GREENER JOURNAL OF EPIDEMIOLOGY AND PUBLIC HEALTH
ISSN: 2354-2381
Submitted: 21/08/2016 Accepted: 02/11/2016 Published: 08/11/2016
Research Article (DOI: http://doi.org/10.15580/GJEPH.2016.2.082116131)
Women’s Views on Knowledge and Barriers to Cervical Cancer Screening among Women in Kaduna State, Nigeria
Mfuh Anita Yafeh*1 and Lukong Christopher Suiye2
1RN, PHN, PhD, FWACN, Lecturer, Department of Nursing Sciences, Faculty of Medicine, Ahmadu Bello University, Zaria, Nigeria.
2FWACS, FACS, Department of Surgery, Usmanu Danfodio University Teaching Hospital, Sokoto Nigeria.
*Corresponding Author’s Email: yaanita123456z@ gmail. com; Phone number: +2348032829978
ABSTRACT
Cervical cancer is a major cause of death among women in Kaduna State. Knowledge and access to regular screening will reduce the incidence of the disease. This study was a community-based, qualitative study on women living in Kaduna State, Nigeria. It assessed women`s knowledge about cervical cancer screening and identified barriers affecting screening for cervical cancer among women in Kaduna State. The population of the study included women of reproductive age group between 15 and 45 years who were purposively selected. Qualitative technique of data collection using Focus Group Discussions were held for the women. The study took place within the three Senatorial Zones of the State. The results were transcribed, themes and patterns emerged, systematically and critically analyzed and results presented verbatim in quotations. The findings showed that various factors influenced utilization of cervical cancer screening among which was the fact that, majority of the respondents were not aware of the screening services, negative beliefs regarding the causation of cervical cancer and prevention, lack of finance, no symptoms, among others. Among those who were aware of the screening, male health personnels screening the females was a major barrier. Major factors identified that can improve screening for the women were, increasing awareness for women and female health personnels screening the women for cervical cancer among other reasons. It was therefore recommended that, information regarding cervical cancer and screening should be disseminated to the populace. Female health personnels should be trained on cheap screening methods such as Visual Inspection using Acetic acid which is a screening method suitable for low resource settings.
Key words: Barriers, Cervical Cancer, Knowledge, Screening, Women`s views.
INTRODUCTION
Worldwide, cervical cancer is the second most common cancer among women after breast cancer, with an estimated 493,000 new cases and 274,000 deaths annually (Parkin et al, 2005). According to Adewole (2010), every 10 minutes, two women die from cervical cancer worldwide. More than half (76%) of new cervical cancer cases overall occur in developing countries. Sub-Saharan Africa has the highest burden of mortality associated with cervical cancer in the world (Okonofua, 2007). According to World Health Organization (WHO, 2010), the annual number of new cases of cervical cancer in Nigeria was 14,550/100,000 women per year. It kills about 80,000 Nigerian women every year (Maliti, 2013). Ujah (2013) stated that, there are about 2 million cancer cases recorded in Nigeria with 100,000 new cases recorded annually of which about 25 percent are cancer of the cervix. According to Abiodun (2014), Nigeria has a population of 40.43 million women aged 15 years or older who are at risk of developing cervical cancer. Zayyan (2013), further stated that, the more frightening part is the World Health Organisation’s projection of 25 percent increased mortality from cervical cancer in Nigeria in the next decade in the absence of intervention. It is the commonest malignancy among women in the Northern part of Nigeria where this study is carried out.
Unlike in the Western countries, majority of women in developing countries present with advanced stage of cervical cancer which is often beyond the scope of surgery and radiotherapy facilities and death is usually inevitable (Olusegun et al, 2012). The incidence, prevalence and mortality from this form of malignancy has been largely reduced in the developed parts of the world because of organised screening for the premalignant lesions of the cervix as well as adequate treatment of these lesions, but still rages in the developing countries due to very limited use of screening methods which are available and affordable in the developed nations, thus the differences (Ahmedin et al, 2010). The difference can also be due to cultural barriers where women in developing countries do not discuss diseases affecting the sexual organs as it is considered to be private and women feel shy to discuss anything affecting it. According to Rafindadi et al, (1999), in Nigeria the morbidity and mortality statistics for cancer are high, due to the ‘late presentation syndrome’ involving 83-87 percent of cancer patients. This is because the awareness level of Nigerian women about cervical cancer is very low. Most patients with cervical cancer arrived at Ahmadu Bello University Teaching Hospital, Kaduna State, late after resorting to different kinds of treatment at home.
Most studies in Nigeria have showed low awareness and utilization of cervical cancer screening. A study by Udigwe (2006) in Nnamdi Azikwe University Teaching Hospital revealed that, although 9.3% of respondents had lost a relative due to cervical cancer, only 5.7% had gone for a Pap smear screening. Similarly, a study by Adefuye (2006) at Remo District of Ogun State showed that only 8.7% of respondents had ever been screened. Study conducted among women visiting the General Out Patient department at Ibadan revealed low level of awareness of cervical cancer and prevention (Anorlu, 2008). Another study by Ibrahim et al (2013) on cervical cancer screening among 400 female undergraduate students and staff in the Niger Delta region of Nigeria indicated that 50.6% of respondents were aware of cervical cancer screening.
Studies in the Northern part of Nigeria have also showed low knowledge among women about cervical cancer screening. A study in Sokoto by Kabir (2005) indicated low knowledge of cervical cancer screening but majority (94.7%) of the women were willing to screen for the disease. A study by Hyacinth et al (2012) on cervical cancer and Pap smear awareness and utilization among 388 Federal Civil Servants in Jos established that, cervical cancer and Pap smear test awareness were 50.9% and 38.6% respectively. Another study by Saad et al (2013) among 260 market women in Zaria, Kaduna State showed poor knowledge about cervical cancer screening but willingness to screen for the disease. Similarly, a study by Oche et al (2013) among 240 female health workers at Usmanu Danfodiyo University Teaching Hospital Sokoto revealed that, despite good knowledge of respondents about cervical cancer screening, only 10% had ever done the screening. Similarly, a study by Anyebe et al (2014) among nurses who were knowledgeable about cervical cancer in Ahmadu Bello University Teaching Hospital showed that respondents were not willing to screen for cervical cancer. The last two studies shows that just a few female health workers who have ample opportunities to screen did so which suggests that those who said they would like to screen may not do so even when the opportunity arises. There is therefore the need for an in-depth study to identify the reasons for low utilization of the screening services.
STATEMENT OF PROBLEM
Zayyan (2013) noted that, cancer of the cervix is the commonest malignancy among women in Kaduna State. This can be connected with some detrimental sociocultural practices, such as early onset of sexual activity. Ahmadu Bello University Teaching Hospital, (ABUTH), Zaria, which is the referral Centre in the North had three to four new cases diagnosed every week. This number represents 75 percent of the total cases of confirmed gynecologic cancers presenting to the unit. A study conducted by Rafindadi (1999) in Zaria, Kaduna State in the Northern part of Nigeria, showed that, most patients with cervical cancer usually present late in the hospital. The researchers observed at several visits to the Obstetrics and Gynaecological unit of Ahmadu Bello University Teaching Hospital Zaria that, most patients with cervical cancer arrived late after receiving different kinds of treatments at home. At this time, only palliative treatment could be rendered to them to prolong their lives and they eventually died. Creating awareness, identifying the barriers to cervical cancer screening and tackling them will encourage the women to go for screening and prevent them developing the disease condition. Cervical cancer screening is not carried out in most hospital settings especially in predominantly rural areas in Kaduna state. Presently, the two (2) screening services in Kaduna State are located in the urban areas which most women in the rural communities rarely visit. Although the Ahmadu Bello University Teaching Hospital Zaria offers cervical cytology screening to all women, especially those attending antenatal clinic, the point is that, the hospital is located in the urban area where a few of the female population receive services, leaving a large number in the rural areas who most of the time only visit the primary health facilities available in their communities with no screening services. Presently, the two (2) screening services in Kaduna State are located in the urban areas which most women in the rural communities rarely visit. . Despite available studies on the subject matter in Kaduna State, qualitative studies are lacking, thus creating a knowledge gap which this study intends to fill. With sensitization and availability of the screening services in this area, only a few women are attending the screening (Saad, 2013). Therefore, there is need for this study to determine the reasons for reluctance of women to go for cervical cancer screening. If the utilization of cervical cancer screening is to be increased to achieve the desired goals, the knowledge and barriers of women need to be understood. This will assist in planning and implementing effective cervical cancer screening programs in order to reduce the mortality and morbidity resulting from the disease. This study therefore aimed at identifying the knowledge and barriers of cervical cancer screening among women in Kaduna State Nigeria towards improving utilization of screening services.
MATERIALS AND METHODS
The study was carried out in Kaduna State in the North-West geopolitical Zone of Nigeria. This was a community-based, qualitative study conducted to document the views of women regarding cervical cancer screening. The study comprised women of reproductive age between 15years and 45 years irrespective of marital status residing within the three Senatorial Zones of the State, that is, Southern, Central and Northern Senatorial Zones. The purpose of the Focus Group Discussion was to complement quantitative data from a study conducted in the State.
Selection of Focus Group Discussants
The discussants were purposively selected with assistance from the Local leaders. This was by identifying the residence of the village head who gave order to persons working with him to reach out to the discussants. Eligible discussants resident in the village were selected. Attempt was made to incorporate different social groups in each of the areas selected for the study. Only discussants who were ready to participate were included in the discussion group. The discussants were grouped according to their ages.
Inclusion criteria: This comprised women aged 15-45 years who agreed to participate in the study. Women who were on ground at the time of the study, sufficiently healthy to be able to understand, communicate well and provide necessary information for the study.
Exclusion criteria: Women who refused to consent to participate in the study, sick women who could not communicate and not willing to participate in the study.
Data collection: Focus Group Discussions (FGDs) were held in twenty-four (24) communities within selected wards in the Local Government Areas of the State. Two hundred and sixty-two (262) females participated in the FGDs. One (1) female FGD among women between the ages of 15-24years, 25-34 years and 35-45years of different socio-economic background in the same communities were selected. This ensured that the women feel free to express themselves regarding issues relating to the reproductive system. The number of participants in a group ranged between 9-10 and seventy-two FGDs were conducted within the twenty-four communities. Trained research assistants were recruited and used for the study. The Focus Group Discussions facilitated access to women’s knowledge and perceptions of obstacles to cervical cancer screening through the comparison and confrontation of opinions and experiences in guided discussions. The GDGs were elaborated around 2 main areas: (1) Knowledge on cervical cancer screening and (2) barriers to cervical cancer screening.
Data Analysis and Presentation: The digitally recorded files were critically analyzed and presented verbatim in quotations.
Ethical Consideration: The Health Research Ethics Committee of Ahmadu Bello University Teaching Hospital was contacted to grant permission to conduct the study for which a research proposal was submitted for ethical review and approval. Formal permission was sought from the leaders in each community prior to initiation of the research. The respondents were briefed in detail about the research and allowed to decide on whether to participate or not in the study. This ensured the right of self-determination and autonomy.
RESULT AND DISCUSSION
The background demographic information was collected from each discussant. There were 262 female participants in the Focus Group Discussions. The median age was 31 years (range 15 -45 years). Less than half (41%) of the females had some form of formal education, were also predominantly Hausa/Fulani, Muslim, mostly housewives and engaged in either petty trading (26%) or farming (28%) (Table 2). Most of the respondents were Islam (73%). This is not surprising as this study is carried out in a Muslim dominated environment with females getting married early with no or low level of educational attainment (70%).
In Nigeria, services dealing with cervical cancer are predominantly curative and have minimal effect on the incidence and mortality of the disease. Recognizing this, cervical cancer screening programme (papanicolaou smear) were initiated by the Medical Association of Nigeria in its three operational zones, namely Western (Ibadan), Easten (Enugu) and Northern (Zaria) Zone (Okeke, 1999). Despite sensitization and availability of the screening services in these areas, only a few women are going for screening. The questions that arises are: Are the citizens aware of these services? Are they utilizing the screening services? Are there barriers that prevent women receiving these services? The screening services have been going on in Kaduna State since 1987 (Okeke, 1999). Despite sensitization and availability of the screening services in this area, only a few women are attending the screening (Saad, 2013).
There is currently no National policy on cancer control in Nigeria; however, control of reproductive cancers is included in the ‘National policy on reproductive health and strategic framework’ (FMOH, 2004; WHO, 2006b). It is also related to the policies on food and nutrition and health promotion (FGN, 2003). Nigeria has less than 100 oncologists, about 100 pathologists and four radiotherapy centres, thus cancer control should focus on prevalent cancer pattern and cost-effectiveness (Durosinmi, 2004).
Knowledge on cervical cancer screening
Across all Focus Group Discussions (FGDs), lack of knowledge about cervical cancer screening was so striking among the women. Focus Group Discussion session with some women between the ages of 15-24 years at Kurmi in Sabon Gari LGA on knowledge of cervical cancer screening revealed that, majority of the women were shy to talk about the subject matter although they were within similar age group. One of them, 17 years of age, who had given birth two times said:
“I have never heard of this kind of sickness, talk less of screening. This is the first time I am hearing about this. I will like to go for the screening if my husband allows me to go. This was followed by the others saying; “ni ma”, “ni ma”, “ni ma”, meaning, “me too”, as the session continued”.
Low knowledge on who should be screened was also demonstrated by almost all the discussants from all the three Senatorial zones as evidenced in this quotation. A 40 years old married woman during Focus Group Discussion in Kachia Local Government Area stated that;
“we do not know about the screening even. How will we even know those who are supposed to go for it? Now that we are hearing that there is something like that, we will now also want to know those who are supposed to go for it.”
Other women nodded their heads in agreement to what the woman said and were waiting to know the answer.
Discussion with some of the women who had smoked to know if they were aware that they are at risk of cervical cancer and the need to go for screening revealed that majority of them were not aware of screening for cervical cancer. One respondent 45 years of age, who had smoked more than ten years ago residing at Kachia Local Government Area said:
“The time I was smoking, I was not well, so I went to the hospital to see the doctor who examined me and advised me to stop smoking due to the problems it can cause to me. He told me that, I am a woman and cigarette smoking can affect my baby when I am pregnant. I was also told that, it can cause lung cancer to me but I was not told that it can also cause cervical cancer and the need for me to go for screening. This is my first time I am hearing about this, that smoking can also cause cervical cancer for me and the need for me to go and screen. Now that I know, I will try to go and screen”.
Further interrogation with respondents who had AIDS also revealed low knowledge of cervical cancer screening. One respondent residing at Bomo village in Sabon Gari Local Government Area , 45 years of age said:
“Since I had this condition about seven years ago, I had been going to the hospital to receive my drugs. I was told how the drugs will help me to be healthy. Since the time I had been going to ABUTH hospital, nobody had told me about cervical cancer screening. I do not know that I am also at risk of having cervical cancer. If I knew I would have gone for the screening. Now that I know, I will go for the screening”.
Interview with two of the women who said they had AIDS and went for screening revealed that, they were informed by a health personnel to check their health status due to the risk of developing cervical cancer. The remaining five respondents said that they did not know they were at risk of having cervical cancer as well. One of the respondent, 48 years of age, a petty trader with five children resident at Gidan Nana in Doka ward, who had never gone for screening, said:
“I have been going to the hospital regularly to collect my drugs for this sickness (AIDS) but I have never been informed that there is need for me to do a cervical cancer screening test. I have accepted my condition from the day I was told about it. Now that I know about this screening I will try and do it so that I can know my status. This will help me live longer and take care of my children”.
A study in Zimbabwe by Mangoma, Chirenje, Chimbari and Chandiwana, (2006) showed that, majority (95.8%) of the respondents had little knowledge about the prevention and treatment of cervical cancer. Similar results were obtained in a study by Mutyaba, Mmiro and Weiderpass (2006) where respondents complained of lack of awareness about cervical cancer screening. Another study by Claeys, Gonzalez, Page, Bello and Temmerman (2002), also found lack of knowledge as the main reason for not being screened. On the contrary, a study by Adanu (2002) among 100 randomly selected female nursing students in Ghana showed that knowledge of cervical cancer screening was good in 77.0% participants. In Nigerian communities, it was found that, majority of the respondents had poor knowledge about cervical cancer screening. For example, a study by Roberts, Ayankogbe, Osisanya, Bamgbala, Ajekigbe and Olatunji, and Inem (2004) among 170 female refugees at Oru Camp of Ogun State found that less than 20% of respondents knew that cervical cancer could be detected early. Similarly, a study by Ezem (2009) in Owerri identified lack of awareness (46.1%) as the major reason for respondents not going for screening. This is contrary to a study by Ojiyi and Dike (2008), where the most frequent reason given for not using Pap smear services was lack of physician referral. A qualitative study by Fort, Makin and Siegler (2011) among women in rural Malawi on how they make health-seeking decisions regarding cervical cancer screening revealed that, the major barrier to seeking preventive screening was low knowledge level. This lack of knowledge is contrary to studies by Ajah, Iyoke, Ezeonu, Ugwu, Onoh and Ibo (2015) among 412 secondary school teachers at Abakaliki, Nigeria who found that 75% of respondents were aware of at least one method of cervical cancer prevention.
The lack of knowledge demonstrated from most of the studies is similar to the findings by James (2011) which showed that majority of the respondents (51.6%) were not aware of cervical cancer screening, although some mentioned Visual Inspection using Acetic acid (VIA) (11%) as a screening method while a few mentioned Pap smear. VIA was mentioned by the respondents because it is a method of screening that is used in that study area. VIA is a test meant to be used in low resource settings such as the communities studied in Kaduna State. According to NHS Cervical Screening Programme (2011), early detection and prompt treatment of cervical cancer provides the best possible protection against cancer. Results from other studies like female nurses working in Nnamdi, Azikiwe University Teaching Hospital, Nnewi Center, Nigeria by Udigwe, (2006) identified lack of physicians' referrals and ignorance about location of screening centres as the two most frequent reasons for failure to utilize screening services. Other respondents from various studies gave similar responses. For example, a study by Oyedunni and Opemipo (2012) at Ibadan, Nigeria found that, reasons for not utilizing screening services include; lack of time (46.5%), fear of the result (12.8%), cumbersome procedure (10.9%), lack of awareness of where the test could be done (8.8%), cost consideration (8.2%), not sexually active (6.4%) and not knowing about the test (6.4%).
Barriers to Cervical Cancer Screening: Barriers hindering cervical cancer screening are as presented below;
Belief on the Cause of Cervical Cancer
During Focus Group Discussions, some discussants were of the view that promiscuity is a cause to cervical cancer. An elderly woman, 50 years of age, at Anguwa Gwari who had attended secondary school, speaks English Language fluently repeatedly emphasized her belief on the cause of cervical cancer in the following words:
“That cancer you are talking about is common in women who had abortions when they were young. I tell you this. There is nothing like cancer is caused by something else. I don`t know what you are asking me as to whether this cancer is caused by something else. I have told you that it is not transferred from one parent to the other or any other thing. I tell you this, I cannot believe any other cause apart from this one I have told you which is abortion. Abortion, I said, is the main cause of this cervical cancer you are telling me about. You are asking me whether I will allow my big daughters or advice other women to go for screening, all I am telling you is that there is nothing like that. It is the girls that cause it for themselves. Abortion is the main cause by girls. I do not even belief the screening you are talking about”.
Another variant of this belief expressed at an FGD held with women at Anguwan Karofi as narrated by one of the discussants was that:
“Cervical cancer is caused when women do not cover their bodies especially at night. Our traditionalist taught us that the disease can be transmitted from infected mothers to their daughters especially at night as it is hereditary”.
The belief about abortion as a cause of cervical cancer screening is similar to the finding by James (2011) where eight women also believed that abortion could cause cancer. One of these women, a church pastor’s wife, qualified her belief with the following statement: “That (cancer) is what happens to women who get abortions, too.” Another woman grouped “getting an abortion” with other undesirable behaviors that have moral implications: “All of that – smoking, drinking alcohol, having a lot of sex partners, getting an abortion, all of that can give you cancer.” , and said, “getting an abortion” with other undesirable behaviors that have moral implications are believed to cause cervical cancer. These statements illustrate the women’s understanding of a grave health consequence as due to socially unacceptable behaviour.
A study by Hyacinth, Oluwatoyosi,, Joy and Tolulope (2012) in Jos, Nigeria also identified lack of awareness and belief that cervical cancer is not preventable as a hindrance for screening. Thus the need to intensify effort towards improving the right knowledge among women about cervical cancer screening.
Support from parents
Discussants were asked whether they will allow their daughters go for cervical cancer screening. Majority of them were reluctant to do so as some did not even believe that cervical cancer exist. An elderly woman stated that “You are asking me whether I will allow my big daughters or advice other women to go for screening, all I am telling you is that there is nothing like that cervical cancer you are calling. I do not even believe the screening you are talking about”. This finding shows lack of motherly support for daughters to go for screening. It is also similar to a study by Wong et al (2008) where married respondents had never talked about Pap smear screening with their spouses and neither did their spouse ever discuss with them or encourage them to go for screening. Two unmarried respondents copied their mothers’ non-practice of cervical cancer screening and stated that, “My mother has not done yet, maybe that is why . . . nobody encourage me”.
These different views can affect prevention as it is difficult for these women to go for screening if they don’t know/believe in the link between Human Papilloma Virus and cervical cancer. The implication of the findings on knowledge is that, more enlightenment about screening and the importance is necessary so that parents can support their children to avail themselves for screening of the disease.
Embarrassing:
Some discussants were of the view that, the test is embarrassing. This was the view of majority of the discussants from the three Senatorial Zones. One discussant from Malali Village in Malali Local Government Area said:
“Kai, that test is not easy to dooooo. I just tried to do it the first time. To go and be opening your private part for someone to see when there is no problem is not easy. When I did it, no problem was identified so I decided to just stay even though they told me to come back after three years. But, well I may still do it one day if it is not late”.
Male screeners:
Male personnels screening women was also identified as a barrier towards utilization of cervical cancer screening. During the FGD sessions among women in Makarfi, Sabon Peggi, Bomo Village and others in the Northern Senatorial district, majority of the women were of the view that, only female doctors should screen the women. There was a similar feeling of only female doctors screening the females in all parts of the State. The representative from the Ministry of Health also said: “the screening should be done by a female health provider”. She said:
“If the doctors screening are women it will be better because women hearing that it is male doctors doing the screening will not really like to go. Being females is still not very easy talk less of male doctors”.
Result from a study by Ojiyi and Dike (2008) at Imo State University Teaching Hospital, Orlu, Nigeria among 450 women randomly selected from various clinics showed that, culture was found to negatively impact on the uptake of cervical cancer screening. Majority of the respondents would prefer a female doctor to perform a Pap smear on them if they were to have one. Another study by Anyebe, Opaluwa, Muktar and Philip (2014) among nurses in Ahmadu Bello University Hospital Zaria, Kaduna State, Nigeria identified fear of exposure of private parts to male doctors as a major reason for lack of screenings. Males screening women has been found to be a barrier for screening. Majority of the women prefer female screeners. It however implies that, the reproductive area is considered private and women will not want to open it for anyone to see unless it is very necessary. This also implies that, if the health personnels doing the screening are females, women will feel freer to go for the screening.
Distance to health facility
Distance from place of residence to health Centre was also a hindrance to screening. This was found to be a barrier affecting women going for cervical cancer screening as expressed by discussants from the different Senatorial districts. For example, a discussant at Makarfi Local Government Area said:
“The distance from here to the screening centre is too far. Except they can be doing the screening here in our village then it will be easy for us”.
No sign of cervical cancer
Due to lack of signs and symptoms of the disease, most women do not go for screening. This was the result from Focus group Discussion conducted with majority of the women in the state. A woman at Kaduna South said:
“But without feeling anything wrong with me, how can i leave my children, my house work and be going to the hospital- Shika just to check my body”?
Similar response was given by women in a Focus Group Discussion at Ruma and Tasha Tsamia in Makarfi Local Government Area. The women all consented to the assertion as expressed by one of them that:
“…..they do not go to the hospital if they are not sick. It is regarded as waste of money to go to the hospital just to screen as other women will even laugh at any one who does contrary. Other women will say that you are wasting your husband`s money, especially the other wives “Kishiyaa” in the compound with you. In short, we do not know anything like when to be going for the screening”.
Similarly, in other FGDS held in the Central and Southern Senatorial Zones, a similar response was gotten. For example, in a Focus Group Discussion held at Mayere in Makarfi Local Government Area, a married woman 26 years of age said that:
“The only scheduled checkup we go to the hospital for is antenatal care which is done in our community by the doctors in our hospitals (lower cadres of health workers like Community Health Extension Workers)”. A date is always given for us to come for checkup, like once in two months, once on three months, etc, as the case may be”.
It was observed that, women in Kaduna State utilize reproductive health services more during pregnancy. They also use reproductive health services for post-natal checkup and family planning or when faced with various gynaecological problems. A study by Ibrahim, Owoeye and Kalada (2013) at Niger Delta Nigeria revealed that, almost half of the respondents, considered themselves healthy and did not see any reason to subject themselves to any form of cervical cancer screening. Similarly, a study by Basu, Sarkar, Mukherjee, Ghoshal, Mittal and Biswas (2006) in India found that, the most common reasons cited for non-attendance to cervical cancer screening was reluctance to go for medical test in the absence of any symptoms and apprehension to have a test that detects cancer.
There is need to ensure that these women are enlightened on the benefit of screening without any signs and symptoms of the disease. Antenatal care visits to the clinics should also be encouraged as it provides opportunity to give them information on the importance of screening and where to get the services.
Lack of finance
Majority of the women said the cost implication of screening was a barrier. A discussant 28 years of age, married with six children in Makarfi Local Government Area said:
“We need money for transportation to the hospital and then the screening again. Most of us are not working. Is our husbands that give us little money for feeding? How can we be asking money for this kind of thing again”.
Similarly, most discussants from Kachia Local Government Area in Kaduna South complained about the cost of transportation from their place of residence to the screening Centre. A 17 years old married woman with two children said:
“how can we be going to the hospital when we are not sick just to check ourselves? Who will give me the transport money? My husband is finding it difficult to give me feeding money. How can I start asking him money to go to the hospital just to check myself?” Other women were found nodding their heads as a sign of acceptance to the fact that lack of finance is a hindrance for accessing screening for cervical cancer.
Attitude of health personnels
Other women reiterated the fact that the attitude of health workers in the hospital scare them from just going to the hospital without any major problem. This was the view of most discussants from all the Senatorial districts. For example, a discussant from Kaduna South LGA said:
“The doctors in the hospital like shouting at someone unnecessarily and waste our time waiting for them”.
Another discussant from Bomo village in Sabon Gari Local Government Area said that:
“I have been saying that I will ask this thing. Why is it that the nurses especially like shouting at someone when one goes to the hospital? My friends have said the same thing, especially when someone goes to deliver in the hospital.”
Markovic (2005) identified that the interplay of social and personal barriers influenced women's poor presentation for screening. According to him, inadequate public health education, lack of patient-friendly health services, socio-cultural health beliefs, gender roles, and personal difficulties were the most salient barriers to screening.
Free services
Discussants were willing to screen for the disease as they considered it to be deadly. Majority of them were willing to go for the screening if available and free. Most discussants said that, making the services free will enhance utilization of the services. Emphasis was also laid on availability and accessibility of screening services. A discussant said:
“Making the services free will enhance women participation. The screening services should be done alongside other services provided for women at the antenatal clinic. Majority said that, “this will reduce time wastage since we will have to go to the hospital once and receive two different services and also reduce cost”. A study by Ibrahim, Owoeye and Kalada (2013) at Niger Delta Nigeria revealed that, the commonest reasons for uptake of screening was when it was free or subsidized or as part of a general screening program.
Empowered women
A group of women at Ankung village of Kaduna South believed that, the services should not be made free, but people should pay something to complement the Governments` effort. This was contrary to the views of women in the Northern and Central Senatorial Zones of the State where most of the discussants said that the services should be made free of charge.
At a Focus Group Discussion session with women at Ankun Gida village in Kaduna South LGA, when asked whether they will go for screening if aware of the availability of the screening services, the popular view was that, they will go, they will not wait for the husbands` approval if he is not around before going to the hospital to check themselves or when they are sick. One of the women emphatically said:
”I will go to the hospital when it is necessary and tell my husband when he returns. Whether is a male or female health personnel doing the screening, I see no reason why I should not go to the hospital and check myself if I am aware of. I am out for my health, what is there? A male screening me will not reduce anything from me. All I want is good health. Even if is work, I will leave it and go to check my health. Work will not run. If I die who will do the work? Without good health can I do anything”? Most women agreed with what she said. The researcher observed a few shaking their heads as a sign of doubt and asked them why nodding their heads. One of the discussants 24 years of age said:
“What the other woman said is true, but it is good to have a female screener for one to be comfortable going for the screening. Even with the female, I am still not very comfortable with this kind of checkup”.
This finding is contrary to the views of women in the Northern and Central Senatorial Zones where most of the discussants said that the services should be made free of charge. This result is not surprising as the Southern part of Kaduna State is a Christian dominated area and majority of the women have attained a certain level of education and are more enlightened compared to those from the Northern and Central parts of the State who are Muslims and early marriage is very common with majority of the girls not going to school.
CONCLUSION
Cervical cancer is a global problem with a large number of women dying from the disease. Despite the fact that many women die from this dreaded disease, the Kaduna State Government has not taken drastic action for women to avail themselves for screening. This is a disease that can be prevented at a very low cost in communities like the ones studied using Visual Inspection with Acetic acid. The study has identified some root causes for poor cervical cancer screening. It revealed that knowledge on screening for early detection of cervical cancer was low. Barriers affecting cervical cancer screening in the State were identified. Thus the need to increase awareness about cervical cancer screening and tackle the identified factors in order to improve utilization of screening services in the State, It is believed that the result from this study can facilitate the design of policies that will deal with the problems associated with cervical cancer screening in Kaduna State. It is also hoped that the information so obtained will be useful not only in planning and implementing a more evidence-based and responsive screening program in the area of study but also be useful in planning and implementing national screening programs in the country as a whole.
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Cite this Article: Mfuh AY and Lukong CS (2016). Women’s Views on Knowledge and Barriers to Cervical Cancer Screening among Women in Kaduna State, Nigeria. Greener Journal of Epidemiology and Public Health, 4(2): 044-054, http://doi.org/10.15580/GJEPH.2016.2.082116131