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East African Journal of Public Health
East African Public Health Association
ISSN: 0856-8960
Vol. 5, Num. 2, 2008, pp. 111-116
Untitled Document East African Journal of Public Heath, Vol. 5, No. 2, August, 2008, pp. 111-116

Evaluation Of Cervical Cancer Screening Program At A Rural Community Of South Africa

Monjurul Hoque, Ehsanul Hoque and  Suriya Bibi Kader

Mangosuthu University of Technology, P. O Box 12363, Jacobs 4026, South Africa 3 Wentworth Hospital, Private Bag JACOBS, JACOBS, 4026, South Africa
Correspondence to: Monjurul Hoque, Medical Manager, Empangeni Hospital, P O Box 2468, New Germany 3620, South Africa, Tel. + 27 31-7071355, Fax. + 27 31-7054475, Cell. + 27 834698602, E-mail: monjurul.hoque@kznhealth.gov.za

Received 18th March 2008, Revised 24th May 2008, Accepted 30th May 2008

Code Number: lp08021

Abstract

Objective: Cervical cancer is a leading cause of deaths among women worldwide. But the condition is preventable through regular screening of women those are ‘at risk’ for abnormal changes in the cervix and treating them who have positive results. Although screening facilities are available in South Africa, the incidence and mortality from cervical cancer remains very high and many women present health facilities with late stage diseases. Purpose of the study is to determine the baseline information on knowledge and practices on risk factors for cervical cancer and Pap smear and to design an intervention to improve Pap smear uptake.
Methods: A cross-sectional population based descriptive study was undertaken at a rural community of South Africa targeting women 30 years and over. The assessment was performed by means of a questionnaire survey. Outcome measures were percentage of women with the knowledge on risk factors for cervical cancer and use of Pap smear test and had undertaken Pap smear test. Binary logistic regression analysis was carried out to identify possible predictors of Pap smear test undertaken. A total of 611 women (random samples) were recruited from the selected households.
Results: The mean age of the sample was 43 years and 54% of them had no education. Only 6% knew all and 65% knew any one of the risk factors of cervical cancer whereas less than half (49%) of them knew that Pap smear is used for prevention of cervical cancer. Only 43% respondents received information on Pap smear from health care workers. Among all the respondents only 18% (95% CI, 15-21) had ever done Pap smear test.
Conclusions: This study showed low uptake of Pap smear test and low level of knowledge on prevention of cervical cancer and risk factors thus warrants urgent extensive health education program for this rural communities.

Key words: Cervical cancer, Pap smear test, knowledge, practice, programme coverage.

Introduction

Cancer of the cervix is a leading cause of deaths among women worldwide. It is estimated that 493,000 new cases and 274,000 deaths occurred worldwide during 2000 (1).Women of poorer communities are mostly affected with this condition as it is reported that 83 percent of the world’s new cases and 85 percent of all cervical cancer deaths occur in developing countries (1). This condition affects not only the health and lives of the women, but also their children, families and their communities at large. Cancer of the cervix is the most common (as reported) form of cancer (malignancy) amongst South African (SA) black women (incidence of over 40 per 100000) but fourth in white women (2). It is estimated that approximately one in every 29 women in their lifetime may develop this form of cancer (3).Deaths due to cervical cancer in SA have been seen to outnumber the maternal deaths during 2000 (1, 4).  

Cervical cancer results from the uncontrolled growth of severely abnormal cells in the cervix and the opening of the uterus. It is considered a disease of early and late middle age. Isolated cases are found to occur among young women, but incidence rates are seen to rise sharply from age 35 years with approximately 87% of cases in women over the age of 35 years in SA (5). The common risk factor is sexually transmitted infection caused by Human Papilloma Virus (HPV) and it is estimated that 50 to 80 percent of sexually active women are infected at least once in their lifetime with the virus (6, 7).The other known risk factors are; early onset of sexual activities, multiple sex partners, long use of oral and injectable contraceptives, immunosuppression, smoking, family history of cervical cancer, HIV infection etc (8).

Public health program such as screening women for precancerous changes, treating and follow-up care at early stages of the disease can potentially protect women from developing cervical cancer and thus reducing the incidence, morbidity and mortality from this condition (9).  To date, screening efforts have relied largely on the Papanicolaou (Pap) smear test, a cytological screening test that has long been used to detect abnormal cell changes in the cervical mucosa. However, while the screening test has achieved tremendous success in industrialized countries through public health program, it has failed to reach a significant proportion of women in developing countries. For example, in the United States, the incidence of cervical cancer has fallen by 75 percent over last 40 years and the mortality from cervical cancer in the UK has reduced by 40% between 1979 and 1995 (10-11).This success is explained as the attribution to the increased uptake of women participating in the cervical screening program as a results of increased awareness amongst women from health education and the media, reduced anxiety around having a smear taken, and the financial incentives to general practitioners for achieving higher coverage targets within their populations (11, 12).On the contrary, a nationwide screening initiative in Mexico, failed to reduce mortality rates from cervical cancer, because of low coverage to the target population (13).In a recent report, it is shown that only 5% women in low-income countries have undergone a Pap smear tests (14).

The National Government (Department of Health) of SA has developed a policy (national guideline for cervical cancer screening) to improve the health of a vulnerable group of population and implemented through its primary health care system since 2000. This policy reflects fairly the best attempt to reduce the incidence and mortality of cervical cancer. The goal of the program is to screen at least 70% of the target women nationally within 10 years of initiating the program (3).  Accordingly, the target population for screening are women of 30 years and older. It is also recommended that all women over the age of 30 years who have not been screened in the last 10 years should have a Pap smear at the first opportunity. After the first screening, women should have a repeat Pap smear at 10 years intervals until the age of 55 years (if the Pap smear results are normal). This means every woman should have three Pap smears in her lifetime free of cost at public health facilities. This is in line with the recommendations of the World Health Organization (15).  The most important components of the national program are: (i) an education program for service users, including outreach targeted at women in the appropriate age categories; (ii) provision of cervical smears at all health facilities including the PHC clinics (fixed and mobile points); (iii) follow-up of patients; (iv) the service site (PHC facilities) must have a relationship with a cytology laboratory which will collect, read and report on smears; and a referral institution for women requiring follow-up treatment; and (v) monitoring of the program to determine coverage and follow-up (16).

Provincial department of health, KwaZulu-Natal (KZN) has developed “KZN cervical cancer screening policy and protocol (2004) to implement the national policy through primary health care (holistic) approach. Priority issues targeted are; baseline data collection, provincial and district strategic plan and resources, cytology services, transport system, dedicated treatment sites, support supervisory systems, data collection, training and development, behavioural change communication programs, advocacy and networking (17).  The success of this program would largely depend on public awareness and knowledge on cervical cancer and the screening program enabling women to make informed sexual and reproductive health choices including cervical cancer screening. Evidence in favour of knowledge on cervical cancer, Pap smear and undertaking Pap smear from South Africa are not favourable. A recent study at a Durban tertiary hospital reported that only 27% of patients reported having had a Pap test (18).

A study conducted in Western Cape province of SA to estimate Pap smear test uptake and effectiveness and is found that 81% coloured and 46% black women had undertaken the test. It is also found that screen has reduced the incidence of invasive disease among black (37%) and coloured (57%) women (19).

Although the intention of the National and Provincial government of SA have expressed through the development of policy, allocating recourses, it is however not known how the program is accepted or reached to the rural communities as the beneficiaries. Therefore, this study was commissioned by Empangeni hospital (maternal and child hospital in the sub-district) management to establish baseline information and to identify gaps in order for necessary intervention. The objectives were therefore: 1) to determine the knowledge on risk factors for cervical cancer and Pap smear test and 2) to estimate the Pap smear test coverage of its catchment population.

Materials and Method

Setting and population

The study was undertaken for the catchment population of Empangeni hospital, which is situated in the Uthungulu district (one of the 11 districts) of KwaZulu-Natal and residence of over 450 000 people. According to census 2001, nearly 90% of its people are rural, black, speak local language (isiZulu), 75% without any income, only 30% has access to any form of piped water and considered poor. It is situated at the eastern and northern part of the province, some parts are on the coastline of the Indian Ocean and approximately 170 kilometres north of the commercial capital and the largest port city of Durban. There are two hospitals and 14 primary health care clinics run by public sectors cover mainly rural and poorer people of the district.  Empangeni hospital is dedicated to Maternal and child health care services and referral centre for all PHC health facilities. There are two private hospitals (Garden hospital in Empangeni and Richards Bay hospital) and approximately 30 general practitioners’ services are based mainly at urban areas and provide services to richer group of population.  There is a general shortage of doctors, nurses and other professional staff (Pharmacist, Radiographer etc.) in public health facilities. Sixty two community health workers (CHW) are appointed from the communities by the public sector to cover more than 90% of rural households to provide a wide range of services including health promotion and education, support communities identifying health problems, referring sick individuals to health facilities and provide treatment support for Tuberculosis and HIV/AIDS. Each CHW (men or women) is allocated approximately 100 (range 90-110) households for their routine activities.  They work 40 hours a week (Monday to Friday) and usually visit each household twice a month. PHC facilities are expected to screen women of targeted group for cervical cancer and refer to Empangeni hospital for any abnormal test results.

Study design, sampling and data collection

A cross-sectional population based descriptive study was conducted targeting the women aged 30 years and over. Community Health workers collected data as part of capacity building. Fifty-nine CHWs participated to collect data for the study (3 CHWs were on holiday) during the month of March 2005. One day training session was conducted for all CHWs in two groups (2 different days) during the month of February 2005. Training session included explanation of the purpose of the study, obtaining written consents from participants, selection of households, and selection of study subjects and data collection for the study. Systematic sampling strategy was adopted to obtain representative sample from the communities covering rural parts of the district. Every 10th households (10% households) starting from 1st household (1st, 11th, 21st etc.) were selected by the CHWs from the community they serve. From each household one woman who was 30 years or over was selected for the study. Women who had done hysterectomy were excluded from the study. If a household had more than one woman aged 30 years or over, the most eldest woman was selected. In case of a household without an eligible subject, the next household was selected until a subject was recruited. If an eligible subject refused to participate for any reason, then it was considered non-participation.  If the eligible subject was absent on the day of the CHW’s visit, an appointment was given at a later date and the CHW visited the subject accordingly.  Pre-tested standard questionnaire (open and close ended) was administered (face-to-face) in the subjects’ preferred language (isiZulu) to collect data. We considered demographic information, knowledge and practices on Pap smear and cervical cancer. Demographic information included the age of the respondents in years, marital, educational and employment status and number of previous deliveries of the respondents.  Knowledge on the risk factors for cervical cancer and Pap smear test were assessed using multiple-choice questions (mix of wrong and correct answers). Single and multiple answers were accepted. If a woman did not understand Pap smear test, the following standard explanation was given. “It is a test to detect abnormal cells on the mouth of the womb that could lead to cancer when performing this test the doctor or nurse places an instrument in the women’s vagina so that he/she can see the mouth of the womb and takes some tissue or cells to send for testing”. The woman was also asked about the timing of the last Pap smear test done. Women were also asked whether they knew the result of Pap test those stated positive on ever done Pap smear test. We accepted their Pap test done when women could answer the results were either normal or abnormal.

Data analysis

Survey data were captured and analyzed using Epi-Info version 6.04b and SPSS 12.0.1, to produce frequency tables with 95% confidence interval (95% CI) and correlation tables. Z-test was carried out to find significant difference between two proportions. Because of the exploratory nature of this study, we did not want to rule out any variable that might have an effect on Pap smear test uptake. Variables having potential association with ever done Pap smear test were identified using Chi-square test. Variables initially considered for analysis included: age of the respondents, education, marital status, employment status, parity, knowledge on risk factors for cervical cancer, and knowledge on Pap smear test. Binary logistic regression analysis was carried out to identify possible predictors of Pap smear test done. 

The survey data were collected with the individual’s informed consent. Full confidentiality and individual rights were maintained. No name of any participant was used in presenting data. Permission was sought from Empangeni hospital.

Results

A total of 611 women who met our selection criteria from 620 households were recruited. Nine women refused to take part in the study. The demographic profiles of the respondents are shown in Table 1. Most of the respondents (76%) were below the age of 50 years, 51% were unmarried and 54% had no education. The mean age of the respondents was 43 years. Most of the respondents (96%) were unemployed. Over half of them (53%) had 4 or more deliveries.

Knowledge on risk factors for cancer of the cervix

Women were asked to name the risk factors for cancer of the cervix. Risk factors such as early onset of sexual activity, sex with multiple partners, prolong use of oral contraceptives, smoking, family history of cervical cancer and sexually transmitted infection (STI) were considered as correct (table 2). Any other answers given by the respondents were considered incorrect.

 At least 322 (64%) women gave correct answers to one or more risk factors whereas only 2% knew all the risk factors. Smoking (35%, 95% CI, 32-39), early onset of sexual activity (24%), multiple sexual partner (19%) were commonly known as risk factors compared to others. Early onset of sexual activity and multiple sex partners can cause cancer of cervix were known to only 7%. Any other two risk factors were reported by 21%, any three factors were reported by 16%, and only 5% respondents reported any four factors. More than half (57%) knew that cancer of the cervix can be prevented. Z-test showed that respondents’ age less than 40 years were more likely (42%) to know smoking was a risk factor for cervical cancer compared to other group (32%) (P < 0.05).There was no other demographic variable that had any association with knowledge on the risk factors of cervical cancer.

Table 1: Demographic profile of the respondents

Variables

Percents

Age distribution

30-39 years

41

40-49 years

35

50-59 years

13

60 years and over

11

Mean age (SD)

43 years (±11)

Marital status

Married

48

Never married

51

Divorced/other

1

Educational status

No education

54

1-5 years schooling

12

6-10 years schooling

13

11 years or more

21

Employment rate

4

Number of previous deliveries

Nil

3

1-3 deliveries

44

4-6 deliveries

36

7 or more deliveries

17

Table 2: Respondents’ knowledge on risk factors for cervical cancer and Pap smear test

Variable

Percentage & (95% Cl)

Risk factor of cervical cancer (n = 611)

Early onset of sexual activity

24 (20-27)

Multiple sexual partners

19 (15-22)

Smoking

35 (32-39)

Family history of Cervical cancer

20 (17-23)

Prolong use of oral contraceptives

4

Sexually Transmitted infection

6

Can cervical cancer be prevented

Yes

57 (53-61)

No

15

Don’t know

28

Ever heard of Pap smear test

49 (45 – 53)

Knew national policy on Pap smear

49 (45 – 53)

How did you know about Pap Smear?

From a friend

4

From family members

3

From a nurse / a doctor

20

From a community Health Worker

23

Others (radio, TV / newspaper)

2

How often a woman should have Pap smear test done?

Once in ten years

13

When a woman should have first Pap smear test done?At the age of 30 years or over/correct answer

31

How many Pap smear a woman should have in life time (healthy woman)

23

Pap smear is used for detection or prevention of cervical cancer

21

Knowledge on Pap smear

Nearly half (49%) of the respondents mentioned ever heard of the national policy on Pap smear or ever heard of Pap smear test. Almost half of the respondents (43%) received information on Pap smear mainly from health care workers. Nurses/doctors contributed 20% and CHWs contributed 23% respectively. Only 2% respondents received information on Pap smear from Media (radio, television and newspaper). Pap smear test is used for detection or prevention of cervical cancer was known to 21% of the respondents. Most of them gave incorrect answers for the uses of Pap smear such as cleaning of the womb, treatment of STI and infertility. Furthermore, 32% mentioned that first Pap smear to be done at the age of 30 years (according to national policy), only 3% of them could mention that at least 3 Pap smears should be done in their life time and every 10 years they should repeat the test if test results were normal (according to national policy). Therefore, majority of the respondents didn’t know how many times and/or how often they should do Pap smear test. Knowledge on Pap smear test was not associated with any demographic variables. 

Practices on Pap smear

Only 18% of the study population mentioned that they had ever done Pap smear and knew the results (table 3). Another 3% reported that they had done the test but did not receive the results. On average of (mean) 4 years earlier (prior to the survey) they had done the Pap smear test. Among those, who knew about Pap smear test (n=302), did not do the test mainly because of personal factors such as fear of the test, cultural or religious and were not ill (72%).  Factors related to health care workers, partners of the individuals and access to health facilities were contributed 25%. We found statistically positive correlation (r = 0.213, p = 0.001) between knowing Pap test and having done the test that means women tend to do the test if they knew about the test.

Binary logistic regression model (backward stepwise) was performed to find the probability of doing Pap smear, where Pap smear was done or not done as dependant variable and age group, marital status, years of schooling completed, known Pap smear policy, number of previous delivery, early onset of sexual behaviour and cigarette smoking were taken as independent variables. We found the model fitted adequately with age group, marital status and known policy because of the model Chi-Square value was 0.005 (< 0.05), Hosmer Lemeshow Test value was 0.535 > 0.05 and classification table showed the overall percentage of 85.2 (Table 4).  There was no demographic variable that had significant association with knowledge on the risk factors for cervical cancer, Pap smear test and or undertaking Pap smear test.

Table 3: Respondents practice on Pap smear

Variables

Percentage

(95% CI)

Ever had done Pap smear  (n = 611)

18 (15 – 21)

Reasons given for not doing Pap smear test  (n = 302)

Fear of the procedure

20

Cultural / Religious reason

24

I’m not ill so it’s not necessary

28

Not suggested by my doctor or a nurse

12

Bad attitude of doctors / nurses

6

Discouraged by partner or others

2

No access to a clinic where Pap smear is done

5

Other reasons

4

Table 4: Output of logistic regression model for adequacy of the model for ever done Pap smear test

Omnibus test (Chi-square)

df

Sig

Hosmer – Lemeshow test (sig)

Classification percentage (overall)

Step 1

16.379

9

.059

0.004

85.2

Step 7

12.258

3

.007

0.535

85.2

Variable(s) entered on step 1: age group, Marital Status, No. of years of schooling completed, Known Pap smear policy, Knowledge on cervical cancer, Early onset of sexual activity, Multiple sexual partners, Cigarette smoking, No. of previous delivery.

Discussion

This study is limited to rural and black women of Empangeni hospital catchment population and the community coverage of knowledge and Pap smear test. The demographic information indicates that these rural black women of Empangeni sub-district are less educated and unemployed. This is the characteristic of underdevelopment and poverty and comparable with the findings of the census 2001 (Statistics SA) for the same population. The present study measures low level of knowledge on risk factors for cervical cancer, Pap smear test and national policy on the prevention of cervical cancer and low coverage of Pap smear test (18%). This is higher than the earlier reports of 5% for KZN but lower than 20% for SA and Western Cape Province of SA (19, 20).Morbidity and mortality from cervical cancer has been found effectively reduced in many developed countries with the use of systematic screening programs. Although the availability and accessibility of screening services are important, this does not guarantee successful screening. A study done in the United States among Vietnamese immigrants revealed that most of them never had Pap smears in spite of availability of facilities (7).This was attributed to lack of knowledge and communication difficulties. Similar findings are reported from Mexico and revealed that in disadvantaged rural communities only 30% of patients had Pap smears and more than 60% were not informed about Pap smears (8).

Although nearly half (49%) of these women reported that they knew about the Pap smear test but more than half of them did not undertake the test. Most of them attributed to personal factors being the reasons such as fear of the procedure or religious reasons or not being sick. Bad attitude of nurses or doctors and discouraged by their partner were significantly lower (6% and 2% respectively). An important aspect with regard to cervical cancer screening is whether women who have a higher educational background and a better knowledge of cervical cancer screening also have a higher rate of Pap smears. The low coverage of Pap smear test thus could be due to low level of knowledge on the benefits of the test and prevention of cervical cancer.

In a study in Germany, it is reported that Pap smear was common but a large proportion (70%) of them had insufficient knowledge on the risk factors for cervical cancer (21).High rate of Pap smear compliance was attributed to an effective registration system in the country which makes sure the follow up and appropriate referral. Significant proportion of women who reported of having had Pap smear, did not receive the test results – indicates the poor follow up system in this rural population. Therefore, one should consider appropriate registration system for Pap smear test in health facilities in SA. Reporting knowledge by individual may encounter recall bias. Explanation of Pap test was given to respondents.  Both under estimation and over estimation have been reported on the basis of self-reported Pap smear history (22).However, the level of knowledge on risk factors for cervical cancer and Pap smear test were considered poor and coverage of Pap smear test low to these communities.

A cohort effect is possible since most of women had done the test on average 4 years ago which could be the time after the introduction of the national policy during 2000.  Using outreach staff to promote cervical cancer has shown positive effect in other sites (23).  In this set up, we could use community health workers to educate our rural population on prevention of cervical cancer. Similar positive effects have also been observed from physician and patient prompts as well as opportunistic screening both in outpatient and inpatient settings. Thus we recommend such initiations strategies in our health facilities (23).Furthermore, good prevention program for cervical cancer requires a number of key features namely; locally understood messages to increase awareness of the disease; must reach a significant proportion of women in their 30s and 40s; motivate them to get tested at least once; make health care facilities widely available and resourceful and appropriate follow-up care. It is therefore, most likely that these people are less educated, unemployed thus less empowered to gain information related to risk factors and prevention of cancer of the cervix of their own.

A number of previous attempts in the past were introduced for cervical cancer screening program at National, provincial and local levels in SA. One of such example was that in 1980, in an urban African area, a well-organized program failed due to poor health education program in the community (24).  In 1995, a policy was introduced in the Western Cape province with the recommendation of three Pap smears and ten years intervals commencing at 30 years of age. It was revealed that the program was not successful due to lack of community education and lack of understanding of health care workers on the rational of the policy (24-26). One should therefore, consider improving public awareness of the program to further their knowledge by educating women about risk factors and benefit of screening using Pap smear test. The role of media campaign should be considered as these are known to work best in promoting cervical cancer screening when multiple media are used (23).  Furthermore, improving the acceptability of screening to women by providing accessible, accurate information, reduce waiting times during screenings, results and treatment that are more acceptable. In our study it is observed that health care workers’ contribution to inform the communities were higher compare to other mode of communications, thus strategies at health facilities to educate clients should be considered as an opportunity.  The information from media was poor (only 2%). It could be possible that rural communities had little or no access to Radio or TV and due to low level of literacy newspapers, posters, pamphlets could make little effect to improve knowledge on Pap smear to rural population.

Adequate coverage is thus dependent on knowledge on the benefits of Pap smear, availability of the test at health facilities and proper functioning of health system (timely testing, receiving test results, referral of abnormal results to appropriate level of care), and perception and attitude of health care workers. Provisions should be made available for target women when attend health facilities for any (such as family planning and antenatal care) other care, health care workers could educate heath care users targeting the risk group on risk factors for cervical cancer and motivate them for performing Pap smear. Therefore, it is also important that health care workers are well informed about the national policy and develop institutional policy to implement national policy on Pap smear. On the other hand CHWs who are close to communities and visit households regularly, educate the target population of the benefit of Pap smear. Further training is needed for CHWs who would then educate the communities to improve awareness through their routine visits to household. Therefore, the success of the screening program in reaching its aim on achieving adequate coverage and thus could reduce morbidity and mortality from cervical cancer.

Conclusion

Most of these rural black women are less educated, have less knowledge and experience of participating in the cervical cancer screening programme, are most important factors to decide whether the screening policy will fail or succeed. It seems therefore, unlikely that the national cervical cancer policy would succeed unless it institutes a comprehensive community and health facility initiated educational program, which would involve health care workers, media and other institutions.

Acknowledgement

The authors wish to acknowledge the Empangeni hospital management team for their support and community health care workers for their contributions to conduct this study.

References

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Copyright 2008 - East African Journal of Public Heath

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