KNOWLEDGE, ATTITUDE AND PRACTICE CONCERNING CERVICAL CANCER SCREENING AMONG MARKET WOMEN
CHAPTER TWO
LITERATURE REVIEW
This chapter presents the literature review of this study. It will provide the details of the various related studies. A literature review is a critical analysis of published sources, or literature, on a particular topic. It is an assessment of the literature and provides a summary, classification, comparison and evaluation of knowledge, attitudes, and practices on cervical cancer screening among health care workers (Mongan-Rallis, n.d.). In this study the researcher obtained and reviewed various KAP surveys of cervical cancer among health care workers from published journals, cervical cancer guidelines, web sources and reports.
The literature review details various studies on knowledge, attitudes and screening practices of cervical cancer among market women in developed and developing countries.
2.2 WHAT IS CERVICAL CANCER?
Cervical cancer refers to abnormal growth of cell lining the cervix (the lower part of the uterus).The abnormally growing cervical cells may be diagnosed at different stages defined as cervical intraepithelial neoplasia (CIN): CIN1, CIN2, or CIN3 and if left untreated, CIN2 or CIN3 (collectively referred to as CIN2+) can progress to cervical cancer (WHO Guidelines for Screening and Treatment of Precancerous Lesions For Cervical Cancer Prevention [WHO-GSTPLCCP], 2013). Following the HPV infection, about 10-15 years later the superficial cells of cervix starts with abnormal multiplication (CIN 1), the atypical cells might involve two layers of epithelium (CIN2) and eventually full thickness of epithelium (CIN3) and progress to cervical cancer. A good number of immunocompetent clients can clear the HPV infection. In the study done in Europe demonstrated that up to 69% patients cleared the HPV infection by natural immunity compared to only 22.8% among HIV positive clients which increases the risk of more HIV positive client to develop cervical cancer (Branca et al., 2003).The progress from CIN1 to CIN2 and CIN3 is also faster among HIV positive clients and chances for regression are rare (Motamedi, Böhmer, Neumann, & von Wasielewski, 2015).
2.3 CERVICAL CANCER SCREENING METHODS
Cervical cancer screening detects pre-invasive neoplasia and making treatment possible before the disease become invasive. There are different screening tests for cervical cancer such as VIA/VILI (Visual Inspection With Acid or Lugol’s Iodine), Cervical cytology (Pap Smear) and HPV DNA PCR test .The accuracy of the screening tests in detecting cervical neoplasia varies in accuracies due to several factors including differences in testing, training of providers, quality assurance methods and consistency of reference standards used to establish true positive disease.
VIA was the first test introduced in 1930 by Schiller (Lynette Denny, MD, Section Editor, Barbara Goff, and the Deputy Editor, and Sandy J Falk, n.d.). A positive test is the detection of well-defined, dull acetowhite lesions on the cervix. The objective of VIA is to detect acetowhite lesions leading to the early diagnosis of high-grade cervical intraepithelial neoplasia and early preclinical, asymptomatic invasive cancer. A major advantage with VIA is that it is a real-time screening test, as the outcome is known immediately after the administration of the test, so that further investigations or treatment can be planned and carried out during the same visit. However, it has poor specificity and is thus replaced with cervical cytology (Pap Smear ).Visual inspection is indicated for women who do not have access to cytology and HPV DNA test and there is no absolute contraindication to Visual inspection test, however women with Iodine allergy can use acetic acid (Arbyn et al., 2008).
Cervical cytology became the standard screening test for cervical cancer and premalignant cervical lesions with the introduction of the Papanicolaou (Pap) Smear in 1941 (Papanicolaou & Traut, 1997). Cervical Pap Smear Test is performed under speculum gynecology examination where by a cytology sample is taken from the external surface of the cervix (ectocervix) and the cervical canal (endocervix) to evaluate the transformation zone (squamocolumnar junction), the area at greatest risk for neoplasia. When pre-cancerous lesions are detected, further evaluation may be warranted with colposcopy with or without biopsy (Foxx et al., 2017).
HPV DNA is an alternative to cytology cervical cancer screening which is more used to detect high risk HPV infections and provides more clinical sensitivity and specificity for detection of cervical intraepithelial neoplasia grade 2 or 3 and treatable cancer (≥CIN 2) to minimize redundant or excessive follow-up procedures (Meijer et al., 2009).
Both Pap smear and HPV DNA Test require gynecology speculum examination procedure and it is basically done by use the same procedure.
The effectiveness of the Pap smear in reducing cervical cancer incidence and mortality has already been demonstrated in many developed countries (Mandelblatt et al., 2002). However, the use of Pap smear in resource-limited setting has proved to be challenging due to the fact that it needs well trained lab personnel, developed lab systems and effective connection to give back reports to clients (Denny, Kuhn, Pollack, Wainwright, & Wright, 2000). The same authors go on to confirm further that the World Health Organization (WHO) recommends VIA as alternative screening methods in resource limited settings and cryotherapy as treatment of choice after VIA as they are cost effective and acceptable by women in the countries such as Malawi and Madagascar.
Namibia has not yet established cervical cancer screening programmes however, women get screening during their postnatal care as part of comprehensive primary healthcare during postnatal visits. Currently, some of the hospitals within the country provide Pap Smear Cervical Cancer Screening Test to the women who are HIV infected during the follow up visits at their clinics as a part of the integration of the service at primary healthcare level. The main screening test used for primary screening in Namibia is cytology (Pap smear) with the screening age of 21-64 years with the frequency of screening after every one (1) year (Human Papillomavirus and Related Diseases Report NAMIBIA, n.d.)
2.4 EPIDEMIOLOGY OF CERVICAL CANCER
As of 2017, the world population of women aged 15 and older who are at the risk of developing cervical cancer has been estimated to be 2,784 million (Bruni, Rosas, Serrano, Mena, & Gómez et al., 2017). The estimated cervical cancer incidence in US Canada, Australia, most of Europe, China and middle East, is lowest, (less than 7.9 per 100,000) (Bruno, et al., 2017). In 2012, 528, 000 new cases and 270,000 deaths were estimated to have occurred worldwide, with the majority of these cases and deaths (90%) occurring in low- and middle-income countries (Torre et al., 2015). In Ethiopia, cervical cancer is the second most commonly diagnosed cancer and the leading cause of cancer death in women, with about 8000 newly diagnosed cases and 4700 deaths every year (Gizaw et al., 2017).
In South Africa, the current estimates indicate that, every year 7735 women are diagnosed with cervical cancer and 4248 die from the disease (“South Africa Human Papillomavirus and Related Cancers, Fact Sheet, 2017). Namibia has a population of 813,157 women ages 15 years and older who are at risk of developing cervical cancer. Current estimates indicate that every year 132 women are diagnosed with cervical cancer and 59 die from the disease. Cervical cancer ranks as the 2nd most frequent cancer among women in Namibia and the 3rd most frequent cancer among women between 15 and 44 years of age. Data is not yet available on the HPV burden in the general population of Namibia (“Namibia Human Papillomavirus and Related Cancers, Fact Sheet, 2017)
2.5 GLOBAL OVERVIEW KAP ON CERVICAL CANCER AMONG market women
The knowledge, attitudes and screening practices on cervical cancer among market women could be one of the determinants of increasing of cervical cancer screening uptake in most the women (Akinyemiju et al., 2015; Idowu, Olowookere, Fagbemi, & Ogunlaja, 2016; Pegu, Dhiman, Chaturvedi, & Sharma, 2017).There is a wide disparity in rates of screening for cervical cancer between countries. The average screening coverage rate in developed countries stands at 63% compared to 19% in developing countries (Gakidou et al., 2008).The reasons for the low coverage rates of cervical cancer screening in most of developing countries are lack of national guidelines on cervical cancer screening and poor quality control, monitoring and evaluation of the screening programmes, women lack of awareness of cervical cancer screening methods, long queues at health centers and waiting times, poor infrastructure and lack of screening equipment and staff knowledge on cervical cancer screening and practices (Othman & Rebolj, 2009 as cited in Allen 2012).
Data regarding KAP survey on cervical cancer screening and practices among twenty- two (22) participants of Haitan market women reported lack of knowledge on cervical cancer disease as 69% of the participants stated they had inadequate knowledge. Zahedi et al., (2014) assert that, with regards to attitudes towards cervical cancer screening to their patients, 52% were willing to do visual screening, 100% agreed screening programme should be started in their community, 25 % stated that screening was too difficult while the majority stated that additional training was definitely needed to perform Pap Smear. However in terms of cervical cancer screening practices, only 17% of participants had ever performed Pap smear tests and those health care workers stated that they had been working more than 5 years yet, none of them had performed Pap smear screening on patients at any given working experience.
Another study done in Morocco at primary healthcare settings on awareness of cervical cancer risk factors, screening practices and attitudes among nurses highlighted two major findings, which are the first one related to the knowledge of cervical cancer screenings which was good however, there were gaps in knowledge on certain risk factors. The majority, 75%, of nurses agreed that STI’S(sexual transmitted infection’s) was one of the main risk factors for cervical cancer, 87% HIV, 71% smoking, 72% family history of cervical cancer, 54% contraception, 61% multi-partners and 89% HPV infection. The difference in knowledge on the risk factors could provide another research opportunity for the future. The second observation on that study was screening practices and attitudes. It was found that 90% of the participants occasionally screening their clients for cervical cancer and the main reasons were that patients refused to be screened by male nurses, many clients awaiting services at facilities leading to limited time for screening, and inadequate space for the examination (Najdi et al., 2016).
A KAP survey among market women in Republic of Korea which had the same experience of good knowledge on symptoms (more than half of the participants), risk (81%) prevention (79%) and treatment of cervical cancer 83%. However, inadequate knowledge on the causes of cervical cancer disease noted was that (31%) respondents failed to associate HPV as the one of the cause of cervical cancer. With regards to attitude and practices of cervical cancer, the majority of the respondents (81%) reported cervical cancer screening programme as a priority health care programme in their community where as 71% of the participants suggested routine education of patients on the subjects in question. All participants, according to Trans et al., (2011) reported to be offering cervical cancer screening at their facilities. However, the study found high significant differences of Pap smear screening practices to the patients where by 21% of urban market women compared to 2% of rural health care workers. The same authorities reiterated further that participants responded that the barriers of Pap Smear screening were due to; (51%) inadequate training of staff, 43% insufficient medical supplies and 45% inadequate laboratory facilities.
A survey done in South Africa, which examined the associations between multiple dimensions of health care access and cervical cancer screening, observed that 25% of the women who attended health facilities for themselves or for children had received pelvic examination with or without Pap smear within the previous three years. The results suggested that the number of healthcare providers available and types of providers were mostly significant dimensions of access to care associated with screening for the women who visited health facility in the previous twelve (12) months. Of note, there were no significant association between cervical cancer screening and affordability, accessibility, accommodation and acceptability dimensions of access to cervical cancer screening.
The most common barriers of low rates of routine screening were noted to be caused by lack of knowledge about cervical cancer or screening, due to fear of unfavorable and unexpected results, and the lack of adequate medical infrastructure and qualified personnel. More importantly, the study noted that patient level factors were less important predictors of screening compared with availability of physicians and physicians’ recommendation for free cancer screening (Akinyemiju, Mcdonald, & Lantz, 2015b).
Another cross-section survey done in Ethiopia assessed market women’ knowledge, attitudes, and practices related to cervical cancer. It was reported that knowledge surrounding cervical cancer was high; awareness of etiology and risk factors was low among nurses however; only few healthcare providers had performed Pap smear to the patients (Kress et al., 2015). However, the authors emphasize that because knowledge, attitude and screening practices of cervical cancer may differ from setting to setting, hence, these results may not be conclusive or practical to every situation or set up, thus conducting this study in the Namibian health system will yield commendable revelation and implications.
The research done in Namibia and Zambia to assess the availability and access to cervical cancer services reported that the population of both countries had a very low level of awareness of cervical cancer screening. The discovery was that the health care workers were not informed of the causes of cervical cancer; and a low uptake of Pap smear testing was due to the lack of prioritization on cervical cancer screening by market women (Chingore-Munazvo, 2010).
In Namibia, six hundred and seven (607) cases of cervical cancer were diagnosed between the years 1995 and 2000; these cases were referred for treatment to the Windhoek Central Hospital Iita, (2009). This data suggests therefore that in Namibia there is a lack of successful large scale screening programs regardless of the intensity of the infections and the mortality rates.
It cannot be over-emphasized that the role of market women remains one of the key factors in increasing of cervical cancer screening programmes, therefore assessing Namibia’s health care providers’ knowledge, attitudes and cervical cancer screening practices to their patients is relevant and way overdue.