This chapter describes the background to the study highlighting the epidemiology and overview of cervical cancer screening on the global, regional and local perspective. The chapter further outlines Chinhoyi Provincial hospital profile, problem statement, justification objectives of the study, research questions and finally the conceptual model to be adopted.
1.2 Background to Study
1.2.1 Global Perspective
Cervical cancer is the third leading cause of death among women worldwide even though it is one of the most easily preventable gynaecological cancers among women (Carter J. & Downs, L., 2011). It is a disease that can be prevented through enhancing proper screening, treatment and follow-up services. Globally cervical cancer is a serious public health problem as it accounts for over 275,000 female deaths and approximately 529,000 new diagnoses each year. Cervical cancer morbidity and mortality rates are expected to double in the next 20 years (Jemal A, 2011). The World Health Organization (WHO) reported that cervical cancer is the second most common cause of female cancer globally. Approximately over 80% of cervical cancer occurs in developing countries. (WHO, 2012).
Over the past three decades, cervical cancer rates have reduced significantly in most of the developed world. This is mainly because of the routine screening programmes that are found in these countries. To date, most cervical cancer prevention efforts worldwide have focused on screening women using the Papanicolaou (Pap) smear, followed by a referral for diagnostic confirmation of a positive smear and treatment of the lesion. These efforts have reduced incidence of cervical cancer by as much as 90%
in developed countries where quality screening and coverage of the population are high.
1.2.2 Regional Perspective
Cervical cancer rates have risen or have remained unchanged in most of the developing countries (Forouzanfar MH, 2011). Cervical cancer screening is seen to have the potential to greatly reduce deaths among women of all age groups. The disease however, poses a major challenge for the developing countries, where lack of resources limits coverage for screening (Gakidou E, 2008).
In sub-Saharan Africa (SSA) alone, 34.8% new cases of cervical cancer are diagnosed per 100,000 women annually and 22.5% per 100,000 women die from the disease (WHO, 2013). According to Denny 2006 this is due to lack of epidemiological data, poor awareness, lack of human and financial resources, non-existent cancer service policies and lack of political will to address the complex problem (Denny L, 2006). The magnitude of cervical cancer problems in the region has been under-recognized and under prioritized compared to other competing health priorities such as HIV& AIDS, tuberculosis and malaria.
1.2.3 Local Perspective
In Zimbabwe 3519 new cases of cancer were recorded in 2014. Among Zimbabwean black women cervical cancer accounts for 33.5% the highest among cancers affecting women in Zimbabwe (Registry, 2014). HIV contributed 60% of all cancers in 2005 (Chokunonga, L., 2014).
Cervical cancer is one of the leading cause of morbidity and mortality among women in Zimbabwe. Despite the fact that cervical cancer is manageable if precancerous cells are diagnosed early by screening most Zimbabwean women do not access healthcare care check-ups. Cytological-based screening programmes in Zimbabwe are also costly and complex. It has been difficult to establish such programmes comprehensively in Zimbabwe and most developing countries. Zimbabwe has however introduced a more reliable cheaper and easy to manage method in the form of Visual Inspection using Acetic acid and cervicography (VIAC) in most district hospitals.
Despite being easily detectable and curable in its early stages few women in Zimbabwe undergo screening for cervical cancer compared to those in developed countries. Screening rates are very low in Zimbabwe and the majority of women present at late stages with invasive and advanced disease. Improving screening services alone is not sufficient enough to result in increased screening uptake. Concerted efforts should be made to understand and address the multifaceted health beliefs that are likely to influence women’s willingness to schedule and obtain screening.
1.3 Chinhoyi Provincial Hospital Profile
Chinhoyi Provincial Hospital the centre for this study is located on the western banks of Manyame river in Makonde district, Mashonaland West province in central northern Zimbabwe. Its location lies approximately 121km by road northwest of Harare along Harare-Chirundu highway. The hospital is the largest and most modern referral hospital in Mashonaland West province. The hospital has 450 beds with various departments offering numerous patient services including cervical cancer screening services. The VIAC centre is located in the Gynaecology department. The centre offer services from Monday to Friday with an average of 15 to 20 patients attended per day.
1.4 Problem Statement
Cervical cancer accounts for 33.5% of the registered cancers in Zimbabwe. Mashonaland West Province accounting for 2.5% of the national cases. Chinhoyi hospital has the highest number of cases in the province with 5.5% for the year 2016 (Provincial Health Information Office 2017).
The hospital reported 234 cervical cancer cases and has never met their monthly screening target between January and June 2017 as shown on Table 1 below.
Year 2017 Number of Cases Number Screened Target Population
Total Pop women 95 344
January 29 942
February 42 234
March 32 671
April 17 856
May 45 356
June 69 422 Target of 1000 per month
Table 1 Chinhoyi Hospital Cervical Cancer Statistics Jan-June 2017.
1.5.1 Broad Objective
To describe the factors influencing uptake of cervical cancer screening among women aged between 18 and 49 years attending Chinhoyi Provincial Hospital in Mashonaland West Zimbabwe.
1.5.2 Specific Objectives
1. To determine the socio-demographic factors associated with uptake of cervical cancer screening among women aged between 18 and 49 years attending Chinhoyi Provincial hospital.
2. To describe the women’s perceived susceptibility to cervical cancer.
3. To determine the women’s perceived severity of cervical cancer.
4. To describe the women’s perceived benefits of doing cervical cancer screening.
5. To identify the women’s perceived barriers to seeking cervical cancer screening services.
1.6 Research Questions
1. What are the socio-demographic factors associated with uptake of cervical cancer screening among women aged between 18 and 49 years attending Chinhoyi Provincial Hospital?
2. What are the women’s perceived susceptibility to cervical cancer?
3. What are the women’s perceived severity of cervical cancer?
4. What are the women’s perceived benefits of doing cervical cancer screening?
5. What are the perceived barriers of these women from seeking cervical cancer screening services?
1.7 Assumptions of the study
The study had assumed that the participants who had participated in the study would provide reliable data which would be used to make conclusions of the study. All the participants who took part in the study had a 100% response rate and were very cooperative.
1.8 Significance of the Study
High morbidity and mortality rates accounts for a Public Health concern that warrants interventions. The findings and recommendations of this study provide valuable information to the Province, Ministry of Health and Child Care and other stakeholders in addressing key policy and programming issues of screening uptake and the common barriers to screening among women in the urban and rural communities. The study is designed to add to the knowledge base and literature that will help in the implementation of successful cervical cancer screening services. It will also increase programme uptake and contribute towards the reduction of cervical cancer incidence in Zimbabwe.
1.9 Health Belief Model
Chinhoyi provincial hospital provides free cervical cancer screening services for all women. Uptake of the screening services among women have been however low and we do not know the reason why this is so. To understand why there is low uptake of cervical cancer screening the Health Belief Model (HBM) was used. It was decided to assess this specific health problem in light of the constructs of the HBM in order to evaluate the effectiveness and applicability of this behavioural framework in recognizing the main factors that might encourage or limit women to adopt the most adequate preventive health behaviours regarding cervical cancer.
The HBM was brought in the 1950s, when researchers and health care providers found themselves at a loss to explain why a free, public tuberculosis screening programme had failed to attract significant participation. It hoped to explain the impact of an individual’s perception and attitude toward a disease and how those perceptions and attitudes impacted their health-related decision-making (Rosenstock, I, 1974).
Rosenstock 1974, describes the Health Belief Model (HBM) as a psychological model that attempts to explain and predict health behaviours among communities. The HBM is given in terms of the four construct namely perceived threats, perceived susceptibility, perceived severity, perceived benefits and perceived barriers (Rosenstock, I, 1974).
Boonpongmanee, 2007, concur with Rosenstock that the uptake of cervical cancer screening among women significantly depends on their perceptions regarding susceptibility to cervical cancer, their perceptions of the severity of cervical cancers, their perceptions regarding benefits of having a cervical cancer screening, and addressing their perceived barriers to seeking cervical cancer screening (Boonpongmanee, C, 2007).