CHAPTER ONE

INTRODUCTION

1.1         BACKGROUND OF THE STUDY

Cervical cancer is reported to be the second most common and the fifth deadliest disease in women. It affects about 16 per 100,000 women per year and kills about 9 per 100,000 per year. Approximately, 80% of cervical cancer occur in developing countries. Globally, in 2008, it was estimated that there were 475,000 cases of cervical cancer, and 253,500 deaths per year (Dim, 2012).

Moon, Cordoso, Baptista, Mohsin, Sten and Vermund (2012), stated that globally, cervical cancer is the second most common cancer in women with approximately 500,000 new cases and 275,000 deaths per year, of which roughly 85% of the cases occur in low-income countries including Nigeria. Southeast Asia only contributes about 25% of the world total disease burden.

In the United States, it is the 8^th most common disease in women and the incidence of new cases of cervical cancer in the United States was 7 per 100,000 women in 2004, but cervical cancer deaths decreased by approximately 74% in the last 50 years, largely due to wide spread screening programmes (Dim, 2012). In the United Kingdom, the incidence is 8.5/100,000 per year in 2006 with 42% reduction from 1997 – 1998 due to screening procedures, which have been highly successful. In Australia, there were 734 cases of cervical cancer in 2005, and the number of women diagnosed with cervical cancer has dropped on average by 4.5% each year since organized screening began in 2005.

The World Health Organization (2006) reported that over the past few decades, 60% of all deaths worldwide has been from chronic non-communicable diseases like cardiovascular diseases,

cancer, chronic respiratory diseases and diabetes.  Mortality due to communicable diseases has

decreased, while there is an increase in that of cancer and heart diseases. The cervical cancer incidence remains unchanged with about 44% overall survival rate or about 10 per 100,000 women dying from the disease over an average of 5 years (WHO, 2006).

According to a report of Alliance for Cervical Cancer Prevention (ACCP) (2004), the regions hardest hit by cervical cancer are among the world poorest regions which are in Central and South America, the Caribbean, sub-Saharan Africa and parts of Asia. Ferley, Bray, Pisani and Parkin (2002) earlier stated that approximately 1.4 million women worldwide are living with cervical cancer, up to 7 million women worldwide may have precancerous condition that needs to be identified and treated early.

In Nigeria, estimated incidence rate of cervical cancer is 25 out of 100,000 women with estimated 8000 new cases diagnosed each year (Adewole, Benedict, Brain and Follen, 2005). Equally, high rate of cervical cancer has been reported from several African countries including Uganda, Malawi, Ethiopia and Kenya (WHO, 2012).

Cervical cancer is a malignant neoplasm arising from cells originating in the cervix uteri. The cervix is the narrow portion of the uterus where it joins with the top of the vagina, and most cervical cancers are squamous cell carcinomas, arising in squamous (flattened) epithelial cells that lie in the cervix. One of the most common symptoms of cervical cancer is abnormal vaginal bleeding but in some cases, there may be no obvious symptoms until the cancer has progressed to an advanced stage (Dim, 2012).

Lauca (2003) earlier stated that Human Papilloma Virus (HPV) infection appears to be a factor in the development of almost all cases of cervical cancer. Usually, women contact HPV between their late teenage and early 30s, with peak infection, coinciding with the onset of sexual activity.

He stressed that most often, cervical cancer is found much often at age of 40, with peak incidence around age of 43 and peak mortality in the late 50s. There is typically a long delay period between the gaining entrance of the organism (infection) and the invasive cancer stage, making screening programmes to be effective.

In developed countries, the use of cytology screening has strongly reduced both cervical cancer incidence and mortality. Due to lack of technical skills, human resources and financing required, to maintain the screening procedure in developing countries, Nigeria inclusive, the need for visual inspection with acetic acid emerged as immediate help. (Basu, Sankanarayanan, Mandal, Roy, Das, Choudhury, Data, Karamakar, Tsu,Chakrabarti, and Siddiqi, 2002).

Cancer of the cervix is a preventable disease, and its prevention is through early detection of premalignant stages of the disease. In recent years, a screening test for cervical precancerous stage using visual inspection aided by acetic acid has been found to be a suitable low cost and a most feasible alternative modality for control of cervical cancer in developing countries (Basu et al., 2002). Visual inspection of the cervix with acetic acid (VIA) involves the inspection of the cervix with naked eye before and after application of 3-5% acetic acid solution with the use of a light source (Dim, 2012). A study conducted by Belinsan, Quao, Pretomus, Zhong, Elson, Li, Pan, Fischer, Lorincz, and Zahniser (2001) in far away rural China on 1,997 women, found that VIA had a 71% sensitivity and 74% specificity. Sankaranarayanon, Esmy and Rajkumar (2007) supported the position by stating that visual inspection with acetic acid (VIA) can be an effective and acceptable method of cervical cancer screening in developing countries like Nigeria. McCarey, Pirek, Tebeu, Boulvain, Doh and Patrick (2011) further stated that creating awareness among health workers on risk factors and current methods for cervical cancer screening is necessary and good step towards implementing effective prevention programs. They further

stated that lack of knowledge about visual inspection with acetic acid (VIA) in our population and among healthcare workers can be a prime barrier for access to cervical cancer prevention.

Recent years have witnessed a significant development in cervical cancer prevention in developed countries in addition to cytology screening services. Previous efforts to implement cytology-based screening in developing countries have been conducted in the early 1980‟s but it has failed to reduce the mortality rates, mainly due to inadequate material resources, and lack of trained providers. In this regard, a recent cost-effective screening strategy using VIA emerged to be use, in developing countries like Nigeria. The screening and clinical services were available on a large scale in rural clinics of Africa.(Moon, Cordoso, Baptista, Mohsin, Sten and Vermund, 2012). Moon et al (2012) reported that VIA had been utilized by nurses and hospital physicians, with a regular clinical feedback for quality evaluation. The test is inexpensive and it‟s performed with minimal infrastructure, which may be done even in health facilities by health workers, and the results are made available immediately, thereby reducing multiple visits to the hospital health facility.

Globally, decrease uptake of cervical cancer screening is predominantly a problem of developing countries, due to limited access to screening facilities, thereby leading to the high increased in the number of women who come up with cervical cancer. The extent to which the number of women diagnosed with cervical cancer keep on increasing has remained a matter of grave concern to the present researcher that a study on awareness, availability and utilization of Visual Inspection With Acetic Acid (VIA) in screening for cervical cancer by health workers becomes necessary with a view to increase the deliverance of screening programmes and subsequently the decline of cervical cancer.

1.2         STATEMENT OF THE PROBLEM

Cervical cancer is the world‟s second deadly disease with an estimate of about 493,243 women diagnosed with it and 273,505 dying from it per year (WHO, 2002). It was responsible for over 250,000 deaths in 2005. Approximately 80% of this incidence occurred in developing countries. The American Cancer Society 2012, (ACS) estimated that in the United States, 12,170 new cases of cervical cancer was diagnosed in 2012. Internationally, more than 500,000 new cases are diagnosed each year; the rates vary widely, ranging from an annual incidence of 4.5 cases per 100,000 in Western Asia to 34.5 per 100,000 women in Eastern Africa. In industrialized countries with well establish cytology screening programs, the incidence of cervical cancer ranges from 4-10 per 100,000 women (American Cancer Society, 2012).The incidence of cervical cancer in Nigeria is 8,000 cases annually out of 10,000 women. Studies in Nigeria showed that it is the commonest female genital tract disease, accounting for 74% and 73.2% in Benin City and Ibadan respectively. It was further stated that 66.25% of all gynecological malignancies occur in Northwestern zone of Nigeria where Kaduna state is located. The relative frequency is 23.5% and at least 25,000 new cases are expected to occur yearly with incidence of 25 per 1000 women (Friday and Kunle, 2003) in future.

Worldwide, successful cervical cancer prevention is based on an organized screening program, and the goal of screening is to detect the pre-invasive stage of the disease and treat it appropriately before it progresses to cervical cancer. In developed countries, initiation and sustenance of cervical cytology programs involving screening of sexually active women yearly, or once every 2-5 years have resulted in a decline of cervical cancer incidence and mortality (Miller, Chamberlain, Day, Hakama and Provok, 1990).

However, an organized screening programme is difficult to implement in developing countries where resources are scarce and the population rate is high. Although cytology screening is being carried out in developing countries, Northwestern Nigeria, Kaduna state inclusive, it is mostly done in the context of opportunistic screening activities which are often inadequately performed (Holowaty, Miller and Rohan, 1999). In Northwestern Nigeria, where Kaduna state is located, there is no established screening service and where it is available, it is rather an opportunistic service (Friday and Kunle, 2003). Many developing countries do not have adequate resources to implement cytology-based prevention program, therefore an alternative low-cost test, of visual inspection with acetic acid (VIA) has emerged for use in low-resource settings where it can be performed by trained health workers (Basu et al., 2002).

The extent to which the number of women diagnosed with cervical cancer keep on increasing has remained a matter of grave concern. It is based on this interests that the researcher intends to find out the level of awareness of health workers in Kaduna state of visual inspection of the cervix with the use of acetic acid to screen cervical cancer, whether the requirements for (VIA) are locally available in Kaduna state, and whether the health workers in Kaduna-state are utilizing it to screen for cervical cancer.

1.3         RESEARCH QUESTIONS

This study was guided by the following research questions;

1. Are the healthcare workers in Kaduna state aware of VIA as a screening tool for cervical cancer?

1. Are there qualified health personnel to offer VIA screening for cervical cancer in Kaduna state?

1. Are the VIA requirement available for healthcare workers to use in Kaduna state?
2. Are the healthcare workers in Kaduna state utilizing the VIA to screen for cervical cancer?

1.4         BASIC ASSUMPTIONS

On the basis of the research questions, the following assumptions were made:

1. Health workers in Kaduna state are aware of visual inspection with acetic acid (VIA) as screening tool for cervical cancer.

1. Health workers in Kaduna state are qualified to offer visual inspection of the cervix with acetic acid to screen for cervical cancer.

1. Visual inspection with acetic acid requirements are available for health workers to use for cervical cancer screening in Kaduna state.

1. Health workers in Kaduna state are utilizing visual inspection with acetic acid (VIA) to screen for cervical cancer.

1.5        PURPOSE OF THE STUDY

The main purposes of this study are:

1. To determine whether the awareness level of using (VIA) as a screening tool for cervical cancer among healthcare workers differ in Kaduna state.

1. To determine whether the healthcare workers in Kaduna state differ in offering (VIA) screening for cervical cancer to their recipients.

iii.          To    identify    whether    the    secondary    healthcare    institutions    differ    in    the

(VIA) requirements that are available for healthcare     workers to use in Kaduna state

to screen for cervical cancer.

1. To identify whether the healthcare workers differ in the utilization of the (VIA) requirement to screen for cervical cancer in Kaduna state.

1.6         HYPOTHESES

On the basis of the research questions, the following hypotheses were formulated;

Major hypothesis

There are no significant differences among the healthcare workers demographic variables (Age-group, Sex, Professional category, Years of working experience, and Secondary healthcare institutions) in the awareness, availability, and utilization of VIA in cervical cancer screening in Kaduna-state.

Sub-hypotheses

1. There are no significant differences among the healthcare workers demographic variables of (Age-group, Sex, Professional category, Years of working experience and Secondary healthcare institutions) in their awareness of VIA cervical cancer screening in Kaduna-State.

1. There are no significant differences among the healthcare workers demographic variables of (Age-group, Sex, Professional category, Years of working experience and Secondary healthcare institutions) in the qualification of health personnel in VIA cervical cancer screening in Kaduna State.

1. There are no significant differences among the secondary healthcare institutions in the provision of available VIA requirements for cervical cancer screening in Kaduna State.

1. There are no significant differences among the healthcare workers demographic variables of (Age-group, Sex, Profession category, Years of working experience, and Secondary healthcare institutions) in the utilization of VIA cervical cancer screening in Kaduna-state.

1.7         SIGNIFICANCE OF THE STUDY

Cervical cancer screening has become a great necessity to woman existence and it is of great importance in stopping cancer, its spread and development. This research work would provide valuable information on the role of (VIA) screening, in the prevention of cervical cancer in Kaduna state, and Nigeria in general. Such information on awareness, availability of qualified health workers, availability of requirements for VIA and level of utilization of VIA among health workers of Kaduna state would go a long way in enrichment of the existing body of knowledge. Most importantly, the health workers in Kaduna state if not aware, will be informed about VIA. It is not known whether the health workers of Kaduna state are qualified to use VIA, this study would provide information on availability of qualified health workers. It is not known whether requirements of VIA is available in Kaduna state, this study would provide information on the availability of VIA requirements. It is not known whether health workers in Kaduna state use the available VIA requirements, this study would provide the level of usage. Moreover, the study will also stimulate healthcare planners/government to develop realistic strategies in providing VIA requirements to healthcare institutions in Kaduna state because of its cost effectiveness and efficacy.

1.8         DELIMITATION OF THE STUDY

The study was delimited to awareness, availability and utilization of visual inspection using acetic acid (VIA) in screening for cervical cancer among health workers (Nurses, Midwives, Nurse-Midwife) in secondary healthcare institutions of Kaduna state. . The use of nurses for this study is justified by the fact that the innovation of VIA is to increase the up-take of cervical cancer screening in developing countries, at primary and secondary health care institutions, also nursing staff have the highest percentage of workers among the health workers of Kaduna- state.

1.9         LIMIITATION OF THE STUDY

The response in the instrument for data collection which is the questionnaire depends entirely on the respondents‟ willingness to give accurate information relating to the study. However, effort was made by the researcher and research assistants to ensure that all the statements were very clear to respondents.