Introduction
According to Canavan and Doshi (2010), cervical cancer is a cancer arising from the cervix which is due to the abnormal growth of cells in the cervix that have the ability to invade or spread to other parts of the body. Tarney and Han (2014) stated that the occurrence of cervical cancer typically is unnoticeable at it early stage but at the late stage abnormal vaginal bleeding, pelvic pain, or pain during sexual intercourse.
Nanda (2006) defined cervical cancer as the occurrence of abnormal cells on the cervix which grow out of control in the cervix which is the lower part of the uterus that opens into the vagina. Kumar, Abbas, Fausto and Michell (2007) identified cervical cancer as one of the most common cancers in women worldwide resulting from infections with a virus called human papillomavirus (HPV) which can be contacted by having unprotected sexual contact with someone who has it. They further stated that it is a significant public health burden in most developing counties where it is a major cause of mortality and morbidity among women. Despite the availability of free papanicolaon (pap) smear screening, cervical cancer is the leading cause of cancer- related cases of cancer among women.
According to the World Health Organization (WHO) (2014), the highest burden of cervical cancer occurs in developing nations, where there is a lack of effective screening programs and low uptake of pap smear or the pelvic examination. Cervical cancer is the seemed most common cancer among women in the world; possible in part of sub-Sahara Africa due to changes in sexual behavior (Parkin & Brany, 2006). It is estimated that women in developing counties account for 80% of annual cervical cancer deaths occurring worldwide. Most of these deaths occur in the poorest regions which include South Asia, sub-Saharan Africa and parts of Latin America (Collymore, 2008). Prior to the development of papanicolaen test (pap smear) in the 1950s, cervical cancer was the leading cause of deaths among women in most tropical and sub-Saharan regions because there was no method for screening for high grade precursors (Nakaleva, 2009). As a result of the screening programs, there has been a remarkable decrease to cervical cancer incidence and mortality (Parkin & Brany, 2006). The pap smear screening program has been beneficial in detecting precursor lesion before the cells can advance to cancer. But despite the availability of this screening program, a very large percentage of women in Africa have not benefited from it due to several factors which include illiteracy, religious and cultural inclinations leading tomany unnecessary deaths preventable by routine pap smears since not all women obtain routine cervical cancer screening and the opportunity to detect these precursor lesions is lost (American Cancer Society (ACS), 2006).
Conceptual framework
The cervix is the bottom part of the uterus, which connects the uterine body vagina or the birth canal (WHO, 2014). The part of the cervix that is closest to the uterine body is known as the endo cervix and the part of the cervix is next to the vagina is called the ecto cervix. Most of the cervical cancer lesions begin in the junction where the endo cervix and ecto cervix meet. Cancers can be caused by DNA (Deoxyribe – Nuclieic Acids ) mutation (gene defects) that activated cells promoting cell division (onco genes). Sometimes this could be caused by inactivation of tumour suppressor genes resulting to abnormal proliferation of cervical cells (Ferlay, 2010). Cancer of the cervix occurs when the cells of the cervix grow out of control where malignant cancer cells continue to divide until they form a growth or tumour that may appear as a cauliflower – like growth that bleeds easily on contact. If left undetected, the cancer cells becomes invasive, spreading to tissue and organs outside of the cervix such as the bladder, intestine, liver, uterus and ovaries (Smeltzer &Bare, 2004). Most cervical cancer develop slowly in the living of the cervix as pre-cancerous change known as pre cancer lesions (dysplasia) that can potentially develop into cancer if not treated early, but some lesions may not be malignant and can disappear without treatment (Goldie,2003).
Screening of cervical cancer
Screening for cervical cancer is the most preventive measure and the purpose of the screening is to detect the early pre-cancerous lesions and treat them before they can develop into invasive cervical cancer (Bosch, 2002), stated that among all the cancers, cervical cancer is the only type that can be totally prevented if there is regular screening and treatment of its pre-cancerous lesions. Smeltzer and Bare (2004), stated that there are several methods available for the detection of several forms of pre cancers and these include direct visual inspection of the cervix aided by chemicals like 5 percent acetic acid and iodine (visual inspection with acetic acid (VIA) and visual inspection with Lugol’s iodine (VILI), which cause recognizable colour changes. Other screening techniques, like cytology (convectional pap smears, liquid- based cytology) and HPV DNA testing and treatment of pre-cancer using cryotherapy or the loop electrosurgical excision procedure (LEEP) are helpful in reducing the burden of cervical cancer
WHO (2014), stated that every woman should be screened at every opportunity of contact with a health professional at postnatal clinics, STI clinics and gynaecological clinics. For every woman who are sexually active, annual screening from age 18 to 35 years is advised thereafter every 3 to 5 years, provided the test result remain negative.
However, the success of cervical cancer screening initiatives depend on high participation of the targeted group, which is also determine by the woman’s knowledge, perceptions attitudes and other socio-cultural issues.
Risks of cervical cancer
HPV is the most important risk factor for cervical cancer and persistent infection with HPV types 16 and 18, which causes the majority cervical cancer case increase the risk of disease development (Gharoro & Ikeanyi, 2006) HPV is sexually transmitted therefore risk of acquiring HPV infection is highest soon after sexual activity begins and in some cases it has a second peak amongst woman at menopause.
Clifford (2005) stated that skin – to skin genital contact is a well recognized mode of HPV transmission. Also stated that, the risk of HPV exposure appears to increase with the number of lifetime sexual partners of woman. Therefore, woman who have had multiple partners or a high risk partners who began having sexual intercourse at an early age are more at risk for HPV infection that others. Sexual intercourse without condom use increases the risk of becoming infected with HPV but not all the woman infected with HPV will eventually develop cervical cancer.
Gharoro and Ikeanyi (2006), stated that woman with HPV who smoke or have a weakened immune system have an increased risk o developing cervical cancer. HIV infected are at higher risk of HPV infection, and persistence of the infection, even when they are on antiretroviral therapy. There is currently no cure for HPV infection apart from management of lesions or growths caused by HPV infection.
Socio-economic factors that influence uptake of cervical cancer screening
The decision to have cervical cancer screening has shown to be mainly influenced by socio-economic factors. Qualitative studies conducted in India, south Africa and Nigeria found that older woman who were of low socio-economic status and unemployed, are less likely to participation in cervical cancer screening (WHO, 2014).
In a qualitative study done in Nigeria, Mutyaba et al., (2007) assert that having money increase the probability of utilizing cervical cancer screening and access to information and utilization of health care service, while Satija(2009) find that low socio- economic status interferes with adherence and follow up treatment leading to further morbidity and mortality from the disease. Kagumire(2010), found that large population of woman in Nigeria cannot afford transport costs to the regional referral hospital which provide cervical cancer screening services. Similar results are found in the United States of America (USA) South Africa and the Netherlands. In USA, Garner(2003) found that woman in minority, socio-economically disadvantaged, and rural population have not equally benefited from popanicolaon test (pap smear) screening. Other studies in south Africa reported that woman without partners were less likely to participated in screening while in the Netherlands, a big number of participants in a study did not view cervical cancer as a big problem (Earker, 2001). Thus, to improve uptake of cervical cancer screening , it is crucial that organized screening programs take services nearer to the communities, and this needs to be complied with information on it’s importance, and increased efforts to understand (and positively change) woman’s perception of the disease.
Knowledge and perceptions about cervical cancer and screening
Nakaleva (2009) revealed that woman’s perceptions and limited knowledge about the importance of cervical screening influence uptake of cervical cancer screening. Woman do not have a clear understanding of the interpretation of the screening outcome result many believe that an abnormal screening result means that a woman already has cancer, so they have fear and distress in case they screen and end up with an abnormal result. These studies also showed that, cultural norms of screen that been woman from discussing issues of reproductive health has made woman not gain knowledge about the importance of cervical cancer screening. Other reasons cited for non-attendance include reluctance to go for a test in the absence of symptoms, uncertainty as to whether the screening is appropriate for certain age groups (post- menopausal woman and young girls up to age 20 years)
However, the results of a qualitative study conducted in Ireland by Riani(2001), showed that 45% of high risk woman actually had knowledge about the purpose of pap smear screening but they were less likely to attend a cervical screening voluntarily because of socio-economic related problems like low income and lack of social support.
Apart knowledge gap on cervical cancer screening, Mutyaba(2007) asserts that cultural and religious issues dictate the reluctance among men to participate in woman’s reproductive health issues in Nigeria yet they remain the sole providers of resources that enable woman to access health care. Mutyaba’s study methodology had wide representation that could produce more convincing results because the participants were a mixture of men, women, and health workers.
Cultural/religious beliefs about cervical cancer screening
Scamlihk, cited in Nicky (2010), stated that several studies in UK and South Asia shows that cultural beliefs and perceptions influence uptake of cervical cancer screening. These studies revealed that black minority ethnic groups in West Africa and East Africa woman consider cervical cancer as being caused by promiscuity: therefore it is considered a taboo, or just punishment from God. As a result of these beliefs, a big proportion of woman show away from screening because they do not want to be associated with such disease that considered a curse from God. Many other studies have also reported embarrassment when seen seeking care for cervical cancer, stigma, and lowered self-esteem when one receives a negative result (International Agency for Research on Cancer, 2005).
Additionally, a UK based study reported that woman had fear of receiving abnormal screening results because of anxiety associated with such results. The women of Ode-Irele claimed that abnormal results would have severe effect on day to day functioning leading to depressed mood, decreased libido and feeling of less attractive, tarnished, defiled or contaminated and dirty feelings.
Nicky (2005), reported an interesting finding of cultural / religions belief that Muslims woman can only be seen naked by their husbands; which influence their preference for female general practitioners especially for cervical smears. Also it was revealed that most of women in Ode-Irele community are Muslims and they are not comfortable being attended to by other religion doctors who are not form the same cultural background. These women would not want to go along for a pap smear test.
Other cultural gender roles and behaviours that hindered cervical cancer screening include inability to leave house hold chores, pre occupation with family problems and lack of approval from husbands. However, Nakalevu (2009) argues that, if woman and communities were educated and understood the importance of having a cervical cancer screenings, and the importance of further follow up, cultural would not be a bigger hindrance since the results of her study showed that, women’s general attitude was positive towards cervical cancer screening. It is importance to note through that in this study, participant recruitment happened at health facilities among patients who could already be having a positive attitudes seeking health.
Practices and behaviours about cervical cancer screening
Institutional factors have also been showed by different studies to be influencing uptake of cervical cancer screening. According to International Agency for Research on Cancer Organization (2005), uptake of screening is increased when the governments ensure that there is an organized screening program in place. Mutyaba et al.(2007), showed that mortality due to cervical cancer reduce drastically in developed countries which had sustained organized screening programs that were equipped with infrastructure, trained human resources, organized follow up and surveillance systems. A review of five qualitative studies that were conducted in Mexico, Peru and Ecuador showed that the main barriers to increasing uptake of cervical cancer included inaccessible and unavailability of high quality health services, the lack of comfort and privacy in facilities and unfriendly health workers (Garner, 2003).
In counties like Chile, Colombia, Costa Rica, Cuba and Mexico which have been having organized screening programs in place, mortality due to cervical cancer has remained the same or even increased. The reasons for this were reported to be other underlying factors such as inadequate infrastructure, insufficient human resource and lack of education among the masses. While the same factors have been considered in almost all of the cervical cancer screening uptakes studies, the findings as the literature indicates have been contradictory in some cases for example, Garner (2003) and Bradly et al.,(2004) found that socio-economic factors were important variable that positively and negatively influence a woman’s decision to participate in screening in India and South Africa. Mutyaba et al., (2007) on the other hand, found that a combination of economic and male partner influences, knowledge, cultural beliefs and health service factors interacted with presence of organized screening programs influencing a woman’s decision to participate in cervical cancer screening in Ode-Irele community. He also found that culture does not matter as long as woman have knowledge about the importance of screening, fears and perceptions addressed then they are likely to participate in cervical cancer screening in the community.
Recommended strategies to increase uptake of cervical cancer screening
Research has recommended some strategies which can increase uptake of cervical cancer screening in Ode-Irele community, for example, Nakalevu (2009) recommended that awareness and health education programs need to be implemented to target women about cervical cancer screening, train more competent health providers ensure could be discussing thoroughly with them and encourage them for further follow –up clinics. Mutyaba(2001), noted that men are potentially wiling partners if appropriately informed about issue of women’s reproductive health; so men should also be targeted during cervical cancer screening awareness campaigns. There is also need to improve women’s satisfaction by using female health workers in cervical cancer screening and adapting the service to meet user’s needs considering for example the timing of screening and the screening place that is more convenient for women and all this is done considering women beliefs.
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