Knowledge, Practice and Acceptability of Cervical Cancer Screening among Midwives in the Gambia

Introduction

Cervical cancer can be defined as a distinct change in the epithelial cells of the transformation zone of the cervix; the cells begin developing in an abnormal fashion in the presence of persistent or long term HPV infection [1]. Cervical cancer is one of the leading malignancy among women in the world with an estimated 527,624 new cases and 265,653 deaths in 2012 [2]. Cervical cancer a largely preventable disease, is one of the most common cancers found in women living in low- and middle-income countries (LMICs) [2]. With the use of cytology–based Papanicolaou smears screening; there has been significant reduction in countries that are able to maintain it. However, cytology-based screening for cervical cancer is not yet successful in reducing cervical cancer burden in developing countries because it is expensive and require a robust and well-funded health care system [2]. This is lacking in many developing countries like Nigeria and The Gambia going by the 2001 Abuja Declaration recommendation, less than 15% of the national budget is spent on health [2].

The burden of cervical cancer in developing countries is huge with an incidence rate that exceeds the average worldwide rates of 15.3 per 100,000 women per year3. Furthermore, countries like Gambia, Mali, Uganda and Zimbabwe have age incidence rate of 32.5, 37.7, 47.5 and 47.4 per 100,000 women per year respectively [3]. Persistent infection with oncogenic subtypes of the human papillomavirus (HPV) results in carcinogenesis, mostly occurring at the cervical transformation zone where the endocervical columnar cells undergo metaplasia to a stratified squamous epithelium. The precursor state of cervical neoplasia may last for years allowing for ready detection through successful screening programs in developed countries using cervical cytology and/or high-risk HPV DNA testing [4]. Well organized and quality assured cytology-based screening programmes have substantially reduced cervical cancer burden in many developed countries. However, there are considerable obstacles to setting up cervical cancer screening programs in developing countries [5]. Countries like Gambia facing enormous health challenges should use alternative way for cervical cancer screening that is cost effective and sustainable so as to increase access to valuable women. Simple screening methods such as visual inspection with Acetic Acid and Pap smear can be integrated into existing reproductive health services thereby increasing access to these important live saving services. Empowerment of women, (education), early screening and treatment of precancers are the most important public health strategy in the prevention and control of cervical cancer in the developing world [6].

Justification

It is estimated that The Gambia has a population of 549,836 women within the ages of 15 years and older who are at risk of developing cervical cancer. Furthermore, estimates indicates that every year about 98 women are diagnosed with cervical cancer and 57 die from the disease [7]. Though data on HPV prevalence in the general population of the Gambia is not available, data in West Africa indicates that about 4.3% of the general population harbour HPV type 16 and18 which are largely attributed to cervical cancer [7].

In a study conducted by Bah, et al. [8] which reviewed the Gambia Cancer Registry from 1999-2009 revealed that cervical cancer was the highest cancer incidence among females forming about 33% of all female cancers. In a similar study conducted by Sighoko [9], finding showed that cervical cancer was the most frequent cancer among women, representing 29% of the all registered female cancers in 1998 -2006 with an Age Specific Rate (ASR) of 15.42 (95% CI) per 100,000 person-years.

Aim and Objectives

Aim: To assess the Knowledge, Practice and Acceptability of Cervical Cancer Screening among Midwives in public health facilities in the Gambia

Literature Review

A study conducted by Olumideet, et al. [3] found that awareness, knowledge and uptake on cervical cancer screening among rural women in Nigeria were very low. Lack of access to screening for cervical cancer is the most important risk factor among women of reproductive age [3]. Early detection of the disease can lead to better prognosis resulting to a decreased in mortality and health care cost [3]. In a study conducted in Gabon by Assoumou, et al. [10] on awareness and knowledge of women on cervical cancer, found that out of 452 women 91.6%

(n=414) heard of cervical cancer. The study further revealed that only 27.9% (n=126) had heard of Pap smear test and 65.1% (n=82) of those who heard of Pap smear test had one done for them and greater number of these tests were initiated by doctors [10].

In another study conducted by Tchounga, et al. [11] on knowledge, attitude and Practises of midwives in Cote d’Ivoire, revealed that out of 592 midwives, 55.7% had appropriate knowledge on cervical cancer. Only 18.4% had a cervical cancer screening test and only 8.4% were able to perform visual inspection screening for cervical cancer. Belete, et al. [12], revealed that out of 110 respondents (34.2%) knew about cervical cancer in which majority of respondents got their source from health professionals. Furthermore, the study stated that majority of respondents 88.2% (n=97) believed that the disease is preventable while about one third (34.4%) knew about the availability of the screening test and 62.7% were willing to screen for cervical cancer [12]. The same study identified the following factors as reasons for not taking up a cervical cancer test; high cost of the test, religious denial, partner acceptance, time consuming, fear of test result and lack of female screeners [12].

A study conducted at Nnamdi Azikiwe University Teaching Hospital Nnewi center by Udigwe [13], found out that out of 144 nurses, 87% (n=122) were aware of the existence of Pap smear screening services. The study further revealed that 9.3% of nurses had lost a relative from cervical cancer, yet still only 5.7% of nurses had ever done a Pap smear. It was also stated that 37.1% (n=52) had no reason for not doing a screening test while 15% (n=21) were afraid of the possible outcome and 25% (n=35) felt they were not at risk of the disease [13].

Maseko, et al. [14] stated that 43% of participants in a study on client satisfaction on cervical screening in Malawi knew that cervical cancer is preventable while 71.8% of participants had no knowledge on visual inspection (VIA) screening test and 23.3% of the respondents knew the clinic time. It was further revealed that about 46.2% of study participants covered a distant of between one and five kilometers to a screening center [14].

A study conducted by Keita [15] on the factors influencing the uptake of cervical cancer prevention services among women of reproductive age (15-49) residing in the Greater Banjul area, The Gambia found out that 94% of the respondents have never been screened for the disease. The study further revealed that the main reasons for not been screened were lack of awareness about the screening services (65%) and unawareness of the disease (13%) [15]. Furthermore, it was found that age (p= 0.010), use of intrauterine contraceptive device (p=0.018), use of condom (p=0.050) and first place to seek care when sick (p=0.019) were statistically significant predictors associated with decreased uptake of cervical cancer screening services whereas knowledge on signs and symptoms of cervical cancer (p=0.001) was significantly associated with increase uptake of cervical cancer screening services in the country [15].

In a study conducted by Mensah [16] found out that the awareness of cervical cancer screening was very high among female nurses at the Korle-Bu Teaching Hospital. It also revealed that most of the respondents expressed high knowledge of the signs and symptoms of screening services. Nurse are expected to have high knowledge on cervical cancer because among their roles is to educate women on the disease. In another study conducted by Abd Allah, et al. [17]. Found out that most of the students (84.0%) were not aware of a screening method other than Pap smear test and approximately half of the respondents (49.9%) have no complete information about the HPV vaccine.

In a study conducted by Anantharaman, et al. [18] found out that all the Health Care Providers were aware of Cervical Cancer and 95.3% of HCPs were aware of the cervical cancer screening either Pap smear or visual inspection using acetic acid or Lugol’s iodine. However, 57.9% felt that they were at risk of cervical cancer and only 18.4% of the female them have ever undergone cervical cancer screening [18].

Finally, cervical cancer which is largely a preventable disease with slow progression but still remains a public health challenge in Sub-Saharan Africa. For a meaningful progress to be made women’s awareness on the disease as well as cultural and socioeconomic barriers to accessing screening services should be tackled. Both primary prevention with the use of vaccination and secondary prevention such as regular screening should be made available, accessible and affordable for women and at a cost the country can afford to maintain at every level of the primary health care delivery system.

Results

The results show that the mean age of respondents was 38 years with a standard deviation of 8.6 and a range of 36 (Table 1), while the mean length of service was 14.8 years with a standard deviation of 9.2 and a range of 37years. The average number of children (parity) was 2 with a standard deviation of 1.8 and a range of 7.

Majority of the respondents were Community Health Nurse Midwives 46.2% (n=42), followed by Enrolled

Midwives 30.8% (n=28) (Table 2), while Registered Midwives account for 18.7% (n-17) and the rest fall into other cadres.

Majority of the respondents 62.6% (n-57) were working in the urban area of the country while the rest works at the rural are of the country. This shows that more midwives are concentrated in the urban area (Figure 1).

Click to enlarge

Conclusion

There is knowledge deficit on cervical cancer among female midwives in working in public health facilities in the Gambia. Very few midwives have been trained on visual inspection using acetic acid. This will make cervical cancer screening services inaccessible to many women in the Gambia hence midwives are the one rendering this service. The study also shows that midwives are ready to do cervical cancer screening test and would allow their daughters to do it and take HPV vaccine.

Recommendation

1. Training on visual inspection with acetic acid should be incorporated into midwifery training curricula so that any midwife who graduate from the training institutions will be equipped with adequate knowledge and skills to offer cervical cancer screening services.
2. Cervical cancer screening should be decentralize into the rural areas of the country so that vulnerable women can get access to screening services.
3. More sensitization using different approaches should be conducted to raise more awareness on the disease among women
4. Visual inspections conducted by midwives should be evaluated to assert its accuracy in detecting pre-cancer of the cervix