INCREASED UPTAKE OF CERVICAL CANCER SCREENING

AMONG WOMEN OF AGES 15-49 YEARS ATTENDING AT GARISA

REFERAL HOSPITAL

By NASRA YUSUF

D/CM/19017/6017

A RESEARCH REPORT SUBMITTED TO THE DEPARTMENT OF

CLINICAL MEDICINE IN PARTIAL FULFILMENT OF THE AWARD
OF DIPLOMA IN CLINICAL MEDICINE AND SURGERY

DECLARATION
This research project is my work and has never been presented for with award of diploma or
degree in any other institution for academic purpose

SIGNATURE.........................................

NASRA YUSUF

D/CM/19017/6017

i
DEDICATION
This research is dedicated to my loving family members, friends and relatives for their
encouragement and motivational through my subject respondents of the study.

ii
ACKNOWLEDGEMENT
This work has benefited immensely from the contribution of many people. I begin by
thanking my supervisor Mr. Hassan kalicha for his continuous support to ensure the
scientific process of this work. Special thanks also goes to my father for his financial support,
his encouragement to me to look beyond the hard times and to focus on the success of the
future has been enriching. I also thank all my fellow students who took their precious time to
review my work to ensure proper editing and helping me shape many ideas discussed in this
dissertation. May God bless you abundantly.

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Table of contents
DECLARATION........................................................................................................................i

DEDICATION...........................................................................................................................ii

ACKNOWLEDGEMENT........................................................................................................iii

DEFINITION OF TERMS.....................................................................................................viii

ABBREVIATIONS..................................................................................................................ix

ABSTRACT...............................................................................................................................x

CHAPTER ONE........................................................................................................................1

1.0 BACKGROUND INFORMATION.................................................................................1

1.1 PROBLEM STATEMENT..............................................................................................2

1.2 JUSTIFICATION OF THE STUDY..............................................................................2

1.3 OBJECTIVES...................................................................................................................3

1.3.1 BROAD OBJECTIVES.................................................................................................3

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 1.3.2 SPECIFIC OBJECTIVES.............................................................................................3

CHAPTER TWO.......................................................................................................................4

1.0 LITERATURE REVIEW.................................................................................................4

1.1 Introduction......................................................................................................................4

2.2 Knowledge of women on cervical cancer........................................................................4

2.3 Attitude towards cervical cancer screening among women.............................................6

2.4 Relationship of prolonged use of hormonal contraceptives with cervical cancer............7

CHAPTER THREE....................................................................................................................9

3.0 RESEARCH METHODOLOGY.....................................................................................9

3.1 STUDY AREA.................................................................................................................9

3.2 STUDY DESIGN.............................................................................................................9

3.3 STUDY VARIABLES.....................................................................................................9

3.4 STUDY POPULATION...................................................................................................9

3.4.1 Sample determination...............................................................................................10

REFERENCES.....................................................................................................................32

DEFINITION OF TERMS
Cervix:The lower, narrow end of the uterus that forms a canal between the uterus and the
vagina.

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Cervical cancer: Cancer that forms in the tissues of the cervix. It is usually slow-growing
cancer.
Metaplastic: This is the reversible transformation of one differentiated cell type to another
differentiated cell type.
Dysplasia: Deviation from normal cellular change.
Mortality: Number of deaths in a specific period.
Screening: To examine or test somebody to find out if there is a disease.
Perceiving barrier: Refers to obstacles that prevent those eligible for cervical cancer
screening from participating in the available cervical cancer screening program.
Perceived susceptibility: Refers to the views of the participants regarding their risk of
having cervical cancer.
HPV vaccine: A vaccine used in the prevention of human papillomavirus infection and
cervical cancer.

ABBREVIATIONS

AIDS: Acquired Immune Deficiency Syndrome

Ca Cx: Cancer of the cervix

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CCC: Comprehensive Care Centre

EA: East Africa

FPAK: Family Planning Association of Kenya

HIV: Human Immune Virus

HPV: Human Papilloma Virus

IARC: International Agency for Research of Cancer

KMTC: Kenya Medical Training College

MCH/FP: Maternal Child Health and Family Planning

WHO: World Health Organization

ICO: International Cancer Association

MOMS: Ministry of Medical Services

MOPHS: Ministry of Public Health and Sanitation

STI: Sexually Transmitted Infection

SA: Strongly Agree

A: Agree

NS: Not Sure

SD: Strongly Disagree

ABSTRACT
Cervical cancer is a sexually transmitted disease caused by the Human Papilloma virus
(Hpv), especially HPV 16 and 18. The research will be done to find out women knowledge of

vii
cervical cancer screening. The research will be done to determine the attitude of women
towards cervical cancer screening. The research will be done to determine how the prolonged
use of hormonal contraceptives leads to cancer of the cervix.

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 CHAPTER ONE

1.0 BACKGROUND INFORMATION

Cervical cancer is the growth of malignant cells in the cervix which is slow and
asymptomatic and is noted in later stages and is treatable if noted in early stages.

Globally cervical cancer screening is the second most killing cancer in women with an
estimate of 500,000 cases diagnosed and 280,000 deaths annually (WHO,2020)There is a
wide variation between the developing and the developed countries because of early detection
through regular screening that has aided in the control and early treatment of the disease
(National cancer institute,2016)

In Africa, cervical cancer has a high incidence of 530,000 new cases and around
275,000deaths annually. In year 2000,22%of all cancer in women was cervical cancer and
80-90% of those women have never done any pelvic examination or cervical screening. They
present to the hospital when the disease is already advanced and comes with other
complications of cervical cancer which has metastasized to other part and lymph nodes
(WWW Cancer Govpg3). According to WHO (2008), it's the leading cause of death in Ghana
where we have around 6.75 million women. Over 15 years are at risk of cervical cancer more
of them practice sex at a very young age and others are multiparous, 3000 newly diagnosed
and 2040 die of cervical cancer every year. The knowledge on cervical cancer screening
among women of reproductive age majorly in developing countries is very low due to lack of
awareness of cervical cancer and in risk factors caused, predisposing factors and signs and
symptoms. These have7that majority, 77% had ever heard of cervical cancer (Kibicho et al.,
2014).

In Nyamira County, the screening coverage of urban women is higher than that of rural
women (ICO 2013). This attributed to the fact that rural women are less educated hence are
likely to be unaware of cervical cancer and method of preventing it (Mutuma, 2016). Women
of this reproductive age seeking services in Nyamira County Referral Hospital are
increasingly being diagnosed with cervical cancer in its last stage. The low health literacy in
the county adversely impacts cervical cancer incidence, mortality and quality of life. The
majority of the women in the county may have limited knowledge of risk factors cervical
cancer thus negative influence on the utilization of cervical cancer screening services (WHO
2015).

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1.1 PROBLEM STATEMENT
Cervical cancer is one of the very serious health problem globally and significant health
issues. It's among the commonest cancer worldwide in women under 45 years of age. It also
affects the significant number of women above the age. It's estimated that it kills an average
of 40 women per day and a woman dies after every 2 seconds (Ferley et al, 2014).

The incidence of cervical cancer is highest in Central America followed by east and southern
Africa. In 2015)it was estimated that 527,400 new cases occurred globally. During the same
period, 274,833 of the women died of the total new cases each year about 86% to 90%of
deaths occur. Its therefore the leading cause of cancer deaths in developing countries as well
as top cancer affecting women in Africa (WHO, 2012)

Uptake of cervical cancer screening is still very low among women of reproductive age in
developing countries since the utilization of the PAP smear remains low among women of
reproductive age. This is due to poor awareness of the indications and benefits of the cervical
cancer smear test. Some have a poor understanding of cervical cancer procedures and fear
cervical cancer screening (WHO, 2010). It has been reported that there are 10_15 new cases
of cervical cancer (Nairobi cancer registry, 2003-2006).

Cervical cancer is the second most common cancer after breast cancer at 19.3% to 20% of all
reported cases in Kenya (KEMRI, 2010). In Kenya, it is estimated that only 3.2% of women
aged 18-68 years have been screened in any 3 years (KDH/MoPHs GOK, 2009)

1.2 JUSTIFICATION OF THE STUDY

The findings of the research were used by health care workers to create awareness on cervical
cancer to women of childbearing age and the availability of screening services. The finding
of the study gave an insight on the perception towards the causes and treatment of the
disease. The study finding were projected to positively influence policies in the hospital
management and the government to develop appropriate strategies to create awareness of
cervical cancer. With regard to the study of the findings and recommendations it is beneficial
to other researchers who might wish to persue the topic further.

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1.3 OBJECTIVES

1.3.1 BROAD OBJECTIVES

To determine factors contributing to increased uptake of cervical cancer screening among
women of ages 15-49 years attending maternal child health and family planning at Mpeketoni
Subcounty Hospital

1.3.2 SPECIFIC OBJECTIVES

1. To assess women knowledge on cervical cancer screening at Mpeketoni Subcounty
Hospital.
2. To determine the attitude of women towards cervical cancer screening
3. To determine how the prolonged use of hormonal contraceptives leads to cancer of
the cervix and the risk factors.

SIGNIFICANCE OF THE STUDIES ON CA CERVIX

1)Early detection and screening helps in treating ca cervix since early detection can
show can show precancer and cancer stages

2)Health education on prevention of human papilloma virus since its the leading cause
of ca cervix and importance of hpv vaccine to be advocated for young girls

3)How to live and attain proper and productive life with less morbidity and mortality
rates due to surgery and chemotherapy and radiotherapy

LIMITATION OF THE STUDY

Uneducated levels of women most especially those in rural who are not aware of
causes,risk factors ,prevention and management of ca cervix

Sensitive matter to most women who feel uncomfortqble to be checked or screened

DELIMITATION

Health education is the best option for these women use of local women or leaders or
elders of the region to convince them on importance of screening and checkup to avoid
late dx after the cancer has metastatasized to other regions.

ASSUMPTIONS

All the respondents will give true information for the success of the research.

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 CHAPTER TWO

1.0 LITERATURE REVIEW

1.1 Introduction
Cervical cancer is one of the leading cancer among women worldwide. 58,000 new cases and
27,4000 deaths reported annually (WHO/ICO information Centre on HPV and cervical
cancer 22010. About 86% of the cervical cancer in developing countries, Kenya being one of
them (WHO, 2010).

Cancer of cervix is divided into cervical cancer squamous cells carcinoma and cervical
adenocarcinomas. Majority of these cases are squamous cells carcinoma and
adenocarcinomas are rare. Squamous cell carcinoma develops gradually from overtime from
pre-existing non-invasive squamous precursors lesions also called cervical epithelial
neoplasia’s (CIN) or squamous intra epithelial lesions(SIL) (Singiders et al., 2020)

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The latency period between normal HPV infections establishment of cancer may take over a
decade (Zur Hausen, 2012) HPV has been known to cause cervical cancer cases. HPV 16 and
18 are the high risk infectious agents which cause cervical cancer. The high risk types
include in their order of prevalence HPV type 16,18,31 and 45. Cervical cancer is a sexually
transmitted disease. Pathogenesis,ut takes 10_15 for development of cervical cancer.It is not
a fast growing cancer .But progression is faster in immunocompromised and can take less
than 3 years .In older women they grow in endocervix and infiltrate into cervical tissues .

MODE OF SPREAD OF CANCER :

1.Local extension ,inferiorly to the vagina and superiorly to the uterus.

2.Lymphatic spread to the pelvis region via inguinal saccral,femoral lymph nodes.

3,Haematogenous spread to the rest of the body.

PRESENTATION OF CA CERVIX

Post coital bleeding

Intramenstrual bleeding

Foul smelling non pruritic discharge

Pelvic pain

Urine incontinence and stool incontinence

Weight loss

Weakness

Anaemia

2.2 Knowledge of women on cervical cancer

Cervical cancer refers to malignant condition of the cervix (the mouth of the uterus). Despite
the pre invasive and implementation of cervical screening program. Cervical cancer has
remained a major health issue especially in developing countries (Harris et al., 2016)

Cervical cancer presents asymptomatic in early stages but in late stages there are symptoms
like pelvic pain not related to menses, pain during sex, abnormal vaginal bleeding and vaginal
discharge.
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A study done in Malaysia on women aged 21-56 years who had never had a pap smear test
with the aim to explore their knowledge and awareness of cervical cancer and its screening
showed that there is lack of knowledge on pap smear test. Many women did not have a clear
understanding of the meaning of an abnormal cervical smear and the need for the early
detection of the cervical cancer. Many believed that the purpose of the pap smear test was to
detect existing cervical cancer leading to the belief that pap smear testing is not required
because the respondents had no symptoms. Despite considerable awareness of the link
between cervical cancer and sexual activity, as well as the role of the sexually transmitted
infections, none of the respondents had heard of human papilloma virus (Lancet,0.09).

In Kuwait, in one-day study regarding cervical cancer screening among Kuwaitian women
found that knowledge was adequate in 147 (52.3%) women only (Richard et al., 2017)

A study of knowledge and attitude towards cervical cancer among female university students
in South Africa reported a low level of knowledge about benefits of cervical cancer screening
and only thirty-eight percentages (38%) knew that it's used for detection or prevention of
cervical cancer (Hogue et al., 2018).

According to study by Bessler et al., (20017) on factors affecting uptake of cervical cancer
screening among clinic attendees in Trelawney, Jamaica ,18% of women who never had pap
smear was not necessary as it will only increase a woman's anxiety if found to be suggestive
of cervical cancer. Among those who had pap smear test 60%reported that cervical cancer
was sometimes cured by early diagnosis from doing pap smear and as a result can be used to
address problems associated with infertility but 42%of those who have never had a pap smear
do not think cervical cancer is treatable (Bessler et al., 2017).

In Africa, a study done in Cameroon to assess the knowledge of cervical cancer by women
living in Maroua, the capital of the far North province of Cameroon showed that 171 of
women studied only 48(28%) had prior knowledge of cervical cancer (Tebu et al.,2018). A
study done in Lagos 81.7% of 139 patients with advanced cervical cancer had never had of
cervical cancer before (Yu, Rymer, 2010).

In Nigeria a cross sectional study done in the general outpatient department of tertiary
hospital in Ibadan Nigeria, women aged 20-65 years attending or visiting the GOP
department in university teaching hospital were studied. Of the respondents only 15% had
heard of cervical cancer (Amorlu, 2018).

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A cross sectional survey among college women in Ghana showed that only 7.9% were aware
of the link between human papilloma virus and cervical cancer (Abotchi, 2019).

In Sub Saharan Africa, knowledge and awareness of cervical cancer and screening are very
poor and mortality still very high (Gichangi et al., 2013).

Tanzania reported very poor knowledge of the disease in a study done among female
inpatients at Muhimbili between August 1999 and January 2000.It was a case control study to
asses knowledge of cervical cancer symptomology where the knowledge ranged between 30
and 50% among cases and control respectively. This study also showed that more than 90%
of patients presented with invasive cervical cancer. A cross sectional study was conducted in
Sogea, Tanzania reported that the knowledge was poor. The results showed that 243(78.6%)
had poor knowledge 61(19.7%) had satisfactory knowledge and only (51.6%) had good
knowledge (James, 2014)

It's well established fact that knowledge does not always translate into behavior but improved
knowledge has been found to increase uptake of cervical cancer screening in most research
settings (corral et al., 2010) Successful cervical screening programs depend on participation
of informed target population through program that build knowledge and address
misconceptions of the screening programs and therefore increase acceptability and thus
improve uptake of cervical cancer screening programs. Is lack of knowledge, information and
awareness an issue in the case of Kenya where availability services at no or little are not
utilized? The reason why at risk groups fail to utilize preventive cervical cancer screening
services

available might be due to the fact that they do not see the benefits of the program. This needs
to be explored with an aim of addressing them in order to improve uptake of cervical cancer
screening.

2.3 Attitude towards cervical cancer screening among women

Mangoma (2006), in a study done in two districts in Zimbabwe revealed that some women
believed that cervical cancer screening is the dirtiness of the womb. Men are known to be the
cause because they were thought to pass STI to women. Others believed that cervical cancer
is the disease of the uterus. Women reviewed screening as a way of testing HIV while others
thought it's a way of cleaning the uterus (uterus douching). They also considered not having
7
sex with many partners and not using vaginal preparation like pessaries and being screened to
be important though they still felt powerless to prevent cervical cancer and other STIs
because of the culture and particular constraints (Chivenye et al., 2013).

Women viewed cervical cancer as caused by witchcraft because it's a terminal illness that
could not respond to any drug treatment. It's known as horrible disease that would cause a
tremendous stress, emotional and physical suffering to the relatives and friends of the
affected persons. Women believe that failure to maintain hygiene is also a major cause of
cervical cancer. They keep themselves clean especially on menstruation and believed in
washing of seamen after sexual intercourse (Chimbari et al., 2016).

Mangoma (2006) in a study conducted among Zimbabwe women revealed that some women
believed that masturbation is another cause of cervical cancer and also for the married ones
were not any lucky because their husbands were not faithful thus they would bring to them
the disease thus there is no need for screening (Mangoma et al., 2006).

The overal knowledge of ca cervix ,screening ,positive attitude towards cervical

screening,positive attitudes cervical ca ,practice towards ca cervix depends highly on

Age

Educational status

Knowing someone dx with ca ceorix

Marital status of the women

Monthly income of the women(dovepress.com2020)

2.4 Relationship of prolonged use of hormonal contraceptives with cervical cancer

Use of oral contraceptives could increase risk of cervical cancer without taking into account
the HPV infection. It was found out that averagely use of hormonal contraceptives more than
5 or more years is associated with increased risk of cervical cancer. A repeat by WHO in the
international agency of research on cancer, showed that women who used hormonal
contraceptives for 5-9 years compared to those who never used were 3 times at risk of

8
developing cervical cancer. Among women who used contraceptives for more than 10 years
or longer they were four times likely to develop cervical cancer (WHO, international agency
for research cancer, 2020).

Virtually all cervical cancer is caused by persist infections of HPV oncogenic types. The
association of hormonal contraceptives and HPV is indirect. The hormones in those
contraceptives may make the cervical cells to be more susceptible to HPV infections, affects
their ability to clear infection or make easier for HPV. Infections to cause changes that
progress to cervical cancer (WHO, 2013)

A study in Thailand showed that the longer the use of hormonal contraceptives increased the
risk of cervical cancer (Publimed, 2018).

A research done on women from Brazil, Peru, Paraguay, Spain and Philippines suggested that
women who have had their a HPV infection and have used contraceptives for over 5 years
and have 3 times increased risk of developing cervical cancer that those who do not (Moreno
et al 2012).

In Africa prolonged use of hormonal contraceptives and cervical cancer has been proved by a
number of studies. According to research done in south Africa it showed that there was
transient increased risk of developing cervical cancer compared to those women who never
had used hormonal contraceptives. The research was done on a group of 18-60 years of age
of females, those who used for 5-9 years’ hormonal contraceptives both oral or injectable
(international agency for research, IARC, 2012).

A case study in Nigeria showed that there was a relative association of cervical cancer with
hormonal contraceptives. This was done in 156 women who never used. Out of 156 who use
1/3 of them used more than 5-10 years were seen to undergo neoplasia changes in the cervix
(National Library of Medicine USA, 2015).

In Kenya it was noted that combined oral contraceptives were risk factors to develop cervical
cancer. This was noted in all women who were seronegative. Two control case studies done
in Kenya showed that there was a slight increased risk of developing cervical cancer
(DMDA) as a method of family planning (Global Library of Women Medicine).

This was mostly noted in long term users (more than 5-10 years) in their life time. A
considerable drop in the risk was noted in those who stopped and sought other contraceptive

9
methods. The mechanism through which these hormonal contraceptives became a risk factor
was neoplastic changes in HPV infections promotion of growth of those lesions broadening
of cells undergoing metaplastic changes (GLOWN, 2012).

In Nyanza region, a research conducted by North Carolina chapel hill in Kisumu in 2010,
there were raising of cancer of cervix but 1/3 of these cases was reported from family
planning clinics, especially those who used hormonal contraceptives as an
independedeterminan

Cancer book of records in Garissa showed that cervical cancer was mostly caused by HPV
infection with no known precipitating factors (among people diagnosed with cervical cancer

CHAPTER THREE

3.0 RESEARCH METHODOLOGY

This chapter deals with methods and procedures used in carrying out the study, it describes
study area, study design, definition of variables, study population, sampling procedures,
sample size determination, data collection tools, data collection procedures, inclusion and
exclusion criteria, study limitation and ethical consideration.

3.1 STUDY AREA

Garissa Referral Hospital is a level 5 Government Hospital in Garissa County. Specifically,
in family planning and gynecological ward. The hospital is locateplin Garissa town 1 km
from Garissa town in north eastern Kenya. It has 6constitutuents and its lead by a governor .

3.2 STUDY DESIGN

This study was a descriptive study carried out at investigating factors influencing uptake of
cervical cancer screening among women of child bearing age attending maternal and child
health and family planning clinic at Garissa county referral hospital.

3.3 STUDY VARIABLES

The independent variables:
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 i. Age

ii. Marital status

iii. Level of education

iv. Types of family planning

3.4 STUDY POPULATION

This include all women of ages from 15-60 years attending Garissa referral hospital
MCH/FP.

3.4.1 Sample determination

Determined the number of respondent to be intervFrequencyGarissa County Referral hospital

Andrew Fisher method of 1994 was used for the population less than 10,000

Where nf= Describes sample size when population is less than 10,000

n=Standard sample size

N=Estimated total population

nf=500

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 REFERENCES

1. Abotchie P. 2009, Cervical Cancer Screening among College Students in Ghana,

International Journal Gynecological Cancer. Ghana
2. AmoluRI, 2008 Nov, Cervical Cancer, The Sub-Saharan African Perspective.
Reproductive Health Matters, European Elsevier Ltd , Europe
3. Bakemier RF, 1995, Attitude of Colorado Health Professionals Towards Breasts and
Cervical Cancer Screening in Hispanic Women, Journal of National Cancer Institute
Monographs; Peru, Spain
4. En.Wikipedia.Org/Wiki.Cervicalcancer 18 January 2014 9.20pm
5. En.Wikipedia.Org/Wiki/Attitude, 18 January 2014,7.36pm
6. Gichagi P, 2003, Knowledge and Practice About Cervical Cancer and Pap Smear
Testing Among Patients at Kenyatta National Hospital, International Journal of
Gynecological Cancer Volume 13, Nairobi, Kenya
7. KEMRI, 2010, Coroscopy and Programme Management Guidelines for the NHS
Cervical Screening Programme, 2nd Edition Nairobi, Kenya
8. Mugenda 1999, Research Methods: Quantitative Approaches, African Center for
Technology, Nairobi Kenya
9. Nairobi Cancer Registry, 2003- 2008, Nairobi, Kenya
10. Parkin D. 2012, Global ,Cancer Facts and Figures 2nd Edition , Usa
11. Sairaf M. 2019; Knowledge, Attitudes and Practice Related to Cervical Cancer
Screening Among Kuwait Women, Med Prin Prac Vol 2, Kuwait
12. Trebeu PM, 2018, The Attitude and Knowledge of Cervical Cancer by Cameroonian
Women, Int. Journal Gynecological Cancer the Capital of far North Province of
Cameroon
13. WHO/ IARC, 2011; International Agency for Research on Cancer, Lyon, France

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13. Yu. CK. Rymer 2010 Women’s Attitude to Awareness of Smear Testing and Cervical
Cancer, Public Health Rep. Vol 91, Rockville, USA

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