles

44
(64, 65), with long-term protection against infection with vaccine types and a moderate

degree of cross-protection against some non-vaccine types (including HPV types 31, 45

and 52) (Toft et al., 2014).

Soon after licensure in 2006, developed countries rapidly introduced HPV vaccines

into their routine immunization programmes. Scale-up of HPV vaccinations in some of

these developed countries has already resulted in a significant reduction among vaccinated

women of both HPV prevalence and cervical abnormalities (Brotherton et al., 2011; Gertig

et al., 2013). In the United States of America, population-based surveillance data show that

the prevalence of HPV types 16 and 18 in CIN2+ lesions decreased significantly among

women who received at least one dose of the HPV vaccine, declining from 53.6% in 2008

to 28.4% in 2012 (Hariri et al., 2015). Substantial decreases in cases of genital warts also

have been observed in countries such as Australia, Denmark, Sweden and the United States

of America following the introduction of a national HPV vaccination programme using a

quadrivalent vaccine (WHO, 2014). Given that HPV incidence rises rapidly following

sexual debut and that the current HPV vaccines are not therapeutic vaccines but

prophylactic, the vaccine is most effective when implemented before sexual exposure.

As of August 2015, 84 countries spanning all regions had implemented national

vaccination programmes, while another 40 had introduced pilot programmes. The national

programmes are concentrated in North and South America and Europe, and most of the

pilot programmes are taking place in Western Africa, Eastern Africa, and Southeast Asia

and the Pacific. Due to the dual need to reach adolescent girls with the HPV vaccine while

engaging women older than 35 in screening, it is a challenge to balance costs (Gakiduo et

al., 2008; Bharadwaj et al., 2009). Donor support for vaccination, however, is strong,

45
 because many are more willing to invest in primary means of prevention and because the

vaccine can, in most settings, be easily delivered through existing programmes (Gakidou

et al., 2008). The GAVI Alliance, WHO, PATH, and other partners are providing financial

and technical assistance to developing countries to scale up campaigns and make the

vaccines more accessible and affordable for girls (PATH, 2014)././. ,,,,,….

WHO recommends that the vaccine be administered to young adolescent girls

between the ages of 9 and 13 years. A two-dose schedule at zero and six months is

recommended for young women below the age of 15 years; a three-dose schedule at zero,

one to two months and six months is recommended for immune-compromised individuals,

including people living with HIV and all young women 15 years and older. HPV

vaccination is safe and best given to young girls before sexual debut (WHO, 2014).

2.7.4 Provision multiple screening centers

Aside the health facility where most screening services are provided, the provision

of multiple screening centers and outlets is crucial to significantly increase the use of

cervical cancer screening services. This approach would effectively address distance,

transportation cost and accessibility problem. This is imperative because women in poor

resource settings domicile far from the nearest health center. The health centers and

hospitals are encouraged to expand their coverage so as to motivate women to use available

services at regular intervals. Personnel should be trained on how to provide good testing

and counselling services.

2.7.5 Training of health care providers

The necessity of training health human resources is to as much as possible address

the health system factors that limits women’s access and use of cervical cancer screening

46
 services. One major factor that needs to be address is the attitude of health care providers

towards their clients. Lack of trained staff to provide service and education pose a serious

barrier to the use of screening services (Hoque et al., 2009). If there is no cordial

relationship between health care providers and their clients, the use of screening services

would be difficult. Hence, health care providers should be trained on confidential of

patients’ information, counseling and testing services, communication with patients and

effective treatment services for women positive with HPV.

2.8 Theoretical framework

This study will be explained using the Andersen's Behavioural Model which was

primarily formulated to understand the level of social inequality in accessing and utilizing

health care services that exist among different groups of people in the society especially

among the minority and rural dwellers (Andersen, 1968). The model further aims to

identify factors that impedes an individual’s decision to access and utilize available

medical care (Andersen & Newman, 1973). The model is principally characterized by

three sets of predictive factors; predisposing, enabling and need factors. The central

premise of the model is that the utilization of health services is determined by a sequence

of factors; the predisposition of the individual to utilize health services, what influences

the individual to use health services and the need to use services. At first, the model adopted

the family structure as the unit of analysis, however, the latter part of the model used the

individual as the unit of analysis (Andersen & Newman, 1973).

The predisposing factors as argued by the Andersen Model is based on the fact that

a set of personal characteristics could exert significant influence on the utilization of health

care services. These characteristics includes; family composition, social structure and

47
 health beliefs (Andersen, 1968). Variables such as age, sex, social class, ethnicity and

family size are personal characteristics which could influence an individual’s physical and

social environment as well as its lifestyle. The enabling factors are factors that motivates

an individual to utilize health care services. These characteristics must be made available

to enable the individual easily access and utilize the needed services. Such enabling factors

include; availability of health services, having health insurance or subsidizing user fees and

availability of human and material resources. The need factor are factors that boost the

individual choice to seek for appropriate medical care. The illness variables and response

variables are the core types of need factor (Andersen, 1968).

However, while the Andersen’s Model have been adopted, applied and widely used

to understanding health seeking behavior among different groups of individual, it has been

largely criticized in certain areas. The aspect of culture and social interaction was not

emphasized in the model; though Andersen argued that social structure, interaction and

relationships is an essential element of the predisposing characteristics. Another criticism

of the model is that the need factors was overemphasized that the social structure and health

beliefs which are core determinants in health service utilization. However, clearly viewed

the need factor as a social construct. Hence, Andersen opined that age, sex and illness can

predict equitable access to health care services. (Andersen & Aday, 1978). On the other

hand, variables such as ethnicity or enabling factors can predict unequal access to health

care (Andersen & Newman, 1973).

2.8.1 Application of the Andersen’s Model to the study

The Andersen’s Model could be applied to understand the determinants of

utilization of cervical cancer screening services among women of reproductive age in the

48
study area. Since the Andersen’s Model is principally anchored on three characteristics;

predisposing, enabling and need factors, the current study will be described from this

perspective. Women of reproductive age must exhibit that predisposition to seek for

medical care. Evidence have shown that variables such as ages, sex, ethnicity, occupation,

education, social interaction, social relationship, culture and belief system could exert

influence women’s’ choice to utilize cervical cancer screening services (predisposing

factor). The availability of screening centers, low cost of transport, low user fees,

availability of trained health human resources, proximity of health facilities as well as good

patient-health care provider relationship could stimulate women to utilize cervical cancer

screening services at regular intervals (enabling factors). Regular advertisement of high

morbidity and mortality rates from cervical cancer could create a picture about the severity

of the disease which may in turn trigger women to see the need to utilize cervical cancer

screening services Need factor). Once women perceive to be at risk of cervical cancer and

material resources are adequately available, it will trigger the need to utilize cervical cancer

screening services.

49
Predisposing
Enabling
factors Need
factors
factors

Demographics Income Perceived need for health services

Social factors Health insurance Viewpoint of one’s health
Health beliefs Availability of health related information

Health service use

FIG. 1: Andersen’s Behavioral Model

50
 CHAPTER THREE

METHODOLOGY

3.1 Study setting

The study area is Calabar Municipality. It is situated in the Southern Senatorial

District of Cross River State, Nigeria. Calabar Municipality is made up of an estimated

population of 176,218 (14). Calabar Municipal council has 10 political wards with a land

mass of 141.33 square kilometer. The Area is bounded by Calabar River to the west,

Akpabuyo Local Government Area to the east, Odukpani Local Government Area to the

north and Atlantic Ocean to the south. It is a cosmopolitan city which embraces all ethnic

groups in Nigeria. The two dominant ethnic groups are the Efiks and Quas which share

common culture and religion. English and Efik are the languages widely spoken. The

municipality is predominantly a Christian city with few Muslims and traditional religious

groups and mainly occupied by civil servants, businessmen and traders. It also has

industries and establishments such as airport, export processing zone, Naval and Army

base, Tinapa, NNPC depot, cement factory etc. The municipal has three levels of health

care namely: primary, secondary, tertiary level as well as private health care. Calabar is

famous for its rich cultural heritage, warm hospitality and peace-loving disposition.

3.2 Study design

The research design of this work was a descriptive cross-sectional study design to

determine the utilization of cervical cancer screening services among women of

51
 reproductive age in Calabar Municipality, Cross River State, Nigeria. This study design

was more preferred because it involves the collection of quantitative data from a cross-

section of an entire population at a given point in time. It draws a sample or subset which

is usually a representative of the entire population using scientific procedures or methods.

Data generated from the subset or group was used to generalize, draw conclusions and

make inferences.

3.3 Study population

The study population comprised all women of reproductive age (15-49 years) in

Calabar Municipality, Cross River State, Nigeria.

3.4 Sample size determination

Sample size for this study was determined using Lutz formula (1982) which is given as

n = Z2Pq
d2
Where n = Sample size
Z = 1.96 (i.e. 95% confidence interval)
d = 0.05 (acceptable margin of error)
p = 34.6% = 0.346 (Proportion of women who have utilized cervical
cancer screening services) (Arulogun et al., 2012)
q = 1-P = 1-0.346 = 0.654 (Proportion of women who have not utilized
cervical cancer screening services)
Therefore, n = (1.96)2 x 0.346 x 0.654
(0.05)2 = 347.7 = 348
The sample size for this survey is 348. However, to make room for non-response,

the desired sample size was increased by 25% giving a sample size of 464 that was used

for the study.

52
3.5 Sampling procedure

Multi-stage random sampling technique was used for the study.

Stage I: Selection of wards: Of the 10 wards in Calabar Municipality, four wards were

selected using simple random sampling technique. Names of wards were written on pieces

of paper folded and put in a basket. After thorough shaking, four pieces of papers were

picked. Names of wards written on the papers that were picked were used for the study.

Stage II: Selection of streets: In each selected ward, simple random sampling technique

was used to select four streets. Names of communities were written on pieces of paper

folded and put in a basket. After thorough shaking, four pieces of papers were picked.

Names of streets written on the papers that were picked were used for the study (i.e 4x 4=

16 streets).

Stage III: Selection of Households: In each selected street, 29 households were sampled

using systematic sampling technique (16 streets x 29 households = 464 respondents). To

obtain the sampling interval, the total number of households was divided by the desired

number of households to be sampled in that community. The sampling interval obtained

was then used to sample every nth household in each community. This procedure continued

until 29 households were duly selected in each street.

Stage IV: Selection of respondents: Systematic random sampling technique was used to

select households with women aged between 15-49 years. In households where there are

no eligible respondents, the next household was sampled as replacement. In polygamous

53
 homes, only one woman was selected using the lottery method. Four hundred and fifty

respondents were sampled in the study area.

3.6 Instruments for data collection

A semi-structured questionnaire (Appendix I) was used to generate quantitative

data from women of reproductive age. The questionnaire was self-administered to the

respondents that gave consent to participate in the study. It consisted of five sections and

26 items. The questionnaire contains questions that elicited information on the socio-

demographic characteristics of women, knowledge of cervical cancer among women,

perception of women about cervical cancer, utilization of cervical cancer screening

services among women and factors affecting the use of cervical cancer screening services

among women.

3.7 Pre-testing of the instrument

The questionnaire was pre-tested among 20 randomly selected women (i.e. 10% of

sample size) in a community in Calabar South Local Government Area of Cross River

State. The essence of pre-testing the questionnaire was to ascertain the accuracy of the

variables under measurement, remove ambiguity where it exists, improve on sequencing

of questions, train field assistants on how best to capture sensitive questions and estimate

maximum time for completion of questionnaire administration and retrieval. Thereafter

necessary adjustments were made before the actual data collection takes place. This was

done with the assistance of the project supervisor.

54
 In order to determine the face validity of instrument of data collection, the items in

the questionnaire were given to two public health professionals as well as the project

supervisor for scrutiny, examination and comments. The project supervisor and two other

health professionals were asked to scrutinize the questionnaire by reading through the items

listed in the questionnaire and rating the items based on their suitability for the research

and to ensure that the items listed in the questionnaires are in line with the hypotheses and

stated objectives.

To determine the content validity, a copy of the questionnaire was given to two

health professionals who are specialist in the area of public health in Cross River State.

They were requested to rate the items in relation to how they reflect the content of the

research objectives by scoring from point 1 (not relevant), point 2 (not very relevant), point

3 (relevant) point 4 (very relevant) for all items. Thereafter, the total items as they were

rated were computed to get content validity index of 0.75.

To ascertain the reliability of the instrument, the test-retest method was used.

Twenty (20) copies of the questionnaire each was administered to randomly selected

women in Calabar South LGA. These group of women will not be included in the study

population. Their identities were obtained, preserved and kept confidential to aid re-

administration of the questionnaire the second time. After two weeks, similar copies of the

questionnaire were again administered to same group of people and both sets were

subjected to statistical analysis using Pearson’s Product Moment Correlation Coefficient

Analysis to obtain the reliability score. A score of 0.77 was obtained which was considered

reliable for the study.

55
3.8 Procedure for data collection

Four hundred and sixty-four (464) copies of the questionnaire were administered to

the respondents in the study area by the researcher and two trained field assistants. The

field assistants were trained for one day on handling, distribution, consistency in

interpretation and retrieval of the questionnaire. The criteria for selection of the research

assistants was based on their knowledge of local language, previous experience in data

collection process, possession of inter-personal and communication skills and familiarity

with the area of study. The questionnaire administration was carried out within two weeks.

Respondents were properly guided and assisted by the interviewer on how to fill in their

responses on the questionnaire. Thereafter, secondary data was obtained from University

of Calabar Teaching Hospital, Calabar. The essence of the secondary data was to compute

a trend analysis on the prevalence of cervical cancer amongst women.

3.9 Method of data analysis

Primary data were coded, entered and analyzed using the Statistical Package for

Social Sciences Software (SPSS 20.0 version, 2012). Results computed were expressed in

simple percentages and presented in tables, charts and graphs. To determine the knowledge

level of respondents on cervical cancer screening services, frequencies and percentages

were used to analyse the response of the subjects. To determine the perception of women

about cervical cancer, the 5-point Likert’s scale system was adopted and used. The

following scoring system was applied; 1= strongly agree, 2= agree, 0= I don’t know,

3=disagree and 4= strongly disagree for negatively worded questions and 4= strongly

agree, 3= agree, 0= I don’t know, 2=disagree and 1= strongly disagree for positively

worded questions. The individual scores were added to obtain the mean score. Scores

56
 below the mean value were adjudged to signify negative perception, while respondents that

scored above the mean value were adjudged to have positive perception. Secondary data

were analyzed using descriptive statistics and results were presented in tables and graphs.

Chi-square was used to test for association between a dependent and independent variable

at 0.05 level of significance. The unconditional logistics regression was used to examine

the relationship between independent variables and utilization of cervical cancer screening

services.

3.10 Ethical consideration

A letter of introduction was obtained from the Head of Department, Department of

Public Health, University of Calabar, Calabar. This letter was used to obtained ethical

approval from Cross River State Research Ethics Committee, Ministry of Health and

UCTH. Informed consent was duly sought and obtained from the respondents verbally that

participated in the study. The objectives, significance and benefits of the study were

explained to the understanding of the respondents and participation in this study was

strictly on voluntary basis. The participants were assured anonymity and confidentiality of

information they provided and they were also informed that they have the right to withdraw

from the study at any time without any penalty accompanying such action.

57
 CHAPTER FOUR
RESULTS

4.1 Socio-demographic characteristics of respondents

Out of the 464 questionnaires administered, 450 copies of the questionnaires were

completely filled and returned for analysis giving a response rate of 96%. The results in

Table 1 shows that 125 (27.8%) were aged between 20-24 years, 93 (20.7%) were aged

between 15-19 years and 86 (19.1%) were aged between 25-29 years. With regards to

educational status, 278 (61.8%) had tertiary education and 110 (24.4%) had secondary

education. In term of marital status, 266 (49.1%) were single and 184 (40.9%) were

married. With regards to occupational status, 269 (59.8%) were skilled labour and 181

(40.2%) were unskilled labour. In terms of religion, 419 (93.1%) were Christians, 218

(48.8%) were low income earners (less than N20, 000) and 245 (54.4%) had no child yet.

4.2 Knowledge of cervical cancer among respondents

Of the 450 respondents, 319 (70.9%) have heard of cervical cancer and their major

source of information were mainly electronic media (TV/Radio) 172 (41.6%) and health

workers 103 (24.9%). While 197 (61.8%) knew that cervical cancer is cancer of the cervix,

90 (28.2%) felt cervical cancer is cancer of the body cells. While Human Papillomavirus

Infection 152 (47.6%) was the most identified cause of cervical cancer, abnormal vaginal

bleeding 145 (41.0%) and vaginal discomfort 51 (14.4%) were the most identified signs

and symptoms of cervical cancer (Table 2). Most respondents indicated that cervical

cancer can be treated and prevented principally by regular body checkup 173 (58.1%) and

using available screening services 113 (37.9%). A reasonable proportion of the

respondents 195 (61.1%) highlighted that both younger and older women are more at risk

of having cervical cancer. Of the 71 (22.3%) respondents who were aware of available

58
screening services for cervical cancer in their locality, 50 (70.4%) identified pap smear test

as the type of test use for cervical cancer screening (Table 3).

TABLE 1

Socio-demographic characteristics of respondents

Variable Frequency (n=450) Percentage (%)

Age (in years)
15-19 93 20.7
20-24 125 27.8
25-29 86 19.1
30-34 56 12.4
35-39 40 8.9
40-45 37 8.2
>45 13 2.9

Educational status
No formal education 27 6.0
Primary 35 7.8
Secondary 110 24.4
Tertiary 278 61.8

Marital status
Single 266 59.1
Married 184 40.9

Occupation
Skilled labour 269 59.8
Unskilled labour 181 40.2

Religion
Christianity 419 93.1
Islam 15 3.3
Traditional religion 16 3.6

Monthly income
Less than N20,000 218 48.8
N20,000-N50,000 144 32.0
>N50,000 88 19.6

Number of children currently have

None 245 54.4
1-3 143 31.8
59
4-6 58 12.9
7-10 4 0.9

TABLE 2

Knowledge of cervical cancer among respondents

Variables Frequency (n) Percentage (%)

Ever heard of cervical cancer
Have heard 319 70.9
Have not heard 131 29.1
Total 450 100
Source of Information on cervical
cancer*
Electronic media (TV/Radio) 172 41.6
School 59 14.3
Campaign/rallies 18 4.4
Health worker 103 24.9
Book/Magazine 44 10.7
Seminar/training/workshop 17 4.1
Total 413 100
Description of cervical cancer
Cancer of the body cells 90 28.2
Cancer of the lungs 20 6.3
Cancer of the chest 10 3.1
Cancer of the cervix 197 61.8
Do not know 2 0.6
Total 319 100
Main cause of cervical cancer
Do not know 37 11.6
HIV/AIDS 29 9.1
Cancer 57 17.9
Human Papillomavirus Infection 152 47.6
Malaria 14 4.4
Diabetes Mellitus 29 9.1
Typhoid 1 0.3
Total 319 100
Possible signs and symptoms of
cervical cancer*
Do not know 33 9.3
No known signs and symptoms of 33 9.3
cervical cancer
Abnormal vaginal bleeding 145 41.0
Malodorous discharge 32 9.0
Chest pain 22 6.2
Dysuria 31 8.8

60
 Vaginal discomfort 51 14.4
Vomiting 7 2.0
Total 354 100
*Multiple Responses

TABLE 3

Knowledge of cervical cancer among respondents

Variables Frequency (n) Percentage (%)

Treatment/prevention of cervical
cancer
Cervical cancer can be 298 93.5
treated/prevented
Cervical cancer cannot be 11 3.4
treated/prevented
Do not know 10 3.1
Total 319 100
Ways cervical cancer can be
treated/prevented
Regular body checkup 173 58.1
Using prescribed herbal medicine 12 4.0
Using available screening services 113 37.9
Total 298 100
Age group more at risk of having
cervical cancer
Younger women 59 18.5
Older women 65 20.4
Both younger and older women 195 61.1
Total 319 100
Aware of any available screening
services for cervical cancer in
your locality
Aware 71 22.3
Not aware 248 77.7
Total 319 100
Type of test use for cervical
cancer screening
Blood test 15 21.1
Pap Smear test 50 70.4
Urine test 4 5.6
Kidney test 2 2.8
Total 71 100

61
4.3 Perception of women about cervical cancer

Results presented in Table 4 shows that 107 (23.8%) strongly agreed to the fact that

they are not at risk of cervical cancer, 80 (17.8%) agreed and 58 (12.9%) strongly

disagreed; 83 (18.4%) strongly agreed to the statement that cervical cancer is a sexually

transmitted disease, 80 (17.8%) agreed and 62 (13.8%) strongly disagreed; 125 (27.8%)

strongly agreed to the fact that cervical cancer is mainly caused by witchcraft attack, 57

(12.7%) agreed and 57 (12.7%) strongly disagreed; 185 (41.1%) %) strongly agreed to the

fact that cervical cancer screening is necessary for every woman and 81 (18.0%) agreed;

96 (21.3%) strongly agreed to the statement that having sex with uncircumcised partners

can increase the risk of cervical cancer in women, 62 (13.8%) agreed and 69 (15.3%)

disagreed; 177 (39.3%) strongly agreed to the statement that cervical cancer can be

avoided and can be treated and 124 (27.6%) agreed.

On the average, 173 (38.4%) had positive perception about cervical cancer while

277 (61.6%) demonstrated negative perception about cervical cancer (Figure 2).

62
 TABLE 4

Perception of women about cervical cancer

Variables Strongly Agree (%) I don’t know Disagree Strongly

agree (%) (%) (%) disagreed
(%)
I am not at risk of cervical cancer 107 (23.8) 80 (17.8) 156 (34.7) 49 (10.9) 58 (12.9)

Cervical cancer is a sexually 83 (18.4) 80 (17.8) 167 (37.1) 58 (12.9) 62 (13.8)

transmitted disease
Cervical cancer is mainly caused 125 (27.8) 57 (12.7) 163 (36.2) 48 (10.7) 57 (12.7)
by witchcraft attack
Cervical cancer screening is 185 (41.1) 81 (18.0) 147 (32.7) 22 (4.9) 15 (3.3)
necessary for every woman
Having sex with uncircumcised 96 (21.3) 62 (13.8) 199 (44.2) 69 (15.3) 24 (5.3)
partners can increase the risk of
cervical cancer in women
Cervical cancer can be avoided 177 (39.3) 124 (27.6) 138 (30.7) 7 (1.6) 4 (0.9)
and can be treated

63
 70 277 (61.6%)

60

50
173 (38.4%)
% of respondents

40

30

20

10

0
Positive perception Negative perception
Perception about cervical cancer

FIG. 2: Perception of women about cervical cancer

64
4.4 Trend in cervical cancer among women

The trend in cervical cancer among women shows that number of cervical cancer

cases decreased from 19 in 2013 to 15 in 2014; thereafter, it increased steadily to 23 in

2016, then slightly dropped to 19 in 2017 (Figure 3). With regards to age, cervical cancer

cases were higher among women aged 41-50 years compared to other age groups (Figure

4). With regards to marital status, married women recorded more cases compared to their

counterparts (Figure 5). With regards to occupational status, women who were self-

employed recorded higher cases of cervical cancer compared to their unemployed and

government employed counterpart (Figure 6).

4.5 Utilization of cervical cancer screening services among respondents

Of the 450 respondents, 28 (6.2%) have utilized available cervical cancer screening

services of which 10 (35.7%) have utilized the services in the less than 6 months preceding

the survey and 8 (28.6%) utilized the services 6-12 months preceding the survey (Table 5).

4.6 Factors affecting the use of cervical cancer screening services among women

Factors affecting the use of cervical cancer screening services among women as

highlighted by the respondents include; lack of awareness about the availability of cervical

cancer screening services 242 (45.3%), low risk perception about cervical cancer 34

(6.0%), no knowledge of where to access cervical cancer screening services 99 (18.5%),

financial constraint 62 (11.6%) and inaccessibility to screening services 22 (4.1%) (Table

6).

65
 25
23

20
19 19
18
Number of Cases

15 15

10

0
Year 2013 Year 2014 Year 2015 Year 2016 Year 2017
Year

FIG. 3: Trend in occurrence of cervical cancer among women from 2013 to 2017 at

University of Calabar Teaching Hospital (UCTH)

66
 8
7
7
6
6
5 5 5 5
Number of Cases

5
4 4 4
4
3 3 3
3
2 2 2
2
1 1
1

0
21-30 31-40 41-50 51-60 61+
Age range

Year 2013 Year 2014 Year 2015 Year 2016 Year 2017

FIG. 4: Trend in occurrence of cervical cancer among women according to age from

2013 to 2017 at UCTH

67
 18
16
16 15

14 13
12
12 11
Number of Cases

10

8
6
6
4
4 3
2 2
2 1 1 1
0 0 0
0
Married Single Widow Separated Divorced
Marital status

Year 2013 Year 2014 Year 2015 Year 2016 Year 2017

FIG. 5: Trend in occurrence of cervical cancer among women according to marital

status from 2013 to 2017 at UCTH

68
 25

21

20
17
15
Number of Cases

15 14
13

10

5 4
2 2 2
1 1
0 0 0
0
Year 2013 Year 2014 Year 2015 Year 2016 Year 2017
Year

Self-employed Government/private sector employed Unemployed

FIG. 6: Trend in occurrence of cervical cancer among women according to

occupational status from 2013 to 2017 at UCTH

69
 TABLE 5

Utilization of cervical cancer screening services among respondents

Variables Frequency (n) Percentage (%)

Ever utilized any available cervical

cancer screening services

Have utilized 28 6.2

Have not utilized 422 93.8

Total 450 100

Last time cervical cancer

screening services was utilized

less than 6 months ago 10 35.7

6-12 months ago 8 28.6

1-3 years ago 5 17.9

4-6 years ago 3 10.7

Over 10 years ago 2 7.1

Total 28 100

70
 TABLE 6
Factors affecting the use of cervical cancer screening services among women

Variables Frequency (n) Percentage (%)

Factors affecting the use of

cervical cancer screening
services among women*
Lack of awareness about the 242 45.3
availability of cervical cancer
screening services
Not necessary to use the 17 3.2
services
Low risk perception about 34 6.0
cervical cancer
No knowledge of where to 99 18.5
access cervical cancer
screening services
Not allowed to discuss 5 0.9
matters on human sexuality in
my community
Financial constraint 62 11.6
Cancer diseases is a taboo in 10 1.9
my community
Long distance to health 6 1.1
facility where the services are
provided
Cost of transport 9 1.7
Negative attitude of health 14 2.6
workers
Inaccessibility to screening 22 4.1
services
Lack of facility for screening 16 3.0
*Multiple Responses

71
4.7 Hypotheses Testing

4.7.1. Test of association between educational status and utilization of cervical cancer screening
services among women

Ho: There is no association between educational status and utilization of cervical cancer

screening services among women.

Ha: There is association between educational status and utilization of cervical cancer

screening services among women.

Decision rule: Reject Ho when P<0.05.

From the result presented in Table 7, the P-value (0.576) is greater than 0.05 alpha

level of significance. We can then conclude that the test is not significant. Therefore, we

fail to reject the null that there is no association between educational status and utilization

of cervical cancer screening services among women.

4.7.2. Test of association between marital status and utilization of cervical cancer screening
services among women

Ho: There is no association between marital status and utilization of cervical cancer

screening services among women.

Ha: There is association between marital status and utilization of cervical cancer screening

services among women.

Decision rule: Reject Ho when P<0.05.

From the results presented in Table 7, the P-value (0.001) is less than 0.05 alpha

level of significance. We can then conclude that the test is significant. Therefore, we reject

the null that there is association between marital status and utilization of cervical cancer

screening services among women.

72
 TABLE 7

Test of association between educational, marital status, age and utilization of cervical
cancer screening services among women

Variables Frequency (%) Chi-square P value

Have utilized Have not Total

cervical utilized
cancer cervical
screening cancer
services screening
services

Educational .312 .576

status
Literate 27 (6.4) 396 (93.6) 423 (100)
Illiterate 1 (3.7) 26 (92.3) 27 (100)

Total 28 (6.2) 422 (93.8) 450 (100)

Marital status 17.54 .001*
Single 6 (2.3) 260 (97.7) 266 (100)
Married 22 (11.9) 162 (88.1) 184 (100)

Total 28 (6.2) 422 (93.8) 450 (100)

Age
15-19 2(4.7) 41(95.3) 43(100)
20-24 1(1.2) 84(98.8) 85(100)
25-29 2(3.0) 64(97.0) 66(100)
30-34 5(10.9) 41(89.1) 46(100)
35-39 4(11.8) 30(88.2) 34(100)
40-45 11(32.4) 23(67.6) 34(100)
>45 3(27.3) 8(72.7) 11(100)
Total 28(6.2) 291(91.2) 450(100)

*p>0.05; p<0.05 respectively

73
74
4.7.3. Test of association between occupational status and utilization of cervical cancer
screening services among women

Ho: There is no association between occupational status and utilization of cervical cancer

screening services among women.

Ha: There is association between occupational status and utilization of cervical cancer

screening services among women.

Decision rule: Reject Ho when P<0.05.

From the result presented in Table 8, the P-value (0.013) is less than 0.05 alpha

level of significance. We can then conclude that the test is significant. Therefore, we reject

the null that there is association between occupational status and utilization of cervical

cancer screening services among women.

4.7.4. Test of association between knowledge of cervical cancer and utilization of cervical
cancer screening services among women

Ho: There is no association between knowledge of cervical cancer and utilization of

cervical cancer screening services among women.

Ha: There is association between knowledge of cervical cancer and utilization of cervical

cancer screening services among women.

Decision rule: Reject Ho when P<0.05.

From the results presented in Table 8, the P-value (0.001) is less than 0.05 alpha

level of significance. We can then conclude that the test is significant. Therefore, we reject

the null that there is association between knowledge of cervical cancer and utilization of

cervical cancer screening services among women.

75
4.7.5. Test of association between perception about cervical cancer and utilization of cervical
cancer screening services among women

Ho: There is no association between perception about cervical cancer and utilization of

cervical cancer screening services among women.

Ha: There is no association between perception about cervical cancer and utilization of

cervical cancer screening services among women.

Decision rule: Reject Ho when P<0.05.

From the results presented in Table 8, that P-value (0.001) is less than 0.05 alpha

level of significance. We can then conclude that the test is significant. Therefore, we reject

the null that there is association between perception about cervical cancer and utilization

of cervical cancer screening services among women.

76
 TABLE 8

Test of association between occupational status, knowledge and perception about cervical
cancer and utilization of its screening services

Variables Frequency (%) Chi-square P value

Have utilized Have not Total
cervical utilized
cancer cervical
screening cancer
services screening
services
Occupational 6.21 .013*
status
Skilled labour 23 (8.5) 246 (91.5) 269 (100)
Unskilled 5 (2.8) 176 (97.2) 181 (100)
labour
Total 28 (6.2) 422 (93.8) 450 (100)

Knowledge of 59.88 .001*

cervical
cancer
Good 24 (21.6) 87 (78.4) 111 (100)
Fair 3 (1.1) 259 (98.9) 262 (100)
Poor 1 (1.3) 76 (98.7) 77 (100)
Total 28 (6.2) 422 (93.8) 450 (100)
Perception 37.35 .001*
about cervical
cancer
Positive 26 (15.0) 147 (85.0) 173 (100)
perception
Negative 2 (0.7) 275 (99.3) 277 (100)
perception
Total 28 (6.2) 422 (93.8) 450 (100)
*p<0.05

77
4.8 Logistic regression analysis of the relationship between age, education, marital

status, occupation and utilization of cervical cancer screening services

A logistic regression was performed to ascertain whether there is an association

between age, marital status, educational status, occupational status and utilization of

cervical cancer screening services. A significant association was only found between age

and utilization of cervical cancer screening services (p=0.001). Age as a factor is 1.6times

likely to increase ones chances of utilizing cervical cancer screening services. Result

showed that respondents between the ages of 20-24 and 24-29 were more likely to utilize

cervical cancer screening services than other age category (Table 9).

78
 TABLE 9

Logistic regression analysis of the relationship between age, education, marital

status, occupation and utilization of cervical cancer screening services

Variable Crude Odds Adjusted Df Confidence P-value Coefficients

Ratio (C0R) Odds ratio interval
(AOR)
Age 1.861 1.662 6 1.231-2.243 0.001 0.508
20-24 0.032 0.048 1 0.004-0.623 0.020 -3.030
25-29 0.083 0.109 1 0.014-0.850 0.034 -2.214
Occupation 2.30 1.44 1 - 0.999 18.789
Education 1.587 1.124 1 - 0.9992 16.235
Marital 5.777 2.190 1 2.190-8.513 0.258 0.784
status

79
 CHAPTER FIVE

DISCUSSION, SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.1 Discussion

5.1.1 Women’s awareness and knowledge level about cervical cancer and its screening services.

A high level of awareness about cervical cancer was documented in this study. The

electronic media (TV/Radio) and health worker were mainly their sources of information

about cervical cancer (Table 2). This finding is congruent with Nigeria studies by Owoeye

et al (2013) and Jacob (2014) where a high level of awareness about cervical cancer was

also reported. There is absolutely no doubt that a high level of awareness about cervical

cancer could be as a result of increasing level of information dissemination via the

electronic media and health workers. During hospital consultations, women tend to exert

the opportunity to access reliable, correct and factual information from trained services

providers at the health facilities. Women may also access information about cervical cancer

especially with regards to causes, morbidity and mortality rate, treatment and prevention

from the electronic media.

A reasonable proportion of the respondents 197 (61.8%) knew that cervical cancer

is cancer of the cervix and nearly half 152 (47.6%) could identify Human Papillomavirus

(HPV) infection as the main cause of cervical cancer. This means that the remaining 52.4%

lack knowledge of the main causes of cervical cancer. This finding is comparable with a

Nigerian-based study where only 8.1% knew that human Papilloma virus was the main

cause of cervical cancer (Ingwu, 2016). The poor knowledge exhibited by the respondents

about the main cause of cervical cancer documented in this study may be attributed to poor

access to correct and factual information about cervical cancer. Almost half of the

80
 respondents were able to identify at least one signs and symptoms of cervical cancer and

113 (37.9%) respondents knew that using available screening services would help prevent

the occurrence of cervical cancer. Personal experiences and access to health information

from service providers during hospital consultation may largely account to high knowledge

demonstrated by the respondents.

5.1.2 Women’s perception about cervical cancer

Results shows that 107 (23.8%) strongly agreed to the fact that they are not at risk

of cervical cancer, 80 (17.8%) agreed and 58 (12.9%) strongly disagreed. These findings

contradict studies conducted by Sudenga et al (2013) and Mukama et al (2017) where over

two-third of women perceived to be at risk of cervical cancer. The low risk perception

about cervical cancer exhibited by women in this study may be as a results of poor access

to adequate information on cervical cancer and absence of family history. It was also

observed that 83 (18.4%) strongly agreed to the statement that cervical cancer is a Sexually

Transmitted Disease (STD), 80 (17.8%) agreed and 62 (13.8%) strongly disagreed. This

was similarly reported by Kaggwa (2013) where 12% believed that cervical cancer is an

STD. This demonstrates gross inadequacy and limited access to information on cervical

cancer and STD.

Results also showed that most respondents demonstrated negative perception

towards cervical cancer especially with regards to causes and risks factors, however, 266

(59.1%) supported the opinion that cervical cancer screening is necessary for every woman

and 301 (66.9%) supported the opinion that cervical cancer can be avoided and treated.

This results were similarly documented by other studies in Nigeria (Jacob, 2014; Modibbo

et al, 2016; Ogbonna, 2017). Respondents’ perception about cervical cancer may largely
81
 be influenced by their level of knowledge about cervical cancer and its screening services,

family history of cervical cancer, level of risk perception and personal experiences or

experiences of families and friends. Generally, 173 (38.4%) had positive perception about

cervical cancer while 277 (61.6%) demonstrated negative perception about cervical cancer

(Figure 2). This finding is congruent with Arulogun et al (2012), Frank (2014), Ehiemere,

et al (2015) and Ogbonna (2017) where two-third of the respondents exhibited negative

perception towards cervical cancer. From the results, there is strong need to strategize

intervention programmes that would help debunk any widely held myths, misconceptions

and erroneous belief about cervical cancer in order to principally promote positivity and

simultaneously improve knowledge level.

5.1.3 Trends in cervical cancer cases amongst women from 2013 to 2017

The trend in cervical cancer among women shows that the number of cervical

cancer cases decreased from 19 in 2013 to 15 in 2014; then, it increased steadily to 23 in

2016, then dropped slightly to 19 in 2017 (Figure 3). This means that cervical cancer cases

was higher in 2016 (23 cases) and lowest in 2014 (15 cases). However, there was a steady

increase in the number of cases diagnosed from 2014 (15 cases) to 2016 (23 cases) (Figure

3). This increase clearly indicates the increasing trend in cervical cancer making it a

growing threat to the health of women. Poor utilization of cervical cancer screening

services, lack of knowledge about cervical cancer and low risk perception may largely

account for the increase in number of cervical cancer cases between 2014 to 2016.

Likewise, the slight drop in the number of cases shown in 2017 may demonstrate increased

level of awareness, and knowledge about cervical cancer and the benefit of using its

screening services. Increase hospital consultation and high risk perception about cervical

cancer may also account for decline in cervical cancer cases in 2017. This was similarly
82
 observed by Forman et al (2012) where the prevalence of cervical cancer decreased in some

LMICs such as Colombia, the Philippines, and India, likely due to screening activities and

improved socio-economic conditions.

It was also observed that cervical cancer cases were higher among women aged 41-

50 years compared to other age groups. Also, as shown in Figure 4, though all age groups

are at risk of cervical cancer, however, older women tend to be more at risk than their

younger counterparts. This finding is comparable with results obtained from a previous

study where all women were seen to be at risk of cervical cancer especially those above 30

years of age (CDC, 2016). The practice of early sexual initiation, having multiple sexual

partners, higher parity, oral contraceptive use, HIV infection and smoking tends to be

common among older women than the younger ones which makes them at higher risk of

getting cervical cancer (Martin-Hirsch et al, 2011; Crosbie, Einstein, Franceschi &

Kitchener, 2013). It was also observed that married women and those who were self-

employed recorded higher cases of cervical cancer compared to their counterparts (Figure

5 and 6). Aside the fact that they were predominantly diagnosed of cervical cancer, most

women above 30 years of age who are often at risk of cervical cancer may have been

married and already engaging in one trade or the other which substantiate why cervical

cancer tends to be higher among these categories of women.

5.1.4 Utilization of cervical cancer screening services among women

It was documented in this study that only 28 (6.2%) have utilized available cervical

cancer screening services of which 10 (35.7%) have utilized the services less than 6 months

preceding the survey (Table 5). This percentage is far lower than 16% reported in Jamaica

(Ncube, et al., 2015), 21% in Tazania (Kilco et al, 2015), 10% in Sokoto (Oche et al, 2013),

13.6% in Markurdi (Utoo et al., 2013), but higher than 0.6% reported in Nigeria (Eze et al,
83
2012). The low uptake of cervical cancer screening services among women documented in

the current study was equally reported in other studies (Ndikom et al., 2012; Arulogun et

al, 2012; Akinyemi, et al. 2015; Idowu et al., 2015). Study design adopted, sample size

used, target population, study setting and method of data analysis may largely account for

the variation observed in the uptake of cervical cancer screening services among women.

The low use of cervical cancer screening services among women reported in this study may

be attributed to poor hospital consultation, low risk perception and lack of knowledge of

the benefits of using such services. Also, absence of family history, absence of visible signs

and symptoms, availability and accessibility constraint may account for low use of cervical

cancer screening services among women.

84
5.1.5 Factors influencing the use of cervical cancer screening services among women

Factors affecting the use of cervical cancer screening services among women as

highlighted by the respondents were majorly lack of awareness about the availability of

cervical cancer screening services 242 (45.3%), low risk perception about cervical cancer

34 (76.2%), no knowledge of where to access cervical cancer screening services 99

(18.5%), financial constraint 62 (11.6%) and inaccessibility to screening services 22 (4.1%)

(Table 6). Ample evidence have also substantiated that lack of awareness and knowledge

about cervical cancer and its screening services was a huge barrier to the uptake of cervical

cancer screening services (Fort et al., 2011; Ngugi et al., 2012; Williams et al., 2013;

Chidyaonga-Maseko et al., 2015; Modibbo et al., 2016; Ndejjo et al., 2016). This obviously

imply that having knowledge of cervical cancer and the benefit of its screening services

may possibly trigger high use of cervical cancer screening services among women.

Low risk perception was identified as a factor affecting the use of cervical cancer

screening services among women in this study. This results was similarly reported by

Ngugi et al. (2012), Ndikom, et al (2012) and Whilte et al (2012) in their studies where low

risk perception about cervical cancer was identified as a barrier to utilization of cervical

cancer screening services. This obviously imply that women utilize cervical cancer

screening services only when there are visible signs and symptoms that could warrant the

pap smear test. There is also a possibility that women with no family history of cervical

cancer may perceive to be at little or no risk of getting cervical cancer. Lack of knowledge

of where to access cervical cancer screening services was indicated as a major barrier in

the current study. This finding agrees with studies conducted by Gatune et al (2005) and

Ndikom et al. (2012) where women exhibited absolute lack of knowledge about where to

85
access the screening services. This may often result from poor record of hospital

consultation and decentralization of screening services. Institutionalizing more cervical

cancer screening centers will be a suitable approach to improve awareness of where to

access cervical cancer screening services.

Another factor affecting the use of cervical cancer screening services identified in

this study was financial constraint. This finding is clearly substantiated in previous studies

where women with lower socio-economic status are low income earners (Mingo et al.,

2012; Chidyaonga-Maseko, et al., 2015). Finance is a major consideration to improve the

uptake of cervical cancer screening services especially with regards to transport fare and

unexpected hidden charges at the screening center except for centers where free screening

services are provided as documented in previous studies (Mutyaba et al., 2007;

Ngugi et al., 2012). In resource-constraint settings where poverty is predominant, out-of-pocket

expenditure for non-emergency health services like cervical screening service is poorly

practiced especially where there are emerging health issues that requires huge financial

attention (Ndikom et al., 2012).

Inaccessibility to screening services was also identified as a barrier to utilize

cervical cancer screening services among women. The inaccessibility problem is an

embodiment of other factors earlier highlighted in this study which include; lack of

knowledge on where to obtain services, long distance to screening center or health facility,

financial constraint for either expenditure on medical exigencies or for transportation to

screening center, socio-economic status, cultural barriers (e.g. lack of autonomy among

women to make decisions concerning their health) and belief system. Hence, establishing

modalities to address the aforementioned barriers should be prioritized for most health

86
 intervention targeted at women. This view was similarly reported in previous studies

conducted elsewhere (Markovic et al., 2005;Thomas et al, 2005; Alemayehu et al 2013;

Lim, et al., 2016).

Furthermore results from logistic regression revealed that there was a strong

predictor of utilization of cervical cancer screening services. Age as a factor is 1.6times

likely to increase ones chances of utilizing a cervical cancer screening services. From our

study, young women between the ages of 20-29 were more likely to utilize cervical cancer

screening than their older counter part. This is in agreement with the findings of Nene et

al. (2007), who also found out that younger women were more likely to use cervical cancer

screening services than their older counterparts.

5.2 Summary

This study was aimed at determining the utilization of cervical cancer screening

services and trends in occurrence among women of reproductive age in Calabar

Municipality, Cross River State, Nigeria. A descriptive cross-sectional study design was

adopted and used for the study. A semi-structured questionnaire was used to generate

primary data from 450 women of reproductive age who were selected using multi-stage

sampling technique. Secondary data was also generated from University of Calabar

Teaching Hospital to assess the trend in occurrence of cervical cancer among women.

Primary data were coded, entered and analyzed using the Statistical Package for Social

Sciences Software (SPSS 20.0 version, 2012). Results computed were expressed in simple

percentages and presented in tables and charts. Secondary data were analyzed using

descriptive statistics and results were presented graphs. Chi-square was used to test for

87
association between a dependent and independent variable at 0.05 level of significance.

Key variables measured in this study include; awareness and knowledge level about

cervical cancer and its screening services, women’s perception about cervical cancer,

trends in occurrence of cervical cancer from 2013 to 2017, utilization of cervical cancer

screening services and factors influencing the use of cervical cancer screening services

among women.

The results of this study is summarized as follows: A total of 111 (24.7%) had good

knowledge of cervical cancer and its screening services, 262 (58.2%) had fair knowledge

and 77 (17.1%) had poor knowledge; 173 (38.4%) had positive perception about cervical

cancer while 277 (61.6%) demonstrated negative perception about cervical cancer; 28

(6.2%) have utilized available cervical cancer screening services of which 10 (35.7%) have

utilized the services in less than 6 months preceding the survey and 8 (28.6%) utilized the

services 6-12 months preceding the survey. Factors affecting the use of cervical cancer

screening services among women as highlighted by the respondents include: lack of

awareness about the availability of cervical cancer screening services 242 (45.3%), low

risk perception about cervical cancer 34 (6.0%), no knowledge of where to access cervical

cancer screening services 99 (18.5%), financial constraint 62 (11.6%). The trend in cervical

cancer among women shows that women who were aged 41-50 years, married and self-

employed showed higher number of cervical cancer cases compared to their counterparts.

There is no association between educational status and utilization of cervical cancer

screening services among women (χ2 = .312; p= 0.576); There is an association between

marital status (χ2 = 17.544; p= 0.001), occupational status (χ2 = 6.21; p= 0.013), knowledge

of cervical cancer (χ2 = 59.88; p= 0.001), perception about cervical cancer (χ2 = 37.35; p=

0.001) and utilization of cervical cancer screening services among women.

88
5.3 Conclusion

Cervical cancer is increasingly becoming a major threat to the health of women in

Nigeria. This is why women are encouraged to use available screening services for prompt

detection, management and treatment of identified cases. Findings in the current study

showed that though awareness on cervical cancer is high, but a greater proportion of the

respondents lack knowledge about cervical cancer, exhibit negative perception towards

cervical cancer and recorded low uptake of cervical cancer screening services. Factors

affecting the use of cervical cancer screening services among women as indicated by the

respondents were; lack of awareness about the availability of cervical cancer screening

services, low risk perception about cervical cancer, no knowledge of where to access

cervical cancer screening services and financial constraint. Hence, to improve the uptake

of cervical cancer screening services among women, there is strong need to institutionalize

a strategic framework that will encourage effective collaboration between the health care

system, private sector and implementing partners.

5.4 Recommendations

Based on the findings in this study, the following recommendations were made;

1. Public health experts in collaboration with service providers from selected health facilities

should carry out advocacy and sensitization campaigns to educate the populace on the need

to utilize available cervical cancer screening services and where they can access such

services. This approach will address any myths and misconceptions about cervical cancer

and its screening services as well as improve their knowledge level.

89
2. Health planners and policy makers should enact policies that would encourage routine body

check-ups and use of screening services on regular basis within a pre-defined interval

especially amongst the older, married and self-employed women.

3. The government at all levels should collaborate with implementing partners and the private

sector to expand and institutionalize more screening centers in other social institutions such

as schools, markets, office outlets, military barracks, religious outlets, etc. for easy

accessibility and improve utilization. It is believed that such close proximity will encourage

high uptake of cervical cancer screening services.

4. The electronic media (Television/radio) can also be used as a media to sensitize the women

on the intricacies about cervical cancer and stimulate their desire to regularly use screening

services in their locality.

5. The hospital management should ensure that cervical cancer screening services should be

either made available at little or no cost or integrated into other maternal health

interventions.

6. An intervention study should be carried out to increase the knowledge and uptake of

cervical cancer screening services among women of reproductive age.

7. An urban-rural analysis should be conducted to identify the factors affecting the use of

cervical cancer screening services and determine the trend in occurrence among women of

reproductive age.

8. To build a rich data-base on cervical cancer screening, trend analysis should be conducted

every five years to keep track on the level of utilization of cervical cancer screening

services among women.

5.5 Contributions to body of knowledge

90
1. The study has identified poor knowledge and negative perception of cervical cancer in

Calabar municipality local government area.

2. Age is a strong predictor of utilization of cervical cancer screening services than education,

occupation and marital status

3. Utilization of cervical cancer screening services is poor in the study area and women

between the ages of 20-29 utilize such services more than other age category.

91
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 APPENDIX I

QUESTIONNAIRE ON THE UTILIZATION OF CERVICAL CANCER SCREENING

SERVICES AND TRENDS AMONG WOMEN OF REPRODUCTIVE AGE IN
CALABAR MUNICIPALITY, CROSS RIVER STATE, NIGERIA

Dear Respondent,

The purpose of this questionnaire is to conduct a study aimed at determining the utilization of

cervical cancer screening services and trends among women of reproductive age in Calabar

Municipality, Cross River State, Nigeria. Data generated from this study will be for academic

purpose only and I assure you of strict confidentiality of information you would provide. Thanks

a lot for participating in this study.

Instruction: Please tick (√) in the appropriate box or fill in where necessary

N/B: You can select more than one option where applicable

SECTION A: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS

1. Age: a] 15-19 [ ] b] 20-24 [ ] c] 25-29 [ ] d] 30-34 [ ] e] 35-39 [ ] f] 40-45 [ ] g] >45 [ ]

2. Education: a) No formal education [ ] b) Primary education [ ] c) Secondary education [ ] d)

Tertiary education [ ]

3. Marital status: a) Single [ ] b) Married [ ] c) Divorced [ ] d) Separated [] e) Widow/widower []

4. Occupation:

5. Religion: a) Christian [ ] b) Islam [ ] c) Traditional religion [ ]

6. Monthly income: a] Less than N20,000 [ ] b] N 20,000-50,000 [ ] c] > N50,000 [ ]

7. Number of children currently have: a] One [ ] b] Two [ ] c] Three [ ] d] Four and above [ ]

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SECTION B: KNOWLEDGE OF CERVICAL CANCER AMONG RESPONDENTS
8. Have you ever heard of cervical cancer before? a] Yes [ ] b] No [ ]

9. If yes, what is your source of information? a] Electronic media (TV/RADIO) [ ] b] School [ ]

c] Campaign/rallies [ ] d] Health worker [ ] e] Books/magazine [ ] f] Others (please specify)

10. What do you think cervical cancer is all about? a] Do not know [ ] b] Cancer of the body cells

[ ] c] Cancer of the lungs [ ] d] Cancer of the chest [ ] e] Cancer of the cervix [ ]

11. What are the possible signs and symptoms of cervical cancer? a] Do not know [ ] b] There is

no known signs and symptoms of cervical cancer [ ] c] Abnormal vaginal bleeding [ ] d]

Malodorous discharge [ ] e] Chest pain [ ] f] Dysuria [ ] g] Vaginal discomfort [ ] h] Vomiting

[ ] i] Others (Please specify)

12. What is the main cause of cervical cancer? a] Do not know [ ] b] HIV/AIDS [ ] c] Cancer [

] d] Human papillomavirus infection [ ] e] Malaria [ ] f] Diabetes Mellitus [ ] g] Others (Please

specify)

13. Do you think cervical cancer can be treated or prevented? a] Yes [ ] b] No [ ] c] Do not know

[ ]

14. In what way(s) can cervical cancer be prevented? a] Regular body checkup [ ] b] Use of

prescribe herbal medicine [ ] c] Using available screening services [ ] d] Do not know any

method of prevention [ ] e] Others (Please specify)

15. Which age group of women do you think are more at risk having cervical cancer? Younger

women [ ] b] Older women [ ] c] Both younger and older women [ ]

16. Are you aware of any available screening services for cervical cancer in your locality? a] Yes

[ ] b] No [ ] c] Do not know [ ]

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17. If your answer in question 16 is YES, what type of test is use for screening for cervical cancer

that you know? a] Do not know [ ] b] Blood test [ ] c] Pap Smear test [ ] d] Urine test [ ] e]

Kidney test [ ] f] Others (please specify)

SECTION C: PERCEPTION OF WOMEN ABOUT CERVICAL CANCER

S/N Variables Strongly Agree I don’t know Disagree Strongly

agree disagree
18 I am not at risk of 1 2 0 3 4
cervical cancer
19 Cervical cancer is a 1 2 0 3 4
sexually transmitted
disease
20 Cervical cancer is 1 2 0 3 4
mainly caused by
witchcraft attack
21 Cervical cancer 4 3 0 2 1
screening is
necessary for every
woman
22 Having sex with 1 2 0 3 4
uncircumcised
partners can
increase the risk of
cervical cancer in
women
23 Cervical cancer can 4 3 0 2 1
be avoided and can
be treated

SECTION D: UTILIZATION OF CERVICAL CANCER SCREENING SERVICES

AMONG RESPONDENTS

24. Have you ever utilized any available cervical cancer screening services in your locality? a] Yes

[ ] b] No [ ]

105
25. If your answer in question 24 is YES, when was the last time you utilized cervical cancer

screening services in your locality? a] less than 6 months ago [ ] b] 6-12 months ago [ ] c] 1-3

years ago [ ] d] 4-6 years ago [ ] e] 7-9 years [ ] f] 10 years and above [ ]

SECTION E: FACTORS AFFECTING THE USE OF CERVICAL CANCER SCREENING

SERVICES AMONG WOMEN

26. If your answer in question 24 is NO, what are your reasons for not using cervical cancer

screening services available in your locality?

a] Not aware of the availability of cervical cancer screening services [ ]

b] Do not see it necessary to use the services [ ]

c] Do not think I am at risk of cervical cancer [ ]

d] Do not know where to access cervical cancer screening services [ ]

e] Not allowed to discuss matters on human sexuality in my community [ ]

f] No money to pay for the services [ ]

g] Cancer diseases is a taboo in my community [ ]

h] Long distance to health facility where the services are provided [ ]

i] Cost of transport [ ]

j] Negative attitude of health workers [ ]

k] Services not easily accessible [ ]

l] Lack of facility for screening [ ]

m] Other reasons (please specify)

106
 APPENDIX II

WORKPLAN FOR THE STUDY ON THE UTILIZATION OF CERVICAL CANCER

SCREENING SERVICES AND TRENDS AMONG WOMEN OF REPRODUCTIVE AGE
IN CALABAR MUNICIPALITY, CROSS RIVER STATE, NIGERIA

S/N TASKS/ACTIVITIES PERIOD/WEEKS PERSONNEL PERSON/DAYS

TO BE PERFORMED ASSIGNED TO OR REQUIRED
RESPONSIBLE
FOR TASK
1. Approval of topic for 1 week Researcher/project 2 x 7 days
research proposal supervisor
2. Presentation of research 1 week Researcher 1 x 1 day
proposal
3. Preliminary visit to the 1 week Researcher 1 x 1 day
study area
4. Clearance and permit 1 week Researcher 1 x 7 days
from appropriate
authorities
5. Training of field 1 week Researcher 1 x 1 day
assistants
6. Approval of instruments 1 week Researcher/ project 2 x 7 days
for data collection supervisor
7. Pre-testing of 1 week Researcher/field 4 x 7 days
instruments for data assistants
collection
8. Finalize data collection 1 week Researcher/ project 1 x 1 day
tools supervisor
9. Collection of baseline 1 week Researcher/field 4 x 7 days
data assistants
10. Collation and analysis 2 weeks Researcher/field 2 x 14 days
of data assistants
11. Report writing and 1 week Researcher/ project 1 x 7 days
preliminary supervisor
presentation of findings
12. Presentation of findings 1 week Researcher 1 x 1 day
at departmental level
(mock defense)
13. External defense 1 week Researcher 1x 1 day
Total number of days 14 weeks
and weeks

107
 APPENDIX III
BUDGET FOR THE STUDY ON THE UTILIZATION OF CERVICAL CANCER
SCREENING SERVICES AND TRENDS AMONG WOMEN OF REPRODUCTIVE AGE
IN CALABAR MUNICIPALITY, CROSS RIVER STATE, NIGERIA

S/N ACTIVITY UNIT COST TOTAL JUSTIFICATION

(N) COST (N)
1 Typing and printing of 2,000 2,000 For supervisor to proofread
draft and make corrections
2 Printing for proposal 2,000 2,000 x 8 = For proposal defense at the
defense 16,000 department
3 Production of 10.00 4,500 Instrument for data
questionnaires(450) collection
4 Pre-testing of the 10,000 10,000 For data collection
instrument
5 Stipend to two field 2,000 x 10 40,000 For administration of
assistants days = 20,000 questionnaires by 2 field
assistant
66 6 Computer analysis 40,000 40,000 To analyze data using SPSS
76 7 Production of report/draft 5,000 5,000 For presentation to the
for supervisor after field Department/supervisor on field
work and data analysis work
88 8 Printing of copies for mock 3,000 3,000 x 6 = For presentation to the
defense 18,000 department on field work
99 9 Printing of copies for 3,000 3,000 x 4 = For external defense
external defense + binding 12,000
10 10 Transportation/logistics 10,000 10,000 For field work
11 11 Contingency 20,000 20,000 To cater for unforeseen
expenditures
Total N177,500

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 APPENDIX IV

INFORMED CONSENT FORM FOR RESPONDENTS

Good morning/afternoon. I am a post graduate student of the Department of Public Health,

University of Calabar, Calabar. I am conducting a study on “Utilization of cervical cancer
screening services and trends among women of reproductive age in Calabar Municipality, Cross
River State, Nigeria”. Findings from the study will help to address identified concerns. This
questionnaire is designed for a research work approved by the Cross River State Ministry of Health
Ethical Committee to be conducted in partial fulfillment for the award of Master in Public Health
in the University of Calabar, Calabar.

Your participation in the study is strictly voluntary and you can withdraw at any time you are no
longer comfortable to be part of the study. All the information you provide will be confidential
and will not be pressurized to respond to any question. You will not be required to put your name
anywhere on this questionnaire.

The questionnaire will take 5-10 minutes to complete

Do you agree to participate in this study? Yes [ ] No [ ]

Participant declaration: The study and the content of this informed consent form have been
explained to me. I have been given an opportunity to ask questions and I am satisfied with the
answers provided. I understand that the information obtained will be kept confidential and I may
withdraw from the study anytime without any prejudice. I hereby voluntarily agree to participate
in this study.

Signature of participant: ___________________________ Date: _______________________

Statement by Researcher:

The researcher provided verbal and written information regarding this study. The researcher agrees
to adhere to the approved protocol and give further clarifications concerning the study.

Signature of researcher:___________________________ Date:_______________________

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