KNOWLEDGE AND ACCEPTABILITY OF CERVICAL CANCER
SCREENING AMONG WOMEN IN NGOMBE COMMUNITY, LUSAKA
NELLY KALONGA
UNZA
2011
THE UNIVERSITY OF ZAMBIA
SCHOOL OF MEDICINE
DEPARTMENT OF NURSING SCIENCES
KNOWLEDGE AND ACCEPTABILITY OF CERVICAL CANCER
SCREENING AMONG WOMEN IN NG'OMBE COMMUNITY,
LUSAKA.
NELLY KALONGA
(RN)
A RESEARCH
STUDY IS SUBMITTED IN PARTIAL
FULFILLMENT FOR THE AWARD OF BACHELOR OF SCIENCE
DEGREE IN NURSING IN THE DEPARTMENT OF NURSING
SCIENCES, SCHOOL OF MEDICINE, UNIVERSITY OF ZAMBIA
MARCH, 2011
ACKNOWLEDGEMENT
I would like to thank the Almighty God for the grace and the strength he granted to me
while working on my research proposal.
To my supervisor Mrs. M. Makukula, I am greatly indebted to her for the commitment, the
time she always spared guiding me and correcting my scripts, the knowledge, the patience
and encouragement she gave to me while working on my research proposal. I really
appreciate her advice and endurance.
My sincere gratitude goes to my research lecturer and coordinator Dr P. Mweemba for the
advice, knowledge and counsel she always gave to me.
I wish to thank the Lusaka District Health Management Board, Ng'ombe Health center in
particular for allowing me to conduct my research at their institution.
I also wish to appreciate my sponsors, Ministry of Health, for sponsoring this research and
the Bachelor of Science Degree in Nursing I am pursuing.
My love and appreciation go to my Husband and son Elisha for their support physically,
materially, spiritually and emotionally.
Finally my heartfelt gratitude goes to all the women who accepted to participate in the study.
May the Almighty God richly bless you all.
TABLE OF CONTENT
PAGE No
Acknowledgement
i
Table of content
ii
List of tables
vi
List of figures
viii
List of abbreviations
ix
Declaration
xi
Statement
xii
Dedication
xiii
Abstract
xiv
CHAPTER 1: INTRODUCTION
1
1.1 Background information
1
1.2 Statement of the problem
7
1.3 Factors influencing knowledge and acceptability of cervical cancer screening
8
1.3.1 Service related
8
1.3.1 Socio economic related
9
1.3.1 Socio cultural related
10
1.4 Diagram of problem analysis
12
1.5 Theoretical framework
13
1.6 Justification
15
1.7 Research objectives
16
1.6.1 General objective
16
1.6.2 Specific Objectives
16
1.8 Hypothesis
16
1.9 Conceptual definitions of terms
16
1.10 Variables and cut- off points
17
CHAPTER 2: LITERATURE REVIEW:
19
2.1 Overview of cervical cancer screening
19
2.2 Knowledge of cervical cancer screening
21
2.3 Acceptability of cervical cancer screening
24
2.4 Barriers to cervical cancer screening
25
2.5 Conclusion
28
CHAPTERS: RESEARCH METHODOLOGY
29
3.0 Introduction
29
3.1 Research design
44
3.2 Research setting
30
3.3 Study population
30
3.3.1 Target population
30
3.3.2 Accessible population
31
3.4 Sample selection
31
3.4.1 District
31
3.4.2 Health Center
32
3.5 Eligible criteria
32
3.6 Sample size
32
3.7 Operational definitions
33
3.7.1 Knowledge
33
3.7.2 Acceptability
33
3.7.3 Cervical cancer
33
3.8 Data collection tool
33
3.9 Validity
34
3.10 Reliability
34
3.11 Data collection technique
34
3.12 Pilot study
35
3.13 Ethical and cultural consideration
35
CHAPTER 4: PRESENTATION OF FINDINGS
36
4.0 Introduction
36
4.1 Data analysis
36
4.2 Presentation of findings
36
IV
CHAPTER 5: DISCUSSION OF FINDINGS AND IMPLICATIONS FOR THE
HEALTH CARE SYSTEMS
5.0 Discussion of findings and the implications for the health care system
55
Introduction
55
5.1 Characteristics of the sample
55
5.2 Demographic data
55
5.3 Discussion of variables
56
5.3.1 Knowledge
56
5.3.2 Acceptability
58
5.2.3 Barriers to cervical cancer screening
60
5.4 Implication to the health care system
61
5.4.1 Nursing practice
61
5.4.2 Nursing administration
61
5.4.4 Nursing education
62
5.4.5 Nursing research
62
5.5 Recommendations
62
5.6 Dissemination of findings
64
5.7 Limitation of the study
64
5.8 Conclusion
65
References
67
LIST OF TABLES
Table 1.1
Clinical staging of cervical cancer
4
Table 1.2
Variables and cut off points.
18
Table 4.1
Distribution of respondents by marital status
37
Table 4.2
Distribution of respondents by religion
38
Table 4.3
Respondent's number of children
39
Table 4.4
Age at first sexual intercourse
39
Table 4.5
Respondents who had heard of cervical cancer.
40
Table 4.6
Source of information,
40
Table 4.7
Respondent's explanations of cervical cancer
41
Table 4.8
Knowledge on predisposing factors to developing cervical cancer
41
Table 4.9
Knowledge on signs and symptoms of cervical cancer
42
Table 4.10
Response on detection of cervical cancer
44
Table 4.11
Where screening can be done
44
Table 4.12
Participant's response on decision to go for screening
46
Table 4.13
Reasons for screening for cervical cancer
47
Table 4.14
Reasons for not screening for cervical cancer
48
Table 4.15
Importance of screening for cervical cancer
49
Table 4.16
Intentions to go for screening
50
Table 4.17
Barriers to cervical cancer screening.
51
Table 4.18
Cited barriers to cervical cancers screening.
51
vi
Table 4.19
Education level in relation with level of knowledge of cervical cancer...
Table 4.20
Cervical cancer screening in relation to level of education
Table 4.21
Knowledge of cervical cancer and screening in relation to
51
education level
53
Table 4.22
Acceptability in relation to level of education
53
Table 4.23
Cervical cancer screening in relation to knowledge
54
Table 4.24
Acceptability of cervical cancer screening in relation to knowledge
54
VII
LIST OF FIGURES
Figure 4.1
Distribution of respondents age
37
Figure 4.2
Highest level of education
38
Figure 4.3
Participants level of knowledge
43
Figure 4.4
Knowledge on detection of cervical cancer
43
Figure 4.5
Participants total knowledge
45
Figure 4.6
Screened for cervical cancer
46
Figure 4.7
Response on whether screening is important
49
Figure 4.8
Respondents acceptability
50
APPENDICES
Appendix: i
Consent form
74
Appendix: ii Questionnaire
75
Appendix: iii Measure of variable
82
Appendix
83
Request/authority to undertake a study
Appendix: iv Work plan
84
Appendix: v Gantt chart
86
Appendix: vi Budget and justification
88
VIM
ABBREVIATIONS
ACCA
American Cervical Cancer Association
ACCP
Alliance of cervical Cancer Prevention
AIDS
Acquired Immune Deficiency Syndrome
ART
Antiretro Viral Therapy
CHW
Community Health Workers
CIDRZ
Center for Infectious Disease Research in Zambia
CIN
Cervical Intraepithelial Neoplasm
CSO
Central Statistics Office
DHMT .
District Health Management Team
HIV
Human Immunodeficiency Virus
HPV
Human Papiloma Virus
ICO
Institut Catala d' Oncology
IEC
Information Education and Communication
LDHMT
Lusaka District Health Management Team
LEED
Loop Electrosurgical Excision Procedure
MCH
Maternal and Child Health
OPD
Out Patient Department
PEPFAR
President's Emergency Plan for AIDS Relief
PMTCT
Prevention of Mother to Child Transmission
STD
Sexually Transmitted Disease
IX
STI
-
Sexually Transmitted Infection
UK
-
United Kingdom
UNZA
-
University of Zambia
UTH
-
University Teaching Hospital
VCT
-
Voluntary Counseling and Testing
VIA
-
Visual Inspection with Acetic acid
WHO
-
World Health Organization
DECLARATION
I, Nelly Kalonga, hereby declare that the work presented in this study for the Bachelor of
Science Degree in Nursing has not been presented either wholly or in part, for any other
degree and is not being currently submitted for any other degree.
Date:
Signed:
(Candidate)
Date:
Approved
OF NURSING
(Supervisor) MCES
PO BOX5C 10 LUSAKA
XI
STATEMENT
I, Nelly Kalonga, hereby certify that this study is entirely the result of my own independent
investigations. The various sources to which I am indebted are clearly indicated in the text
and references.
Signed: . . f t *
Date..P.a-.p.&r.Q,OH
(Candidate)
XII
DEDICATION
To my husband John whose Love, patience and support have been sustaining me throughout
my training.
To my son Elisha, for being considerate for the motherly love he was deprived of at the time
he needed it most.
XIII
ABSTRACT
Cancer of the cervix remains the most common malignant neoplasm of the female genitalia
and the second most common cancer in women (WHO/ICO, 2010). Cancer screening tests
serve to detect the possibility that a cancer is present. It has also shown to be effective in
reducing the incidence and mortality from cervical cancer. The World Health Organization
(WHO) estimates that a one-time screening among women around the age of 40 could
reduce the chance of fatality due to cervical cancer by 25-30% if adequately followed up.
Since cervical cancer usually progresses slowly, this once-in-a-lifetime screening could
prevent abnormal cells from becoming fatal (WHO-ACCP, 2009).
The main objective of the study was to determine the knowledge and acceptability of
Cervical Cancer Screening among women in Ng'ombe community, Lusaka. The hypothesis
for the study was: there is a relationship between knowledge of cervical cancer and
acceptability of cervical cancer screening. A non experimental quantitative methodology using a
descriptive study design was used in the study. A probability sampling method called simple random
sampling was used to select the sample. The sample consisted of 50 women aged 35 years and above
accessing care at Ng'ombe Health Center. Data was collected using a structured interview schedule.
Data were analyzed manually using a scientific calculator and SPSS version 16.0 for significant
statistics.
The study findings revealed that slightly above half 28(56%) of the respondents had low
knowledge of cervical cancer and screening services. It also revealed that more than half 34
(68%) of the respondents had never been screened for cervical cancer. The study further
showed that the majority 6(86%) of the respondents who had not accepted cervical cancer
screening services had low knowledge of cervical cancer and the screening services. Nurses
should engage more on giving Information Education and Communication (IEC) at all levels
of Health Care Delivery. Nursing management should improve on staffing levels so that
sufficient time is allocated to IEC. It is also important that many nurses are trained in
preventive strategies of cervical cancer and the available screening methods such as Visual
Inspection with Acetic acid (VIA). VIA screening method should be scaled up to other
districts so that women can easily access the service.
xiv
CHAPTER 1: INTRODUCTION
Women's health emphasizes the overall experience of women; general physical,
psychological well being, child bearing functions and diseases. Various factors and
conditions affect the health of the women; therefore they must be viewed holistically and in
the context in which they live. Their physical, mental, and social factors must be considered
because these interdependent
components influence women's
health and illness
(Lowdermilk and Perry, 2004). One of the major threats to women's health is cancer of the
cervix which has been on the increase.
1.1 BACKGROUND INFORMATION
Cancer of the cervix remains the most common malignant neoplasm of the female genitalia
and the second most common cancer in women (World Health Organization / Institut Catala
d' Oncology - WHO/ICO, 2010). It's the common cause of death among middle aged
women, with an estimated 529,409 new cases and 274,883 deaths in 2008 (WHO/ICO,
2010). It is the most difficult lesion to treat successfully when it reaches a clinically
detectable stage (Nelson, 1970, in Holland and Frei, 1999). The hardest - hit regions are
among the world's poorest countries such as Central and Southern America, the Caribbean,
Sub Saharan Africa and part of the Oceania and Asia with the highest incidence over
30/100,000 women (Alliance of Cervical Cancer Prevention- ACCP,2005).
An estimated 1.4 million women worldwide are living with cervical cancer and 2 to 5 times
more up to 7 million worldwide may have precancerous conditions that need to be identified
and treated(ACCP,2005). In the United Kingdom (UK), cervical cancer is the second most
common cancer among females under 35 years of age accounting for 702 new cases in 2007.
According to the UK' statistics report for 2010, 2,828 new cases were diagnosed in 2007.
Peru has recorded a high incidence of cervical cancer and there are no organized screening
programmes in the country (Sankaranarayanan et al 2001). According to the WHO 2008
report, cervical cancer remains a major public health problem. The report further indicates
that approximately 500 women develop cervical cancer and 274 deaths occur each year from
cervical cancer in developing countries (WHO, 2008). Greater than 80% of the world's new
cases and deaths due to cervical cancer occur in the developing world and less than 5%
women in these settings are never screened for cervical cancer even once in their life time
(Sanghvi et al, 2005).
In the developing world, cervical cancer is the most common cancer among women. In
Ghana, cervical cancer is the leading cause of cancer related deaths in Ghanaian women,
accounting for about 25% of all female cancers (Sanghvi et al, 2005). In Nigeria, the
national incidence - of cervical cancer is 250/100,000 (Adewole et, al, 1997) while in
Malawi, cervical cancer is one of the leading cancers affecting women. According to the
Malawi Cancer Registry (2001 to 2002) cervical cancer accounted for approximately 28% of
all female cancers nationally and up to 80% of the women with cervical cancer who sought
care were in inoperable, terminal stages of the disease when they reached the health facility.
Zambia has a population of 3.21 million women aged 15 years and above who are at risk of
developing cervical cancer (WHO/ICO, 2010). Current estimates indicate that every year
1,839 women are diagnosed with cervical cancer and 1,276 die from the disease. Cervical
cancer ranks as the first most frequent cancer among women between the age of 15 and 44
in Zambia (WHO/ICO, 2010).
Historically, access to cervical cancer screening in Zambia as in most resource- constrained
nations, has been limited and only available to the affluent and overtly symptomatic
(Mwanahamuntu, 2008). A pilot study on cervical cancer screening conducted by Center for
Infectious Disease Research in Zambia on 150 women seeking HIV care and treatment at
the University Teaching Hospital, showed that 33% of Papanicolaou Smear indicated
evidence of high grade pre- cancer cells and 20% evidenced cancer (Center for Infectious
Disease Research in Zambia- CIDRZ, 2005).
Cervical cancer is a cancer of the cervix or neck of the uterus (Altman and Sarg, 2000). The
risk of invasive cervical cancer increases with age, occurring between 35 and 55 years of
age (Gulanick and Myers, 2007). Human Papiloma Virus (HPV) is the leading cause of
cervical cancer (Black and Hawks, 2005). Several factors increases one's risk of developing
2
cervical cancer including; having multiple sexual partners or a partner who has had multiple
sexual partners, having a sexual partner with a history of penile or prostate cancer, early age
of first sexual intercourse, smoking tobacco, low socioeconomic status, untreated chronic
cervicitis, Sexually Transmitted Diseases (STDs)
and Contraceptive pills (Black and
Hawks, 2005).
Cervical cancer is asymptomatic in the early stages. As the disease progresses, the woman
may experience watery vaginal discharge and occasional blood spotting especially after
sexual intercourse. There may also be post menopausal bleeding. With advanced disease a
dark Foul smelling vaginal discharge may develop from sloughing of epithelia tissue. Pain is
usually a late symptom and can either be abdominal or pelvic ((Monahan, et al, 2007).
Anorexia, anaemia, leg oedema, dysuria and rectal bleeding may develop as complications
(Black and Hawks, 2005). Invasive squamous cell carcinoma usually remains localized or
regional for a considerable time, while distance metastases occurs late (Berkow and Beer,
1999).
Table 1.1 Clinical Staging of Cervical Cancer
STAGE
DESCRIPTION
0
Carcinoma in situ, intraepithelial carcinoma
I
Carcinoma strictly confined to the cervix
IA
Pre - invasive carcinoma, micro invasive carcinoma
IB
Clinical lesions confined to the cervix
II
Carcinoma extends beyond the cervix but has not extended to the
pelvic wall or involving the vagina but not the lower 1/3
IIA
No obvious parametrial involvement
IIB
Obvious parametrial involvement
III
Carcinoma extending to the pelvic wall, with rectal examination
detecting no cancer -free space between the tumor and the pelvis
wall, involving the lower 1/3 of the vagina.
IIIA
Extension to the pelvic wall
IIIB
Extension to the pelvic wall and hydronephrosis, non functioning
kidney or both.
IV
Carcinoma extending beyond the true pelvis or clinically involving
the mucosa of the bladder or rectum.
IVA
Spreads to adjacent organs
IVB
Spreads to distant organs.
The 5 year survival rates are 80 to 90% for stage I, 50 to 65% for stage II, 25 to 35% for
stage III and 0 to 15% for stage IV. Nearly 80% of the recurrences manifest within 2 years
(Berkow and Beer, 1999).
More than 80% of early asymptomatic cases of Cervical Intraepithelial Neoplasia (CIN) can
be detected preclinical by various examinations such as; Papanicolaou smear (Pap smear)
which is a primary diagnostic tool for cervical cancer, cold conization which is done by
collecting a biopsy, Loop Electrocautery Excision Procedure (LEEP) which is the newest
and most common procedure performed by excising the cervical areas of concern and
Visual Inspection with Acetic Acid (VIA) which is the recent method " see and treat"(
Black and Hawks,2005).
Cervical cancer screening is very important as it prevents cervical cancer by identifying and
treating abnormal cervical cells that have become or have the potential to become cervical
Neoplasia or cervical cancer. Screening also allows for early detection and treatment of
HPV associated with cervical lesions, leading to decreased cervical cancer rate and mortality
rate in women (Black and Hawks, 2005). Screening has shown to be effective in reducing
the incidence and mortality from cervical cancer. The incidence of cervical cancer can be
reduced by as much as 80% if quality coverage and follow- up of screening are high
(Sankaranarayanan et al, 2001).
The WHO estimates that a one-time screening among women around the age of 40 could
reduce the chance of fatality due to cervical cancer by 25-30% if adequately followed up.
Since cervical cancer usually progresses slowly, this once-in-a-lifetime screening could
prevent abnormal cells from becoming fatal (World Health Organization- Alliance of
Cervical Cancer Prevention-WHO-ACCP, 2009). However, improvement in screening
services will not by itself be sufficient to result in increased screening uptake, unless we
understand and address the multifaceted health beliefs that are likely to influence women's
willingness to be screened for cervical cancer.
Despite the high incidence of cervical cancer worldwide, most women have little knowledge
about cervical cancer screening and thus low uptake. Utilization of cervical cancer screening
services is greatly affected by knowledge. In Malaysia, It was observed that lack of
knowledge on cervical cancer and the Pap smear test was significant among the respondents
as a result many women did not have a clear understanding of the meaning of an abnormal
cervical smear and the need for the early detection of cervical cancer (Wong et al, 2009).
5
In Pakistan, only 37% of respondents recognized Pap smear as a screening test (AH, et al,
2009). Knowledge of cervical cancer and screening is reportedly low even among the
educated women in Ghana and opportunities to learn more about the reproductive health are
beyond the reach of many women particularly in rural areas (Adanu, 2002).
Regardless of the screening services being available in some countries, many women do not
utilize the service due to other factors such as distance, cost, other cultural factors and
acceptability. For instance in Singapore, many women who were aware of Pap smear, did
not perceive themselves to be at risk, and therefore did not indicate the future intention to
have a smear (Seow 1995. In London, most women did not go back for a regular smear
testing for cervical cancer due to embarrassment and discomfort of the test (Yu, 1998).
The Zambian Government has embarked on the cervical cancer prevention programme in
order to improve the quality of life of women by early detection and treatment of cervical
cancer. This aims at reducing the morbidity and mortality rate of women in order to attain
the Millennium Development Goal commitment number 5, which focuses on promoting
women's and children's health and other initiatives against poverty, hunger and disease. The
Cervical cancer screening programme was integrated within the pre-existing Health Centers
to ensure sustainability and access by the target population. This programme was integrated
into the public clinics as a routine health care for women. It is offered in ten (10) clinics in
Lusaka district, 3 in Kafue district and at Monze Mission Hospital. Ng'ombe clinic is one of
the clinics in Lusaka which is offering the cervical cancer screening programme. Since the
inception of the cervical cancer screening program in 2006, over 30,000 women have been
screened and 7,000 women have been treated as of May 2009 (CIDRZ, 2010).
Cooperating partners such as CIDRZ joined in the fight against cervical cancer targeting
only HIV infected women. The United States, President's Emergency Plan for AIDS Relief
(PEPFAR) programme and other charitable organizations also started the innovative
programme for cervical cancer prevention targeting not only HIV infected women
1.2 STATEMENT OF THE PROBLEM
Despite efforts put in place by the Government and other stake holders in the prevention of
cervical cancer, and the cervical cancer screening programme being offered in 10 clinics in
Lusaka, Ng'ombe clinic has recorded low number of women utilizing the cervical cancer
screening service. In addition, many women access the service when the cancer is in an
advanced stage.
Ng'ombe clinic has a catchment population of 7,172 women in child bearing age (15 to 49)
who are eligible for cervical cancer screening service (District Health Management TeamDHMT, 2010). According to the Ng'ombe cervical cancer screening report for 2010, 2,650
(36%) women have been screened for cervical cancer since 2007 and about 9 have been
referred to UTH for treatment. The report further indicates that not all women who have
been screened go back for review. This can be attributed to ignorance, embarrassment, lack
of appreciation of medical checkups, fear of being diagnosed with cervical cancer and
attitude of women towards screening services.
Late screening affects detection of pre cancer cells thereby making staging and treatment
difficult. Health care providers often can do little to save women's lives when the cancer has
reached an advanced stage. This affects the quality of life of women, consequently disease
burden and death rate may also increase. Affected families often suffer emotional, social and
financial stress as they may find it difficult to get to the hospital (the need for multiple visits
and high costs associated with treatment). The length of treatment may cause resource
constraint on the Government, as there are other priority areas of concern such as Child
Health, Malaria and HIV/AIDS which require a lot of resources. Screening for cervical
cancer can be cost effective for the health services and convenient for women if it is
adequately utilized, therefore reducing the financial burden on the government.
Based on the above, the situation warrants a detailed study on the knowledge and
acceptability of cervical cancer screening among women of 35 years and above in Ng'ombe
Community, Lusaka.
1.3 FACTORS THAT INFLUENCE KNOWLEDGE AND ACCEPTABILITY OF
CERVICAL CANCER SCREENING.
There are several factors that may influence knowledge and acceptability of cervical cancer
screening such as: service related, socioeconomic related and cultural related.
1.3.1
SERVICE RELATED
Location of the service
For some women, especially those living in communities where there is minimal access to
health care, the location of the service facility is an important determinant of participation.
Geographic inaccessibility remains a central barrier in most resource-poor settings, as a
significant portion of the population at risk for cervical cancer may be located in areas where
little or no coverage currently exists (Bingham et al, 2003). Additionally, if the cervical
cancer screening room is located in a place where other services such as Voluntary
Counseling and Testing (VCT) for HIV are offered, it may influence the acceptability of
cervical cancer screening as women may feel embarrassed to be seen in that place because
of the stigma attached to HIV.
1.3.1.2 Misinformation
Misinformation about the screening procedure and the equipment used from other women
who have accessed the service before, may influence the knowledge and acceptability of
cervical cancer screening. If women do not have adequate information about cervical cancer
and screening services, it may influence decision making and therefore may not accept the
screening.
1.3.1.3 Staff competences
If the service providers are not competent enough, they will not be able to perform
procedures in a skilled manner and further more provide accurate information on cervical
cancer to women. Most women have wrong information about the screening procedure and
therefore health workers need to perform the procedure skillfully so that women may
appreciate the service thereby enhancing acceptability.
8
1.3.1.4 Staff Attitude
The provider attitude greatly affects client satisfaction. If the staff attitude towards cervical
cancer screening is negative, they may not spend enough time giving the women
information which may help them understand the benefits of screening.
Conditions under which counseling takes place, how effective and respectful the provider
communicates information to the woman, the woman's ability to ask questions, the process
of informed consent, and the respect for privacy and confidentiality all are important factors
that influence acceptability (Bingham et al, 2003).
1.3.1.5 Staff shortage
Staff shortage has a major impact on cervical cancer knowledge and acceptability. It may
affect delivery of quality care as the health care providers may not spend the required time
to perform the procedure. If the staffing levels are adequate, the health care providers will
have enough time to go in the community and educate the women about cervical cancer and
screening. They may also create special programmes for workplaces, women gatherings, and
women seminars where they will educate the women on cervical cancer screening. While
this is going on, the normal operations of the clinic will not be disturbed, as there is always
someone to attend to those women seeking cervical cancer screening services at the Health
Center.
1.3.2 SOCIO ECONOMIC RELATED
1.3.2.1 Education level
Educational level of women plays a major role in their understanding and accepting the
cervical cancer screening. Women who have attained basic education are in a better position
to understand issues related to cervical cancer and screening, whereas women who have not
been to school will have problems in understanding issues related to cervical cancer and
screening because of the Information Education and Communication (IEC) materials and
methods used, thereby may not accept cervical cancer screening.
1.3.2.2 Attitude
The attitude of the client may influence the acceptability of cervical cancer screening. If the
client has a positive attitude towards the health promotion and disease prevention, they will
accept cervical cancer screening. On the other hand, if client's attitude towards cervical
cancer screening is negative, the probability of accepting cervical cancer screening is low.
1.3.2.3 Fear of being diagnosed with cervical cancer
Fear of being diagnosed with cervical cancer may influence acceptability of cervical cancer
screening. This is because cervical cancer is a very big threat to a woman's health, as it
affects her sexual life and consequently her procreation. Further, the length of time one has
to be on treatment and number of visits they have to make to the hospital may result in
emotional and financial stress on the family.
1.3.2.4 Cervical cancer treatment
The length of time one has to be on treatment may also influence acceptability of cervical
cancer screening, as preventive efforts around the world require multiple visits for
screening, confirmatory diagnosis, treatment, and follow-up, compounding both financial
and opportunity costs to women. On the other hand, cervical cancer treatment is dependent
on the clinical stage (if it is confined to the outermost layer of the cervix that is carcinoma in
situ, it can be removed completely by removing the affected part, but if the cancer is more
advanced, treatment is difficult and this may affect a woman's decision to be screened.
1.3.3 SOCIO CULTURAL RELATED
1.3.3.1 Embarrassment
Embarrassment may influence knowledge and acceptability in that, women may not be
comfortable discussing issues related to reproductive health with male providers .They are
more free discussing sensitive health issues with their female counterparts which increases
the acceptability. Moreover, they may feel embarrassed to expose their private parts; they
express the need for confidentiality especially when privacy is lacking or when male
providers perform the examination and therefore, may not accept the screening service.
10
1.3.3.2 Age
Younger women may not perceive themselves to be at risk of cervical cancer and as such
may not go for cervical cancer screening. On the other hand, older women may be
embarrassed to expose themselves and may not accept the service.
11
1.4 ANALYSIS OF FACTORS INFLUENCING KNOWLEDGE AND
ACCEPTABILITY OF CERVICAL CANCER SCREENING.
SERVICE RELATED
Staff Attitude
Misinformation
Staff
competences
Location of the
service
Staff shortage
SOCIOCULTU
RAL RELATED
Knowledge and acceptability
of cervical cancer screening
among women in Ng'ombe
community
Embarrassment
SOCIOECONOMIC
RELATED
Cancer
treatment
12
Fear of being
diagnosed
with cancer
1.5 THEORETICAL/ CONCEPTUAL, FRAME WORK
Selected "Health Belief Model"
1.5.1 Description of the predicted relationship.
The Health Belief Model (HBM) is a psychological model that attempts to explain and
predict health behaviors by focusing on the attitudes and beliefs of individuals (Glanz et al,
2002).This model is the theoretical framework which seeks to explain behavioural factors
that influence an individual's willingness to engage in health enhancing behaviours. It
postulates that a person's willingness to engage in health seeking behaviour is influenced by
perceived benefits, perceived barriers, perceived susceptibility and perceived seriousness of
the disease and cues from the social environment to take action to enhance one's health.
The key variables of the HBM are as Follows.
1. Perceived Threat: Consists of two parts which are perceived susceptibility and
perceived severity of a health condition.
• Perceived Susceptibility: One's subjective perception of the risk of contracting a
health condition.
• Perceived Severity: Feelings concerning the seriousness of contracting an illness or
of leaving it untreated (including evaluations of both medical and clinical
consequences and possible social consequences).
2. Perceived Benefits: The believed effectiveness of strategies designed to reduce the
threat of illness.
3. Perceived Barriers: The potential negative consequences that may result from taking
particular health actions, including physical, psychological, and financial demands.
4. Cues to Action: Events, either bodily (e.g. physical symptoms of a health condition)
or environmental (e.g. media publicity) that motivate people to take action. Cues to
actions are an aspect of the HBM that has not been systematically studied.
5. Other Variables: Diverse demographic, sociopsychological, and structural variables
that affect an individual's perception and thus indirectly influence health-related
behavior.
6. Self-Efficacy:
The belief in being able to successfully execute the behaviour
required to produce the desired outcomes.
13
1.5.2 Health Medical Model predicated relationship with the study
Background
Socio demographic factors
•
•
•
•
Educational level
Sex and age
Ignorance
Attitude.
Perceptions
\
Expectations
Threat
Perceived benefits
Diagnosis of cancer of
the cervix
Early detection
Access to treatment
Prevention of cervical cancer
How to cope with it
Perceived barriers
Cost and length of
treatment
Ignorance
Educational level
Non availability of services
Fear
Action
Cues to action
Behaviour
Door to door
sensitization.
Workplace
sensitization
Women
gatherings
Personal
influence.
Media
Women should become
aware of cervical cancer
and screening services and
be able to accept the
service.
14
1.6 JUSTIFICATION OF THE STUDY
Cervical cancer screening has been found to be effective in the prevention of cervical
cancer. Studies have shown that most women who come with invasive cervical cancer have
not been screened even once in their life time (WHO, 2008). When diagnosed at an early
stage, survival rate is nearly 100% (Gulanick and Myers, 2007). According to the American
Cancer Society, invasive cancer that is diagnosed while still confined to the cervix has a 5
year survival rate around 91%. In addition, treatment options depend on the tumor stage and
diagnosis, therefore women need to be informed of the benefits of screening and early
detection of the disease as well as the consequences of late screening and not screening at
all.
Ng'ombe clinic has recorded low utilization of cervical cancer screening service since the
inception of the programme in 2007; therefore it is important that a study be conducted to
determine the knowledge and acceptability of cervical cancer screening in its catchment
area. For many years studies on cervical cancer related issues have focused on knowledge,
attitude and practice towards cervical cancer. There is no evidence of studies done on
knowledge and acceptability of cervical cancer screening in Lusaka, the study which was
done in Lusaka by Mkumba (2006) was to assess the safety, feasibility, acceptability and
implementation on cervical cancer screening.
In view of this gap in studies done on cervical cancer, it is important that the researcher
conducts a study to determine the knowledge and acceptability of cervical cancer screening
among women in Ng'ombe catchment area, Lusaka. It is envisaged that the findings from
this study will be used by the health care team to increase strategies on increasing
knowledge and awareness on cervical cancer screening to women. Findings will also be
used in planning and designing training manuals and guidelines and formulating deliberate
policies in training nurses, doctors and other health personnel involved in the fight against
cervical cancer. It has also been found appropriate to carry out this study because the results
will be used to influence women's behavior and practice towards cervical cancer screening
in a positive way. Furthermore, the study results will form a basis for further research on
cervical cancer screening.
15
1.7 RESEARCH OBJECTIVES
1.7.1
General Obj ective
• To determine the knowledge and acceptability of cervical cancer screening among
women in Ng'ombe community, Lusaka.
1.7.2 Specific Objectives
1. To assess the knowledge of cervical cancer screening among women in Ng'ombe
community.
2. To determine the acceptability of cervical cancer screening among women in
Ng'ombe community.
3. To identify barriers to cervical cancer screening service.
1.8 HYPOTHESIS
-
There is a relationship between knowledge of cervical cancer and acceptability of
cervical cancer screening.
1.9 CONCEPTUAL DEFINITIONS OF TERMS
1.9.1 Cervical cancer
Cervical cancer is a cancer of the cervix or neck of the uterus (Altaian and Sarg, 2000)
1.9.2
Screening
Screening is a test used to try and detect a disease when there is little or no evidence that a
person has a disease (Berkow and Beer, 1997).
1.9.3 Papanicolaou smear
Pap smear is the cytological gynecologic test that examines the structure, function,
pathology and chemistry of the cell (Black and Hawks, 2005).
16
1.9.3 Knowledge
Knowledge: information in mind: general awareness or possession of information, facts,
ideas, truths or principles. It is a fact or condition of being aware of something or range of
one's information or understanding (Microsoft. Encarta, 2008).
Acceptability
Acceptability is a state of welcoming something or acknowledging something (Geddes and
Crosset, 2006).
1.10 VARIABLES AND CUT - OFF POINTS
A variable is an attribute of a person or object that varies, that is, takes on different values
e.g. body temperature, age, heart rate (Polit and Beck, 2006).
Dependent variable
The dependent variable is the variable hypothesized to depend on or be caused by another
variable (independent variable); the outcome variable of interest (Polit and Beck, 2006).
Independent variable
Independent variable is the variable that is believed to cause or influence the dependent
variable; in experimental research, the manipulated (treatment) variable (Polit and Beck,
2006).
17
1.10.1 Variables and Cut - off Points
Table 1.2 Variables and Cut - off Points
NO
VARIABLE
INDICATOR
CUT OFF POINT
QUESTION
NUMBERS
1
Dependent variable
Not accepted
Able to answer 0-2 16-24
questions on
Acceptability of
acceptability.
Cervical Cancer
Screening
Able to answer 3 - 4
Accepted
questions on
acceptability
3
8,10-14
Knowledge of cervical
cancer screening.
18
CHAPTER 2
2.0 LITERATURE REVIEW
INTRODUCTION
Literature review is an organized written presentation of what has been published on a topic
by scholars (Burns and Grove, 2005). Literature review presents a strong knowledge base
for the conduct of the research (Burns and Grove, 2005). Literature review helps the
researcher determine what is already known about the proposed study and obtain a
comprehensive picture of the state of knowledge on the topic to avoid duplication. Literature
review gives the researcher clues on methodology and instruments that existed and tried or
not tried. It makes the researcher familiar with the practical or theoretical issues relating to a
problem area, generating ideas or focus on the research topic. It also helps the researcher to
refine certain parts of the study and support collection and analysis of data in qualitative
studies (Polit and Hungler, 2001).
This Literature review focuses on both published and unpublished studies about knowledge
and acceptability of cervical cancer screening from journals, internet data base globally,
regionally and nationally. Literature review will be presented in the following manner,
overview of cervical cancer screening, knowledge of cervical cancer screening, acceptability
of cervical cancer screening, barriers to cervical cancer screening and Conclusion.
2.1 OVERVIEW OF THE CERVICAL CANCER SCREENING.
Cancer of the cervix uteri is the second most common cancer among women in the world
(Leyva et al, 2006) and the most common in the developing countries accounting for more
than 80% of all cases worldwide (Walraven, 2003). Globally, estimated half a million cases
are detected and over a quarter million women die from cervical cancer each year (Parkin,
2001). Cervical cancer ranks as the most frequent cancer among women between the ages of
15 and 44. In Zambia, current estimates indicate that every year 1,839 women are diagnosed
with cervical cancer and 1,276 die from the disease (WHO/ICO, 2010).
19
Cancer screening tests serve to detect the possibility that a cancer is present. When cancer is
detected in its earliest stages, it can usually be treated before it spreads (Berkow and Beer,
1997). To date, cervical cancer prevention efforts (worldwide) have focused on sexually
active women using cytological smears and treating precancerous lesions. It has been widely
believed that invasive cervical cancer develops from dysplastic precursor lesions,
progressing steadily from mild to moderate to severe dysplasia, to carcinoma in situ and
finally to cancer. (Sankaranarayanan et al, 2001). Screening has shown to be effective in
reducing the incidence and mortality from cervical cancer. The incidence of cervical cancer
can be reduced by as much as 80% if quality coverage and follow- up of screening are high
(Sankaranarayanan et al, 2001). Good results can be achieved if the disease is diagnosed
early and the woman is given the treatment. It is possible to reduce illness and death from
cervical cancer with relatively modest investments in health services and training (Ashford
et al, 2005).
The WHO estimates that a one-time screening among women around the age of 40 could
reduce the chance of fatality due to cervical cancer by 25-30% if adequately followed up.
Since cervical cancer usually progresses slowly, this once-in-a-lifetime screening could
prevent abnormal cells from becoming fatal (World Health Organization- Alliance of
Cervical Cancer Prevention-WHO-ACCP, 2009).
While cervical cancer screening has reduced cancer incidence and deaths dramatically in
industrialized countries, this has not been true in developing countries despite the greatest
burden of cervical cancer. Screening whether conventional or liquid based, has proven
difficult to implement in these countries due to lack of supplies, trained personnel,
equipment, quality control, health care infrastructure and ineffective follow-up procedures
(Sherris et al, 2009). For instance, in India, screening was not feasible because of high cost,
inadequate infrastructure, lack of trained health care providers and logistical difficulties
(Sankaranarayanan et al, 2001).
Zambia has not been spared by cervical cancer. Despite its public health importance, there
are few effective prevention programmes which are just in few places and hence the risk of
20
disease and deaths from cervical cancer remains uncontrolled. In November 2005, the
Center for Infectious Disease Research in Zambia (CIDRZ) began enrolling women in their
Cervical Cancer Prevention Program that targets both HIV positive and non-HIV-infected
female patients (Wong, 2009). Since then the programme has been expanding although it is
just confined to specific places in few districts making it difficult for women in other areas
especially rural areas to access. The cervical cancer preventive programme aims at
empowering women with adequate information on the dangers of cervical cancer and benefit
of screening through vigorous sensitization in order to enhance acceptability of cervical
cancer screening.
2.2 KNOWLEDGE OF CERVICAL CANCER SCREENING
Increasing women's knowledge of cervical cancer and preventive health-seeking behaviour
can have a great impact on cervical cancer incidence and mortality (WHO, 2005). The
uptake of preventive cervical cancer services is greatly affected by knowledge. According to
the findings of the study in Hong Kong on knowledge about cervical cancer and cervical
cancer screening practice, most women had little or no knowledge about risk factors of
cervical cancer. The study concluded that there was need for more knowledge about
preventive strategies, particularly the processes involved in the screening procedure (Twinn
et al, 2002). In a related study conducted in Asia on women's knowledge and attitude on
utilization of cervical cancer screening services, women were reported not to have utilized
the cervical cancer screening services due to lack of appropriate and sensitive preventive
health care or lack of knowledge about the importance of routine cervical cancer screening
(Steve et al, 2006). Interventions to increase knowledge about the preventive nature of
cervical cancer screening and regular screening, particularly the need for health promotion
and intervention strategies have a positive influence on cervical cancer screening.
Wong and colleagues (2009) conducted a study on knowledge and awareness of cervical
cancer and screening among women in Malaysia. It was observed that lack of knowledge on
cervical cancer and the Pap smear test was significant among the respondents. Many women
did not have a clear understanding of the meaning of an abnormal cervical smear and the
need for the early detection of cervical cancer. Many believed that the purpose of the Pap
21
smear test was to confirm the diagnosis of cervical cancer, leading to the belief that Pap
smear screening was not required because the respondents had no symptoms. The study
findings highlighted the importance of emphasizing accurate information about cervical
cancer and the purpose of Pap smear screening when designing interventions aimed at
improving cervical cancer screening.
Women need to be aware of the existing screening services in the area and the purpose of
the service need to be emphasized during Information Education and Communication (IEC)
for them to appreciate the importance of being screened. Most women did not screen for
cervical cancer due to the fact that, according to them screening was for detecting existing
cervical cancer and not preventing it. In a similar study conducted by Ali and others in 2009
on knowledge and awareness about cervical cancer and its prevention among interns and
Nursing staff in a Hospital in Pakistan. The study revealed that 37% of respondents
recognized Pap smear as a screening test. The study further revealed that the majority of
working health professionals was not adequately equipped with knowledge concerning
cervical cancer. Ali and colleagues suggested that, continuing medical education
programmes should be started at the Hospital level along with conferences to spread
knowledge about cervical cancer. This study indicates the importance of knowledge in
addressing the prevalence of cervical cancer and the role of health workers (Nurses) in the
fight against cervical cancer. Since nurses are frontline workers, they need to be well
equipped with adequate knowledge as they play a critical role in IEC.
In African countries, awareness of cervical cancer screening has a bearing on women's
decision to participate in preventive health programmes due to various factors like access,
educational level and cultural beliefs. A study conducted in Kenya revealed that few women
were aware that early diagnosis and treatment of precancerous lesions greatly improve the
probability of a successful cure and prevention of cervical cancer (Wood et al, 1997).
Knowledge of cervical cancer and screening is reportedly low even among the educated
women in Ghana and opportunities to learn more about the reproductive health are beyond
the reach of many women particularly in rural areas (Adanu, 2002). This is because the Pap
test which is the most commonly performed test in developed countries is limited to a few
22
health care locations in the country and the absence of a comprehensive national screening
programmes limit the number of women who receive screening (Adanu, 2002). Lack of
knowledge that the purpose of pap screening is to diagnose cancer was demonstrated in a
study conducted in Ghana by Abotchie and Shokar, (2009) among college women in the
university. In another study conducted by Tebeu and colleagues (2007) to assess the
knowledge, attitudes, and assumption of cervical cancer by women living in Maroua,
Cameroon, it was revealed that the knowledge of cervical cancer by women in Cameroon
was inadequate. In this study Tebeu and colleagues suggested that, there was need of
aggressive campaign to make women aware of cervical cancer and its prevention to avoid
deaths from cervical cancer, a curable and preventable disease (Tebeu et al, 2007)
In a similar study conducted by Harries and colleagues (2009) in South Africa to explore the
key challenges and opinions towards HPV vaccination, the study revealed that the purpose
and preventive nature of pap smear was poor, the study further revealed that many women
knew about the availability of cervical cancer screening but did not fully understand the
purpose of Pap smear. Some women associated Pap smear with cleansing or scraping the
womb after possible exposure to a sexually transmitted infection and this could have
influenced them not to accept the cervical cancer screening service (Harries et al, 2009).
From the above studies it can be deduced that knowledge and awareness are key in helping
women participate in preventive health programmes. 'As they say knowledge is power,' it
gives somebody the ability to make a right choice if they are given adequate and right
information on the subject matter.
In Zambia, the knowledge of cervical cancer and screening services is low. A study
conducted at the University Teaching Hospital (UTH) in Lusaka on "knowledge, attitude of
women towards cervical cancer and Human Papiloma Virus (HPV) vaccination. The study
revealed that introduction of HPV vaccination must be complimented by cervical cancer
education and advocacy of screening visits (Vwalika et al, 2010). Mkumba (2006)
conducted a study on safety, acceptability, feasibility and implementation of cervical cancer
screening in Zambia. Lack of knowledge even among health care workers was significant
(Mkumba, 2006). From the above literature, it is evident that many women have little or no
23
knowledge about cervical cancer and its preventive measures. Increased knowledge on
cervical cancer and screening services can influence women's decision in participating in
health preventive programmes.
2.3 ACCEPTABILITY OF CERVICAL CANCER SCREENING
Many women find it difficult to participate in cervical cancer screening services due to
various factors such as, non availability of screening services, fear of being diagnosed with
cancer, coping with cancer and lack of knowledge and awareness about cervical cancer and
screening services. In a study conducted in Singapore by Seow (1995), many women who
were aware of Pap smear, did not perceive themselves to be at risk, and therefore did not
indicate the future intention to have a smear. The study further revealed that a means of
increasing acceptability of screening for cervical cancer for both women who had had a
smear and those who had not had a smear are culture - specific and must address the
appropriate health beliefs and attitudes. Similarly, a study conducted by Yu (1998), at Guy's
hospital in London, to gain an insight into women's attitude towards and awareness of smear
testing for cervical cancer, embarrassment and discomfort played part in women's decision
in not returning for a regular smear. In another study conducted by Dzuba and colleagues
(2002) to explore the acceptability of self-collection of samples for Human Papiloma Virus
(HPV) testing in comparison with that of the Pap test in Mexico, 98% of women reported
privacy and comfort with the self-sampling procedure than a Pap test as it consistently
provoked more discomfort, pain, and embarrassment than self-sampling. It was concluded
that incorporation of self-collected samples to detect HPV could encourage participation in
screening programmes among those women who reject the Pap test because of the necessary
pelvic examination (Dzuba et al, 2002). From the above studies, it is evident that there are
many factors that affect women's acceptability of cervical cancer screening and such factors
must be addresses in order to enhance uptake of screening.
Whereas issues of acceptability of cervical cancer screening affect many countries, it is of
importance in the developing countries where screening services are not well developed.
From the studies conducted in Kenya and South Africa, women were reported to having
24
powerful and quite frightening images of cancer. These fears may contribute to a woman's
reluctance to get screened. Images were associated with words such as "devour or eating",
"putridity", or "plague". For instance, women in Kenya described the inevitability of
cervical cancer and the belief that, (at a minimum), their womb will be "cut out", resulting in
the loss of womanhood and sexuality (Bingham et al, 2003). In South Africa, the pelvic
examination is referred to as "hanging the legs" and women refer to the experience as
"surrendering oneself. In this setting, a cervical examination is especially problematic. A
positive cervical screening test implies that a woman is somehow "dirty" or promiscuous"
(Bingham et al, 2003).
In a study conducted by Aniebue and Aniebue (2010) on knowledge and practice of cervical
cancer screening, among female undergraduates in a University in Nigerian. It was revealed
that practice of cervical cancer screening was still very low amongst female university
students (Aniebue and Aniebue, 2010). The commonest reasons for never being screened
include; ignorance of the existence of screening services, lack of doctor's recommendation
and absence of symptoms. From this study it can be concluded that knowledge influences
practice, for women to be using health services they need to be empowered with adequate
information on cervical cancer screening so that they can have a clear understanding of the
service and its benefits so that they can freely utilize the service without waiting for the
doctor's recommendation. In addition, screening services should be integrated into the
existing university medical services so that female students can easily access them.
In Zambia, Mkumba (2006) conducted a study to assess the safety, acceptability, feasibility
of implementation of cervical cancer screening program using Visual Inspection with Acetic
acid. It was established that, it was feasible to implement the cervical cancer screening
program in Zambia.
2.4 BARRIERS TO CERVICAL CANCER SCREENING
A number of factors may affect a woman's ability and desire to participate in cervical cancer
prevention programmes, and the impact of a woman's decision-making process cannot be
25
ignored. It is therefore essential that cervical cancer prevention efforts eliminate the most
critical barriers that affect women's participation, as well as identify and foster conditions
that support their use of services (American Cervical Cancer Association- ACCA, 2003).
For instance, Agursto et al, (2004) in their 5 separate studies conducted a study among lowincome women in Venezuela, Ecuador, Mexico, El Salvador, and Peru regarding barriers
and benefits of cervical cancer screening found that the main barriers identified by all
participants were accessibility and availability of quality services. Facilities that lack
comfort and privacy, high costs, and courtesy of providers, contribute to poor service
delivery. They further found that barriers that pertain to women's beliefs are anxiety borne
by women awaiting test results, associated with negligence and fear of cancer. However, the
results indicated that except for the accessibility and availability of quality services, these
results are consistent with findings from other studies in developed and developing
countries. Similarly in a study in Peru where screening rates were much lower in districts
where services were distant or difficult to access, the importance of providers taking time to
converse with women,
answering questions, explaining procedures, and giving
encouragement was highlighted (Bingham et al,2003).
These barriers could be lifted if health service delivery was improved, for instance, through
quality improvement techniques that are available at low cost. Women's anxiety over test
results still need to be further assessed to work out risk communication strategies that take
into account broader educational frameworks (Bingham et al, 2003). It is to be noted that
such strategies should infuse the way health services are provided for cervical cancer
prevention regardless of the specific test used. Bingham and colleagues concluded that a
key step to achieving optimal coverage is to gain broad community support. Developing
Communication strategies for raising knowledge about services and encouraging
participation can have a positive influence on acceptability (Bingham et al, 2003). From the
above studies it can be concluded that non availability of quality cervical cancer screening
and lack of information on cervical cancer are major barriers to screening for cervical
cancer.
In some instances, the lack of screening also reflects the lack of political will to prioritize
cancer prevention in women. Competing healthcare priorities posed by the striking burden
26
of diseases other than cancers coupled with a trend of shrinking public health budgets is
overwhelming in many developing countries (Denny et al, 2006). From other studies
conducted in low - and middle - income developing countries it was observed that there are
no organized or opportunistic screening programmes (Sankaranarayanan et al, 2001).
In Africa, barriers to cervical cancer screening have been cited in several studies. According
to a study conducted in Nigeria by Ezem (2007), lack of knowledge that cervical cancer
screening could be done locally, fear and anxiety of the positive result were demonstrated in
the study. In a related study conducted in Ghana by Abotchie and Shokar on knowledge and
beliefs of cervical cancer and cervical cancer screening among college women. The study
revealed that lack of information about where to obtain screening services, not perceiving
one to be at risk, belief that Pap smear is painful and that it can take away the virginity were
most prevalent barriers (Abotchie and Shokar, 2009). Lack of knowledge is a prime barrier
to preventing cervical cancer (Harries et al, 2009). Banda and Malata (2010) in their study to
identify factors that act as barriers to the uptake of cervical cancer screening programmes
among urban and rural women in the Blantyre district of Malawi found that the main
barriers to cervical cancer screening were lack of knowledge and information about cervical
cancer and lack of publicity about cervical cancer screening services. Lack of knowledge
was found in relation to - risk factors, prevention of, detection of and benefits of cervical
cancer screening with a greater knowledge deficit being found in the rural women (Banda
and Malata, 2010). Based on the above literature, it can be concluded that there are many
factors surrounding women's failure to screen for cervical cancer. Therefore, increased
sensitization on cervical cancer and the benefits of screening, availability of screening
services can improve the use of cervical cancer screening services.
Zambia, like most African countries experiences the same barriers other countries are
experiencing. The few screening programmes available are only confined to few districts
making it difficult for other women especially those in hard to reach places to access even
though they are aware.
27
2.5 CONCLUSION
From the studies conducted, cervical cancer is among the major cause of morbidity and
mortality among women worldwide. Literature revealed that screening for cervical cancer
has been effective in reducing the incidence and mortality from cervical cancer. The
incidence of cervical cancer can be reduced if the quality coverage and follow- up of
screening are high. Further, literature also reveals that some countries especially developing
countries do not have organized screening services and most women in such areas have no
access to screening services. According to studies conducted in various countries, lack of
awareness about cervical cancer and availability of screening services, accessibility, nature
of disease, lack of information about the risks, staff attitude and health facility have been
cited to be hindrances to acceptability of cervical cancer screening.
Despite the findings from the different studies on knowledge and acceptability of cervical
cancer screening that is globally, regionally, there are studies done in Zambia on incidence
of cervical cancer, feasibility, acceptability of the implementation of cervical cancer
screening and knowledge and attitude of Pap test and HPV vaccine. Still, there has not been
a study done on knowledge and acceptability of cervical cancer screening. It is therefore
believed that the results of the study will help intensify the preventive strategies of cervical
cancer screening.
28
CHAPTERS
3.0 RESEARCH METHODOLOGY
INTRODUCTION
Research methodology refers to the process or plan for conducting the specific steps of the
study (Burns and Grove, 2009).This chapter focuses on the research methodology that was
used in this study. It focuses on the research design, study setting, study population, sample
selection, sample size, data collection tools, data collection technique, validity and reliability
of the tools for data collection, pilot study, ethical considerations, plans for data analysis,
and plans for dissemination of the findings.
3.1 RESEARCH DESIGN
A research design is the structure framework or blue print of the study and it guides the
researcher in the planning and implementation of the study while optimal control is achieved
over factors that could influence the study (Burns and Grove, 2005).
A non experimental quantitative methodology using a descriptive study design was used.
The study was non experimental because independent variables occurred naturally and there
was no manipulation. The study was descriptive because the objective was to observe,
describe and document aspects of a situation or groups or frequency with which certain
phenomena occur (Polit and Beck, 2006), for example, the study purpose was to determine
the knowledge and acceptability of cervical cancer screening among women in Ng'ombe
community, Lusaka. The research was quantitative because it involved investigation of the
phenomena that lend themselves to precise measurement and quantification, involving a
rigorous and controlled design. The investigator progresses logically through series of steps
according to the specified plan of action. The researcher used to the extent possible
mechanisms designed to control the study, which involved imposing conditions on the
research situation so that biases are minimized and precision and validity are maximized
(Polit and Beck, 2006). This design was appropriate for this study as the researcher sought to
describe knowledge and acceptability of cervical cancer screening.
29
3.2 RESEARCH SETTING
Research setting is the physical location and conditions in which data collection takes place
in the study (Polit and Beck, 2008). The study was conducted at Ng'ombe Health Center.
Ng'ombe Health Center is one of the Health Centers run by the District Health Management
Team under the Ministry of Health in Lusaka. It was opened on 20th December 1998. It is
situated 15km North- Eastern part of Lusaka. The nearest Health Centers are: Ngwerere
Health Centre on the Northern side, Kaunda Square on the Southern side and Kalingalinga
Health Centre and University of Zambia clinic on the East. It has a catchment population of
32,650 (DHMT, 2010). It comprises the General Outpatient Department which offers
integrated health care to all patients including ART patients, Maternal and Child Health
(MCH) Department which offers antenatal care including Prevention of Mother to Child
Transmission of HIV (PMTCT), Post Natal Care and Child Health Care. It also offers
Voluntary Counseling and Testing (VCT), cervical cancer screening service, and obstetric
services.
The site was chosen because it is one of the clinics offering cervical cancer screening and it
has recorded low number of women accessing cervical cancer screening service. It also gave
the researcher chance to get views from women with different socio and cultural back
grounds and was convenient and accessible to the researcher as well.
3.3 STUDY POPULATION
Study population refers to the entire number of units under study (Walter et al, 2005). In
this study, the study population included all women above 35 years of age because they are
at risk of developing cervical cancer as the risk of invasive cervical cancer increases with
age, occurring between 35 and 55 years of age.
3.3.1 Target Population
A target population is a group of individuals who meet sampling criteria to which the study
findings will be generalized (Burns and Grove, 2005). The target population included all
women aged 35 years and above, accessing care at Ng'ombe Health Center from MCH,
OPD and any other department except cervical cancer clinic.
30
3.3.2 Accessible Population
Accessible population is a portion of a target population to which the researcher has
reasonable access (Burns and Grove, 2009). Accessible population for this study was
women above the age of 35 from Ng'ombe community, Roma, Kalundu and the surrounding
areas accessing care at Ng'ombe Health Center.
3.4 SAMPLE SELECTION
Sample selection is a process of selecting a group, event, behaviours or other elements that
are representative of the population being studied (Burns and Grove, 2009). In this study the
district and the Health Center were purposively selected and respondents were selected
using a simple random sampling. Sampling is the process of selecting a portion or subset of
designated population to represent the entire population (Wood and Haber, 2006). Simple
random sampling is a probability strategy in which the population is defined, a sampling
frame is listed, and a subset from which the sample will be chosen is selected; members are
randomly selected (Wood and Haber, 2006). The researcher used the simple random
sampling method in which elements were selected at random from the target population.
Participants were selected randomly from various departments including MCH, OPD with
an exception of cervical cancer screening clinic. The participants included women aged 35
years and above, accessing care at Ng'ombe Health Center.
3.4. 1 District
Lusaka District
Lusaka district was purposively selected because most of the centers offering cervical cancer
screening are in Lusaka. Purposive sampling is a non-probability sampling strategy in which
the researcher selects subjects who are considered to be typical of the population (Wood and
Haber, 2006).
31
3. 4 .2 Health Center
Ng'ombe Health Center
Ng'ombe Health Center was purposively selected because it is one of the Health Centers
offering screening for cervical cancer. According to Ng'ombe cervical cancer screening
report 2010, 2,650 (36%) out of the total women population of 7,172 have been screened
for cervical cancer since 2007 and about 9 have been referred to UTH for treatment.
3.5 ELIGIBILITY CRITERIA
Eligibility criteria are the list of characteristics essential for inclusion or exclusion in the
target population (Burns and Grove, 2009).
3.5.1 Inclusion criteria
Inclusion criteria are characteristics that the subjects or elements must possess to be part of
the target population (Burns and Grove, 2009).
Participants who were included in the study were women aged 35 years and above accessing
care at Ng'ombe Health Center other than cervical cancer screening.
3.5.2 Exclusion criteria
Exclusion criteria are those characteristics that can cause a person or element to be excluded
from the target population (Burn and Grove, 2009). Women from the cervical cancer
screening clinic, those who are below 35 years of age and those women who were very sick
and could not stand the interview were excluded from the target population.
3.6 SAMPLE SIZE
A sample size is a number of subjects or participants recruited and consenting to take part in
a study (Burns and Grove, 2009). A sample size for this study included 50 women above 35
years of age. This sample size was considered due to constrained material and financial
resources in which the study was conducted.
32
3.7 OPERATIONAL DEFINITIONS
3.7.1 Knowledge
In this study knowledge means a woman who was able to define cervical cancer, state risk
factors, signs and symptoms and mentioned services available for detection and prevention
of cervical cancer.
3.7.2 Acceptability
In this study acceptability means a woman who was able to acknowledge the importance of
screening for cervical cancer, had the intensions of going for cervical cancer screening and
had accessed the screening service.
3.7.3 Cervical cancer
In this study, cervical cancer means a growth or a sore on the cervix or uterus.
3.8 DATA COLLECTION TOOL
Data collection tool is an instrument used to collect data needed to address research
questions (Polit and Beck, 2008). A structured interview schedule was used to collect data
from the respondents. (A structured interview is a verbal interaction with the subjects that
allows the researcher to exercise control over the content of the interview to obtain the
essential data for a study (Burns and Grove, 2009). The interview schedule had four (4)
sections; section A covered demographic data, section B covered knowledge of cervical
cancer and screening, section C covered acceptability of cervical cancer screening and
section D covered barriers to cervical cancer screening. The interview schedule contained 29
questions, both open and closed ended. The schedule had been developed on the basis of
systematic review of literature that examined awareness, knowledge and acceptability of
cervical cancer and screening.
33
3.9 VALIDITY
Validity is the degree of the research instrument to measure what it intends to measure (Polit
and Beck, 2008). It constitutes both internal and external validity. External validity is a
degree to which findings of a study can be generalized to other populations or environments
(Wood and Haber, 2006). To ensure external validity the researcher included respondents
from various economical, religious, social, political and education backgrounds. However,
the findings in this study will not be generalized due to a small sample. Internal validity is
an extent to which the effects detected in the study are a true reflection of reality rather than
being the result of the effects of the extraneous variables (Burns and Grove, 2009). To
ensure internal validity, the research questions were simple, clear and specific. A pilot study
was conducted to test the effectiveness of the instrument. The research instrument was
reviewed by the research supervisor to ensure that it met the standards for the study.
3.10 RELIABILITY
This refers to the degree of consistency and accuracy with which an instrument measures the
attributes it is designed to measure (Polit and Beck, 2008). Reliability is concerned with
consistency, accuracy, precision, stability, equivalency and homogeneity. A reliable
instrument is one that can produce the same results if the behavior is measured again by the
same scale (Wood and Haber, 2006). Reliability was upheld by using the same instrument to
collect data from the respondents and clarifications were done so that they did not
misunderstand the questions. A pilot study was also conducted before the actual research to
test the efficiency of the data collection instrument.
3.11 DATA COLLECTION TECHNIQUE
Data collection technique is the method followed in the gathering of information needed to
address a research problem (Polit and Beck, 2008). In this study, a structured interview
technique was used by the researcher. An interview is a method of data collection in which a
data collector questions a subject verbally. Interviews may be face to face or performed over
a telephone, and they may consist of open- ended or closed ended questions (Wood and
Haber, 2006). A face to face interview was used; using both open ended and closed ended
34
questions. The interview was conducted in a quiet private room after explaining the purpose
of the study, obtaining consent from the participants then proceeded with the interview using
the structured interview Schedule. This technique allowed interaction between the researcher
and the respondents and also helped the researcher to observe the respondent's verbal cues.
3.12 PILOT STUDY
A pilot study is a smaller version of a proposed study conducted before the actual research
to develop or refine the methodology, such as the treatment, instrument or data collection
process (Burns and Grove, 2009). The pilot study was conducted at Mtendere Health Center
in Lusaka. The Center was selected because it had the similar characteristics with the study
setting as it offers screening for cervical cancer as well. The pilot study was done to test the
validity and consistency of the data collection tool in order to detect problems before the
actual study. The sample for the pilot study was selected using simple random technique and
the size was 10% of (50) respondents (actual sample size) which was 5 respondents.
Respondents were selected from MCH, and OPD.
After the pilot study, few changes were made to the data collection tool. Some questions on
knowledge of cervical cancer and screening services (Section, B) were rephrased as some
respondents could not easily understand the questions.
3 1 3 ETHICAL AND LEGAL ISSUES
Ethical considerations refer to the ethics which are a system of moral values that is
concerned with the degree to which research procedures adhere to professional, legal and
social obligations to the study participants (Polit and Beck, 2008). The researcher asked for
a written permission from the Lusaka District Health Management (DHMT) office for the
pilot study and the actual study. Written permission was also gotten from Health Center in
charges for Ng'ombe and Mtendere Health Centers. A written consent was obtained from
each participant before administering the interview schedule. The respondents were assured
of confidentiality of the information provided. Confidentiality was upheld by interviewing
the respondents one by one in a private room. Numbers were used instead of names to
ensure anonymity.
35
CHAPTER 4
4.0 DATA ANALYSIS AND PRESENTATION OF FINDINGS
INTRODUCTION
In this chapter the researcher discusses the analysis and presentation of the findings of the
study. The purpose of the study was to determine the knowledge and acceptability of
cervical cancer screening among women in Ng'ombe community, Lusaka. A total of 50
respondents were randomly selected.
4.1 DATA ANALYSIS
Data analysis is the process of categorizing, scrutinizing and cross checking the research
data (Basavanthappa, 2007)
The raw data was collected, edited and checked for completeness, consistency and accuracy
and then coded. Responses to closed ended questions were entered on the data master sheet
for easy analysis, whereas information from the open ended questions was categorized into
different themes and entered on the data master sheet. Data analysis was done manually
using a scientific calculator and SPSS 16.0 for cross tabulations and for statistical
significance.
4.2 PRESENTATION OF FINDINGS
The data was presented using frequency tables, graphs and pie charts because they are easy
to interpret and depict meaning from. Cross tabulations were also used to show the
relationships between variables in relation to the problem under study.
The findings were presented under sections A, B, C and D. In Section A, respondents
Demographic data is presented, Section B presents the respondent's Knowledge of Cervical
Cancer and Screening, Section C presents the respondent's Acceptability of Cervical Cancer
Screening and Section D presents Barriers to Cervical Cancer Screening.
36
4.2.1 SECTION A: DEMOGRAPHIC CHARACTERISTICS OF THE SAMPLE
Figure 4.1 Distributions of respondents by age n= 50
135-40 • 41-46 • 47-52 • 53-61
More than half 29 (58%) of the respondents were aged between 35 and 40 years
Table 4.1 Marital status n= 50
MARITAL STATUS
FREQUENCY
PERCENTAGE
Single
2
4
Married
35
70
Divorced
5
10
Widowed
7
14
Separated
1
2
Total
100
50
The majority 35(70%) of the respondents were married.
37
Figure 4.2 Highest level of education n=50
None
Primary
Secondary
Tertiary
Thirty (60%) of the respondents had primary education while 14 (28%) had secondary
education.
Table 4.2 Respondents religion n=50
RELIGION
FREQUENCY
PERCENTAGE
Christian
50
100
Islam
0
0
Hindu
0
0
Total
50
100
All the 50 (100%) respondents were Christians
38
Table 4.3 Participant's number of children n=47
NUMBER
OF FREQUENCY
PERCENTAGE
CHILDREN
1-3
8
17
4-6
27
58
7-9
11
23
10-12
1
2
Total
47
100
Majority 27(58%) of the respondents who had children had between 4 to 6 children.
Table 4.4 Participant's age at first intercourse n=50
AGE AT FIRST SEXUAL FREQUENTCY
PERCENTAGE
INTERCOURSE
13-15
6
12
16-18
23
46
19-21
11
22
22-25
4
8
Could not remember
6
12
50
100
Total
Most 23 (46%) of the respondents experienced their first sexual intercourse between the
ages of 16 and 18.
39
4.2.2 SECTION B: KNOWLEDGE OF CERVICAL CANCER AND SCREENING
Table 4.5 Heard of cervical cancer n=50
FREQUENCY
PERCENTAGE
Yes
46
92
No
4
8
50
100
Total
The majority 46 (92%) of the respondents stated that they had heard of cervical cancer.
Table 4.6 Source of information n=46
SOURCE
OF FREQUENCY
PERCENTAGE
INFORMATION
38
83
Media
1
2
Relatives and friends
1
2
Community
5
11
Church
1
2
Health facility
Total
46
100
The majority 38 (83%) of the respondents got the information about cervical cancer from the
health facility.
40
Table 4.7 Participant's explanation of cervical cancer n=50
EXPLANATION OF
FREQUENCY
PERCENTAGE
CERVICAL CANCER
Growth or sore on the cervix 21
42
or uterus
Vaginal discharge
3
6
Disease of women
4
8
Cancer of the vagina
3
6
I don't know
19
38
Total
50
100
Twenty one (42%) of the respondents explained cervical cancer as a growth or sore on the
cervix or uterus.
Table 4.8 Knowledge on predisposing factors to developing cervical cancer n=50
FREQUENCY
PERCENTAGE
No correct response
21
42
1 Correct response
'17
34
2 Correct responses
6
12
3 Correct responses
6
12
50
100
PREDISPOSING
FACTOR
(HIV/AIDS, STI and
Multiple Sexual partners,
vaginal herbs, age,
multiparty, oral
contraceptives).
Total
Most 21(42%) of the respondents did not give any correct response.
41
Table 4.9 Knowledge on signs and symptoms of cervical cancer n=50
SIGNS AND SYMPTOMS
FREQUENCY
PERCENTAGE
Abdominal pain
11
22
Watery vaginal discharge
1
2
Bleeding and vaginal discharge
5
10
5
10
Bleeding and painful coitus
2
4
Bleeding and abdominal pain
5
10
Vaginal discharge and painful coitus
2
4
Bleeding , painful coitus, abdominal
3
6
3
6
Don't know
13
26
Total
50
100
Watery
vaginal
discharge
and
abdominal pain
pain
Bleeding,
watery
discharge
and
abdominal pain
Thirteen (26%) of the respondents did not know any sign and symptom of cervical cancer.
42
Figure 4.3 Participants level of knowledge of cervical cancer
90%
80%
70%
60%
50%
40%
30%
20%
10% ;
0%
Low
High
Medium
The majority 42(84%) of the respondents had low knowledge of cervical cancer while
16(32%) had medium knowledge on cervical cancer
Figure 4.4 Knowledge on detection of cervical cancer n=50
i Yes »No
32%
The majority 34(68%) of respondents stated that they knew how cervical cancer could be
detected while 16(32%) stated that they didn't know how cervical could be detected.
43
Table 4.10 How cervical cancer can be detected n = 34
DETECTION OF CERVICAL FREQUENCY
PERCENTAGE
CANCER
Screening for cervical cancer 29
85
(VIA)
Blood
3
9
Urine
2
6
Total
34
100
The majority 29(85%) of the respondents stated that cervical cancer is detected by
screening.
Table 4.11 Where cervical cancer screening can be done n=34
WHERE SCREENING
FREQUENCY
PERCENTAGE
26
76
8
24
34
100
CAN BE DONE
Health facility
Don't know
Total
The majority 26(76%) of the respondents stated that cervical cancer screening could be done
at the Health Center.
44
Figure 4.5 Participant total knowledge n=50
0%
20%
40%
• Low knowledge
60%
80%
100%
High knowledge
Slightly above half 28(56%) of the respondents had low knowledge of cervical cancer and
screening services.
45
4.2.3 SECTION C: ACCEPTABILITY OF CERVICAL CANCER SCREENING
Figure 4.6 Ever been screened for cervical cancer n=50
No
Yes
o%
20%
60%
40%
80%
More than half of the respondents 34 (68%) had never been screened for cervical cancer.
Table 4.12 Participant's response on whether they decided to go for screening on their
own n =16
RESPONSE ON GOING
FREQUENCY
PERCENTAGE
13
81
3
9
16
100
FOR SCREENING
On their own
Not on their own
Total
Majority 13(81%) of the respondents decided to go for screening own their own.
46
Table 4.13 Reasons for screening for cervical cancer n= 16
REASONS FOR SCREENING
FREQUENCY
PERCENTAGE
Presence of symptoms
7
43
Referred by health personnel
3
19
Wanted to know after hearing
6
38
16
100
FOR CERVICAL CANCER
about it
Total
Less than half 7(43%) went for cervical cancer screening due to the presence of symptoms
while 3(19%) were referred by the health personnel.
47
Table 4.14 Reasons for not having been screened for cervical cancer n=34
REASONS FOR NOT HAVING FREQUENCY
BEEN
SCREENED
PERCENTAGE
FOR
CERVICAL CANCER
Laziness
10
29
No symptoms
6
18
Was pregnant
6
18
Not aware about the service
6
18
Fear
3
8
Not married
1
3
Embarrassment
1
3
Usually late
1
3
Total
100
34
Ten (29%) respondents who had not screened for cervical cancer mentioned laziness as a
reason for not having been screened for cervical cancer.
48
Figure 4.7 Participant's responses on whether they think screening for cervical cancer
is important n=50
i Yes
i No
The majority 48(96%) of the respondents stated that screening for cervical cancer was
important.
Table 4.15 Importance of cervical cancer screening n=48
IMPORTANCE OF CERVICAL FREQUENCY
PERCENTAGE
CANCER SCREENING
Early detection and treatment
19
39
Physical wellbeing
26
54
3
6
48
100
I don't know
Total
Slightly above half 26 (54%) of the respondents stated that screening for cervical cancer was
important for their physical wellbeing while 19 (39%) stated that screening for cervical
cancer was important for early detection of cervical cancer and treatment.
49
Table 4.16 Intentions to screen for cervical cancer/ again n=50
INTENTIONS FOR
FREQUENCY
PERCENTAGE
Yes
45
90
No
1
2
Not sure
4
8
50
100
CERVICAL CANCER
SCREENING
Total
The majority 45(90%) of the respondents stated that they would go for cervical cancer
screening even those who had been screened before.
Figure 4.8 Respondent's responses on acceptability n=50
Accepted
Not accepted
The majority 43(86%) of the respondent accepted cervical cancer screening services.
50
4.2.4 SECTION D: BARRIERS TO CERVICAL CANCER SCREENING
Table 4.17 Difficulties in accessing cervical cancer screening n=50
DIFFICULTIES IN
FREQUENCY
PERCENTAGE
Yes
37
64
No
13
26
Total
50
100
ACCESSING CERVICAL
CANCER SCREENING
Thirty seven (64%) of respondents indicated that there were difficulties in accessing cervical
cancer screening.
Table 4.18 Cited barriers to cervical cancer screening n=37
FREQUENCY
PERCENTAGE
22
59
Embarrassment
5
14
Stigma
1
3
Inadequate information
3
8
Fear of instrument
6
16
Total
37
100
BARRIERS TO CERVICAL
CANCER SCREENING
Fear of the diagnosis
More than half 22 (59%) of the respondents cited fear of the diagnosis as the barrier to
cervical cancer screening.
51
RELATIONSHIP BETWEEN VARIABLES
Table 4.19 Relationship between level of education and level of knowledge n=50
KNOWLEDGE ON
LEVEL OF EDUCATION
CERVICAL CANCER
None
Primary Secondary Tertiary TOTAL
Low
3(7%)
26(62%) 11(26%)
Medium
1(12%)
Total
4(8%)
4(50%)
3(38%)
2(5%)
42(84%)
0(0%)
8(16%)
30(60%) 14(14%) 2(4%)
50(100%)
Among 42(84%) respondents who had low knowledge, 26(62%) had primary education (P=
0.78).
Table 4.20 Screening for cervical cancer in relation to level of education n=50
LEVEL OF EDUCATION
SCREENING
None
Primary Secondary Tertiary TOTAL
0(0%)
11(69%)
4(25%)
1(6%)
16(32%)
No
4(12%) 19(56%) 10(29%)
1(3%)
34(68%)
Total
4(8%)
30(60%) 14(14%)
2(4%)
50(100%)
Yes
The majority 11(69%) of the respondents who had been screened had primary education
(P=0.46).
52
Table 4.21 Knowledge of cervical cancer and screening services in relation to level of
education n=50
LEVEL OF EDUCATION
TOTAL KNOWLEDGE
None
Primary Secondary Tertiary TOTAL
Low knowledge
2(7%)
17(61%) 8(29%)
1(3%)
28(56%)
High knowledge
2(9%)
13(59%) 6(27%)
1(5%)
22(44%)
Total
4(8%)
30(60%) 14(14%)
2(4%)
50(100%)
Among the 28(56%) respondents who had low knowledge of cervical cancer and screening
services 17(61%) were those who had primary education (P=0.99).
Table 4.22 Acceptability of cervical cancer screening in relation to level of education
n=50
LEVEL OF EDUCATION
ACCEPTABILITY
Primary Secondary Tertiary TOTAL
None
Not accepted
1(14%)
4(57%)
2(29%)
0(0%)
7(14%)
Accepted
3(7%)
26(60%) 12(28%)
2(5%)
43(86%)
Total
4(8%)
30(60%) 14(14%)
2(4%)
50(100%)
The majority 26(60%) of the respondents who had accepted cervical cancer screening were
those who had primary education (P=0.86).
53
Table 4.23 Screening for cervical cancer in relation to knowledge of cervical cancer and
screening services n=50
TOTAL KNOWLEDGE
SCREENING
Low knowledge
High knowledge
TOTAL
Yes
6(37%)
10(63%)
16(32%)
No
22(65%)
12(35%)
34(68%)
Total
28(56%)
22(44%)
50(100%)
The majority 22(65%) of the respondents who had not been screened for cervical cancer had
low knowledge of cervical cancer and screening services (P=0.07).
Table 4.24Acceptability of cervical cancer screening in relation to knowledge of
cervical cancer and screening services n=50
TOTAL KNOWLEDGE
ACCEPTABILITY
Low knowledge
High knowledge TOTAL
6(86%)
1(14%)
7(14%)
Accepted
22(51%)
21(49%)
43(86%)
Total
28(56%)
22(44%)
50(100%)
Not accepted
The majority 6(86%) of the respondent who had not accepted cervical cancer screening
services had low knowledge of cervical cancer and the screening services (P=0.08).
54
CHAPTER 5
5.0 DISCUSSION OF THE FINDINGS AND THE IMPLICATIONS FOR THE
HEALTH CARE SYSTEM.
INTRODUCTION
The discussion of the findings is based on the research analysis of the responses from 50
respondents who accessed care at Ng'ombe Health Center. The study purpose was to
determine the knowledge and acceptability of cervical cancer screening among women in
Ng'ombe community. The outline of the discussion consists of the characteristics of the
sample, discussion of each variables used in the study, the implications of the findings to the
Nursing care system, recommendations, dissemination of findings, limitation of the findings
and the conclusion.
5.1 CHARACTERISTICS OF THE SAMPLE
The sample constituted 50 women accessing care at Ng'ombe Health Center excluding those
who were coming for cervical cancer screening. Respondents were randomly selected from
Out Patient Department (OPD), Maternal and Child Health (MCH) and other departments
except Cervical Cancer Clinic.
5.2 DEMOGRAPHIC DATA
In terms of age distribution, the majority 29 (58%) of the respondents were aged between 35
and 40 years, 13 (26%) were aged between 41 and 46 years, 7 (14%) were aged between 47
and 52 and 1 (2%) was aged between 53 and 61 years old (Figure 4.1). The age range of the
respondents was from 35 to 61 years. The mean age of the respondents was 40.70. The
higher percentage of the age group between 35 and 40 years can be attributed to the fact that
the household population in Zambia has a greater number of younger people than older
people (CSO, 2007). The majority 35 (70%) of the respondents were married, 7 (14%) were
widowed, 5 (10%) were divorced, 2(4%) were single and 1(2%) was separated (Table 4).
The higher proportion of married Women can be attributed to the age of women interviewed.
55
Regarding education, the majority 30 (60%) of the respondents had primary education, 14
(28%) had secondary education, 4 (8%) had never been to school and 2 (4%) had tertiary
education (Figure 4.2). This may be due to the fact that 20% of females in Zambia have no
education and the highest (39.6%) proportion of women in Lusaka province has primary
education (CSO, 2007). All 50(100%) respondents were Christians (Figure 4.3).This can be
attributed to the fact that Zambia is a Christian nation with over 80% of the population
believing in the Christian faith (African Safari, 2010).
5.3 DISCUSSION OF EACH VARIABLE
5.3.1 KNOWLEDGE OF CERVICAL CANCER SCREENING.
Knowledge: information in mind: general awareness or possession of information, facts,
ideas, truths or principles. It is a fact or condition of being aware of something or range of
one's information or understanding (Microsoft. Encarta, 2008).
Knowledge of the availability of the service is very important if people are to make use of
the service. Section B of the interview schedule contains questions which helped in
determining the level of knowledge of women on cervical cancer and whether they were
aware of the availability of screening services.
The study findings indicate that the majority 34 (68%) of the respondents stated that they
knew how cervical cancer could be detected while 16 (32%) did not know. (Figure 4.5).
Most of the respondents were aware about detection of cervical cancer. This may be due to
the increased sensitization programmes on cervical cancer and the available screening
services in Lusaka. This is in line with what was reported in Xinhua article (2011), which
stated that Zambia has recorded an increase in the number of women undergoing cervical
cancer
screening
following vigorous sensitization
programs being undertaken
(Xinhua,2011).
In relation to how cervical cancer can be detected, slightly above half 29 (58%) of the
respondents stated that cervical cancer can be detected by Visual Inspection with Acetic acid
and 21 (42%) did not know (Table 4.9). In terms of where screening services can be offered
56
the majority 34 (68%) of the respondents stated that cervical cancer screening could be
offered at the Health Center while 8 (16%) did not know (Table 4.10). Currently there have
been intensified sensitization programmes on prevention and treatment of cervical cancer at
health care system level such as IEC at various departments every morning.
Regarding the respondent's knowledge on cervical cancer and screening, 13 (26%) of the
respondents did not know any sign and symptom , slightly above half 28 (56%) of the
respondents had low knowledge on cervical cancer and screening services. Information and
Education is usually given at the Health Center and so those women who do not often go to
the Health Center may not have access to the information. Additionally, those women who
may get the information from the community may not get the right information on cervical
cancer and screening services because the information may be given by other women who
may not give them the full information. These study results are similar to the study findings
by Twinn and collegues in Hong Kong on knowledge about cervical cancer and cervical
cancer screening practice; where most women had little or no knowledge about risk factors
of cervical cancer (Twinn et al, 2002). In another study conducted in Kenya it was revealed
that few women were aware that early diagnosis and treatment of precancerous lesions
greatly improve the probability of a successful cure and prevention of cervical cancer (Wood
et al, 1997). Wong and colleagues (2009) also noted lack of knowledge on cervical cancer
and the Pap smear test among the respondents and many women did not have a clear
understanding of the meaning of an abnormal cervical smear and the need for the early
detection of cervical cancer (Wong et al, 2009). In another study conducted by Mkumba
(2006) on safety, acceptability, feasibility and implementation of cervical cancer screening
in Zambia, lack of knowledge even among health care workers was demonstrated.
In terms of knowledge of cervical cancer screening services, in relation to the level of
education, out of 28 (56%) women who had knowledge of cervical cancer and screening,
the majority 17 (61%) of the respondents were those with primary education. The study
shows that there is no relationship between knowledge and level of education. This means
that any woman can have knowledge of cervical cancer and screening services regardless of
their level of education as long as they have access to the right information.
57
The study results are similar with study findings by Abotchie and Shokar (2009) on women
in the university in Ghana where lack of knowledge that the purpose of pap screening is to
diagnose cancer was demonstrated. Adanu also reported low knowledge of cervical cancer
and screening even among the educated women in Ghana (Adanu, 2002). There was no
significant difference between screening and knowledge of cervical cancer and screening
services, the majority 22(65%) of the respondents who had not been screened had
knowledge of cervical cancer and screening services (Table 4.22). Decision to participate in
health prevention programmes such as cervical cancer screening is affected by many factors
that can be social or cultural. Some women may have knowledge but the attitude towards the
service is negative, and so may not appreciate the importance of screening as the result they
may not see the need for screening.
5 3 2 ACCEPTABILITY OF CERVICAL CANCER SCREENING.
Acceptability is a state of welcoming something or acknowledging something (Geddes and
Crosset, 2006). In this study acceptability means acknowledging the important of cervical
cancer screening, having the intentions to access the cervical cancer screening service and
accessing the screening service. Section C of the interview schedule (Appendix ii) deals
with questions to assess the respondent's acceptability of cervical cancer screening.
The study showed that the majority 34 (68%) of the respondents had not been screened for
cervical cancer while 16 (32%) had been screened for cervical cancer (Figure 4.7). This may
be due to the fact that most women do not understand the benefits of screening for cervical
cancer which are early detection and prevention and so they do not consider it to be
important. Some women may have heard of cervical cancer but they may not understand
what it is and how serious it may be. The study also revealed that among the respondents
that did not go for screening, 10 (29%) of the respondents mentioned laziness, 6 (18%)
mentioned no symptoms, 6 (18%) said they were not aware about the service and 3 (8%)
mentioned fear (Table 4.12). Based on the reasons given for not going for screening, it can
be deduced that women do not perceive cervical cancer to be a serious disease. Ezem
(2007), in his study conducted in Nigeria on knowledge and uptake of cervical cancer
58
screening also noted lack of knowledge that cervical cancer screening could be done locally,
fear and anxiety of the positive result as barriers to cervical cancer screening. Lack of
knowledge is a prime barrier to preventing cervical cancer (Harries et al, 2009). Regarding
the decision to go for cervical cancer screening, majority 13 (81%) of the respondents
decided to go for screening own their own (Table 4.12).Reasons for screening for cervical
cancer were presence of symptoms 7 (43%), advised by health personnel, 3 (19%) and after
hearing about it 6 (38%) (Table 4.13). In terms of the importance of cervical cancer
screening, majority 48 (96%) of the respondents stated that screening for cervical cancer
was important while 2 (4%) were not sure whether screening for cervical cancer was
important (Figure 4.6). Reasons why screening for cervical cancer is important were,
physical wellbeing 26 (54%) and early detection and treatment of cervical cancer 19 (39%).
On the other hand 3 (6%) did not give any reasons (Table 4.15).
Regarding the intention to go for cervical cancer screening, the majority 45 (90%) of the
respondents stated that they would go for screening (Table 4.16). This may be attributed to
increased sensitization on cervical cancer screening and treatment of cervical cancer through
health teaching, brochures, televisions and radio progrmmes and the availability of screening
services (Xinhua, 2011). Furthermore, the Cancer Disease Hospital in Lusaka at the
University Teaching Hospital (UTH) (where all types of cancers are being treated cervical
cancer inclusive, is a source of hope) this has given women hope since they know that when
they are found with cervical cancer they will be helped. This is different from the findings in
the study conducted in Singapore by Seow (1995) on beliefs and attitudes as determinants of
cervical cancer screening, where many women who were aware of Pap smear, did not
perceive themselves to be at risk, and therefore did not indicate the future intention to have a
smear (Seow et al, 1995).
Regarding acceptability of cervical cancer screening in relation to the level of education, the
majority 27(63%) of the respondents who had accepted cervical cancer screening were those
who had primary education. From the above study findings, it can be concluded that there is
no relationship between education level and acceptability of cervical cancer screening.
These study findings are in agreement with the findings in the study conducted in Mexico by
59
Majiaa and colleagues (2002) on characteristics of respondents to a cervical cancer
screening programme. The study revealed that low educational level is not a limitation for
cervical cancer screening among women (Majiaa et al, 2002). In another study conducted by
Aniebue and Aniebue (2010) on knowledge and practice of cervical cancer screening among
female undergraduates in a University in Nigerian, it was revealed that practice of cervical
cancer screening was still very low amongst female university students. The commonest
reasons for never being screened included; ignorance of the existence of screening services,
lack of doctor's recommendation and absence of symptoms.
In terms of acceptability in relation to knowledge of cervical cancer and screening services,
the majority 6 (86%) of the respondents who had not accepted cervical cancer screening
services had low knowledge of cervical cancer and the screening services. These study
findings are similar with the study findings by Steve and colleagues in Asia on women's
knowledge and attitude on utilization of cervical cancer screening services where women
were reported not to have utilized the cervical cancer screening due to lack of appropriate
and sensitive preventive health care or lack of knowledge about the importance of routine
cervical cancer screening (Steve et al, 2006). This shows that knowledge is power, if women
are empowered with the right information on the service and its availability, they would be
able to make use of the service. The study results fail to reject the researcher's hypothesis
which states that there is a relationship between knowledge of cervical cancer and
acceptability of cervical cancer screening.
5 3.3 BARRIERS TO CERVICAL CANCER SCREENING
The majority 37(64%) indicated that there were difficulties in accessing cervical cancer
screening, while 13(26%) said there were no difficulties (Table 4.15). Out of the 37
respondents who said there were difficulties in accessing cervical cancer screening services,
the more than half 22(59%)
of the respondents cited fear of the diagnosis, 5(14%)
mentioned embarrassment, 6(16%) stated fear of instruments used, 3(8%) mentioned
inadequate information on screening services and 1(3%) cited stigma (Table 4.16). From the
above result it is evident that fear of the diagnosis was a more prominent barrier. These
results are consistent with the findings in a study by Ezem (2007) on knowledge and uptake
60
of cervical cancer screening; fear and anxiety of the positive result were significant barriers
(Ezem, 2007).
5.4 IMPLICATIONS TO THE HEALTH CARE SYSTEM
5.4.1 Nursing practice
Nurses have a leading role in the delivery of quality health care in the country. With the
increase of cervical cancer and it being the commonest cause of mortality in women in the
country, the health care system is experiencing a lot of strain on resources especially that
they are other priority areas of concern such as, malaria, tuberculosis and HIV/AIDS.
The study revealed that the majority 28(56%) had low knowledge of cervical cancer and the
screening services. The study further revealed that, the majority 6 (86%) of the respondents
who had not accepted screening for cervical cancer had low knowledge of cervical cancer
and the screening services. This implies that Nurses should engage more on giving
Information Education and Communication (IEC) at all levels of Health Care Delivery. It is
also important to devise outreach programmes aiming at sensitizing women including those
in hard to reach places in order to empower them with adequate information on cervical
cancer and its preventive strategies. This will therefore encourage more women to utilize
cervical cancer screening services. The Ministry of Health should also organize workshops
on cervical cancer and the screening services for Nurses so that they can be equipped with
new trends on cervical cancer and preventive strategies.
5.4.2 Nursing Administration
Nurses as educators, have a primary role in IEC which is supposed to be given to patients on
a daily basis, this is not happening due to staff shortages, instead the Community Health
Workers give IEC most of the time. Therefore it is imperative that the Nursing management
improves on staffing levels so that sufficient time is allocated to IEC. Nurses should be
trained in preventive strategies of cervical cancer and the available screening methods such
as Visual Inspection with Acetic acid (VIA). With the availability of Cancer Disease
Hospital at the University Teaching Hospital in Lusaka where various forms of cancers are
61
being treated cervical cancer inclusive, the Ministry of Health in conjunction with other
stakeholders like CIDRZ should scale up the screening services like VIA to other areas so
that many women can have an opportunity to be screened for cervical cancer.
5.4.3 Nursing Education
Since cervical cancer is the second most common cancer among women in the world, it's
important that all the women become aware about cervical cancer and the screening cervices
available. This implies that a comprehensive component on cervical cancer and screening
services be included in the Nursing curriculum. This will help students acquire adequate
knowledge on the risk factors, signs and symptoms, available screening methods and other
preventive strategies to enable them educate women on cervical cancer and screening
services wherever they are go to work. They will be equipped with adequate skill to enable
them work efficiently.
5.4.4 Nursing Research
The study has revealed that the majority 34(68%) of the respondents had not been screened
for cervical cancer and as shown from literature, screening is effective in reducing the
incidence and mortality due cervical cancer. It is important that a study on factors
influencing uptake of cervical cancer screening is undertaken. When these factors are
identified, there would be coordinated effort from various stakeholders in the fight against
cervical cancer in order to address these factors and enhance uptake of cervical cancer
screening services.
5. 5 RECOMMENDATIONS
In view of the findings of this research study, the following recommendations were made to
the Center for Infectious Disease Research in Zambia (CIDRZ), Ministry of Health, Lusaka
District Health Management Team (LDHMT) and the Health Care Providers.
•
Center for Infectious Disease Research in Zambia (CIDRZ)
CIDRZ should scale up the cervical screening service to other areas other than Lusaka so
that women from other districts can have the opportunity to be screened.
62
Currently screening is only done in three districts which are Lusaka, Kafue and Monze.
They should also train Nurses who have other specialties like Operating Theatre Nurses
(OTN) in VIA screening methods not only midwives in order to improve staffing levels.
Additionally, they should also introduce the outreach programmes using mobile clinics
in order to extend the services to the areas that are not being served. This would enable
women in such areas to have access to information on cervical cancer and screening
services and can be screened as well.
•
Ministry of Health
The Ministry of Health should lobby for more cooperating partners and international
organizations such the Johns Hopkins Program of International Education in
Gynecology and Obstetrics (JHPIEGO) which is implementing visual inspection
screening programmes in other countries like Ghana and Planned Parenthood
Association of Zambia (PPAZ), an organization which promotes the wellbeing of
mothers by offering safe motherhood, to supplement what CIDRZ is doing. The new
method of cervical cancer screening (VIA) should be promoted since Pap test has proved
to be expensive, takes long and it's not available in most of the health facilities. This
would help increase the access of cervical cancer screening services by women. The
Ministry of Health should also increase funding to cervical cancer prevention
programme since its one of the major threats to women's health. They should also come
up with education programmes which will target women in schools, colleges, churches
and market place. This will increase awareness of cervical cancer and screening services
to women and also the consequences of not screening.
•
Lusaka District Health Management Team (LDHMT)
The Lusaka District Health Management Team (LDHMT) should train more Community
Health Workers (CHW) in skills and knowledge of cervical cancer and screening
services that will help in giving IEC to women in the community. They should also
provide (I.E.C) materials which are simple to use and are interpreted in the local
languages so that more women are able to read.
63
•
Health Care Providers
Health Care Providers at Ng'ombe Health Center especially nurses, should take a lead in
the prevention of cervical cancer. They should make use of every opportunity to educate
women on cervical cancer and screening services at every gathering. They should also
be actively involved in research activities so that the findings can be used to improve on
the means and ways of preventing cervical cancer, to find ways of capturing many
women to screen for cervical cancer and also to make recommendations to policy
makers on prevention of cervical cancer.
5.6 DISSEMINATION OF FINDINGS
The findings of this study will be disseminated through summaries of the research findings
and recommendations to the LDHMT, policy makers and other interested organizations such
as CIDRZ. The researcher also intends to have a meeting with Ng'ombe Health Center
members of staff to inform them of the study findings and the recommendations.
A copy of the research findings will be submitted to University of Zambia, Department of
Nursing Sciences and Medical library.
5.7 LIMITATIONS OF THE STUDY
•
The study targeted only women of 35 years and above which was difficult to capture
as most women who were going to the clinic were in their twenties.
•
The research study on knowledge and acceptability targeted only women accessing
care at Ng'ombe Health Center but the health workers point of view was not
considered. For more studies on knowledge and acceptability of cervical cancer, the
health workers perspective should be considered was well.
•
The study was conducted within a short period of time which made it impossible for
the researcher to conduct the research on a bigger scale.
•
The study sample was small; therefore the study findings cannot be generalized to
the larger population of Zambia.
64
•
There was limited published literature on knowledge and acceptability of cervical
cancer screening in Zambia as a result much of the literature review was from other
countries.
5.8 CONCLUSION
The study sought to determine the knowledge and acceptability of cervical cancer screening
among women in Ng'ombe community, Lusaka.
The study comprised five chapters of which chapter one covered introduction, background
information, statement of the problem, factors influencing acceptability of cervical cancer
screening, justification of the study, research objectives stating of the hypothesis, definition
of terms and identification of variables and their cut off points. Chapter two covered
literature review on cervical cancer screening globally, regionally and locally. Chapter three
was research design, chapter four was presentation of findings and chapter five was
discussion of research findings. The study addressed three specific objectives which were: to
assess the knowledge of the cervical cancer screening among women in Ng'ombe
community, to determine the acceptability of cervical cancer screening among women in
Ng'ombe community and to identify barriers to cervical cancer screening. All the three
specific objectives were met.
The study findings revealed that slightly above half 28(56%) of the respondents had low
knowledge of cervical cancer and screening services. It also revealed that majority 34 (68%)
of the respondents had never been screened for cervical cancer. The study further showed
that the majority 6(86%) of the respondents who had not accepted cervical cancer screening
services had low knowledge of cervical cancer and the screening services. The study
findings revealed that there was a relationship between knowledge of cervical cancer and
acceptability of cervical cancer screening as the majority of the respondents who had not
accepted cervical cancer screening had low knowledge of cervical cancer and screening
services. This fails to reject the researcher's hypothesis which states that there is a
relationship between knowledge of cervical cancer and acceptability of cervical cancer
65
screening. According to the study, there was no relationship between acceptability and level
of education as the majority of the respondents who had accepted cervical cancer screening
were those who had primary education.
66
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73
APPENDIX: I
CONSENT FORM
My name is Nelly Kalonga, lam a student at the University of Zambia; School of Medicine
in the Department of Nursing Sciences pursuing a Bachelor of Science Degree in Nursing.
In partial fulfillment of this degree program, lam required to undertake a research project.
My topic is "Awareness and Acceptability of Cervical Cancer Screening". The main
objective is to determine the Awareness and Acceptability of Cervical Cancer Screening
among women aged 35 years and above in Ng'ombe community.
You have been randomly selected to participate in this study. I wish to inform you that
participation is voluntary and you are free to withdraw at any stage of the study if you so
wish. During the interview you will be asked questions on Awareness and Acceptability of
Cervical Cancer and Screening. Your name will not appear on the interview schedule and
the information will be treated as confidential.
You will not receive any direct benefit from the study like monetary gain. Nevertheless, the
information will be used to influence policy making regarding ways and means of improving
the Awareness and Acceptability of Cervical Cancer Screening among women.
If you have any questions, please contact me on cell number 0977-702161.
I (name)
On
understand the purpose of this study and lam willing to participate.
Signature / thumb print of participant
Signature of interviewer
74
2010, declare that I
APPENDIX: II
UNIVERSITY OF ZAMBIA
SCHOOL OF MEDICINE
DEPARTMENT OF NURSING SCIENCES
STRUCTURED INTERVIEW SCHEDULE
TOPIC
KNOWLEDGE AND ACCEPTABILITY OF CERVICAL CANCER SCREENING
AMONG WOMEN AGED 35 YEARS AND ABOVE IN NG'OMBE COMMUNITY
DATE OF INTERVIEW
INTERVIEW SCHEDULE NUMBER
LOCATION
INSTRUCTIONS FOR INTERVIEWER
1. Introduce yourself to the respondent and explain the purpose of the study
2. Assure the respondent of confidentiality
3. No name should appear on the interview schedule
4. Tick responses in the box next to your choice
5. Write responses to open ended questions in the space provided
6. Thank the respondent at the end of the interview
75
for
SECTION A
DEMOGRAPHICAL DATA
1. How old were you on your last birthday?
2. What is your marital status?
a) Single
b) Married
c) Divorced
d) Widowed
e) Separated
3. What is your religion?
a) Christian
b) Islam
c) Hindu
d) Others (specify)
4. How far did you go in your education?
a) None
b) Primary
c) Secondary
d) Tertiary
76
official
use
5. Do you have children?
a) Yes
b)No
6. If yes to question 5, how many children do you have?
7. At what age did you experience first sexual intercourse?
SECTION B
KNOWLEDGE ABOUT CERVICAL CANCER AND SCREENING
8. Have you ever heard of cervical cancer?
a) Yes
b)No.
9. If yes to question 8, where did you hear about cervical cancer?
a) Health facility
c) Media
d) Friends / relatives
e) Others, specify.
10. Describe what cervical cancer is in your own words.
77
11. Mention some of the risk factors to developing cervical cancer.
12.
Mention signs and symptoms of cervical cancer.
13.
Do you know how cervical cancer can be detected?
a) Yes
b)No
c) I don't know
14.
If yes to question 13, how can cervical cancer be detected?
a) Through blood test
b) Screening test for cervical cancer(VIA)
c) Urine test
d) Others specify
15.
Where can screening for cervical cancer be done?
78
SECTION C
ACCEPTABILITY OF CERVICAL CANCER SCREENING.
16. Have you ever had a test for cervical cancer?
a) Yes
b)No
17. Give reasons for your answer to question 16.
18. Did you decide to go for a test on your own?
a) Yes
b)No
19. Give reasons for your answer to question 18.
20. Where was it done?
a) At the clinic
b) At the hospital
c) Others, (specify)
21. How was the test done?
79
22.
Do you think testing for cervical cancer is important?
a) Yes
b)No
23.
Give reasons for your answer to question 22.
24. Do you have any intentions of going for a test/ again?
a) Yes
b)No
25. Give reasons for your answer to question 24.
26. Would you encourage your friend to go for a test?
a) Yes
b)No
27. Give reasons for your answer to question 26.
80
SECTION D
BARRIERS TO CERVICAL CANCER SCREENING
28. Are there difficulties in accessing screening for cervical cancer?
a) Yes
b)No
29. If your answer to question 28 is yes, which ones? (Tick)
a) Fear of being diagnosed with cancer
b) Location
c) Embarrassment
d) Stigma
e) Staff attitude
f) Others (specify).
THANK YOU FOR YOUR TIME AND COOPERATION
81
APPENDIX: III
MEASURE OF STUDY VARIABLES
VARIABLE
QUESTION NUMBERS
CATEGORIES
Knowledge
8
Low - 0-5
High -6- 15
Total -15
9
10
11
12
13
14
Acceptability
Not accepted -0-2
16
22
24
Accepted - 3-4
26
Total -
82
5
The University of Zambia
School of Medicine
Department of Nursing Sciences
7th October 2010.
The District Director of Health,
Lusaka DHMT,
Lusaka.
UFS: The Head - Department of Nursing Sciences
P.OBoxSOllO
Lusaka
Dear Sir / Madam,
RE: REQUEST FOR PERMISSION TO CONDUCT A RESEARCH STUDY
lam a fourth (4th) year student pursuing a Bachelor of Science Degree in Nursing at the
above mentioned school. In partial fulfillment for the award of the degree, lam required to
undertake a research project. My research topic is 'Knowledge and Acceptability of Cervical
Cancer Screening'. The purpose of writing this letter is to ask for permission to conduct a
pilot study at Mtendere Health Center and the actual research study at Ng'ombe Health
Center. I intend to interview women aged 35 years and above from 7th October to 7l
November 2010.
Your consideration towards this request will be highly appreciated.
Yours faithfully,
Nelly Katanga.
4th Year BScN Student.
83
;ox 50S27
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2(,« I \ i-.'.JiSSS-t
2<M ~i\ \ 2H»|2 l >
Republic oJ'Ziuiibia
MINISTRY OF HEALTH
^_
LUSAKA DISTRICT HEALTH MANAGEMENT TEAM
15thOctober,2010
The Health Centre In-Charges
Ngombe and Mtendere Health Centres
LUSAKA.
Dear Sir/Madam,
RE:
REQUEST FOR PERMISSION TO CONDUCT A RESEARCH AT NGOMBE
AND MTENDERE HEALTH CENTRES.
This serves to introduce Nelly Kalonga a fourth year student at the University of Zambia
and is asking for permission to conduct a pilot study on Awareness and Acceptability of
Cervical Cancer Screening at Mtendere Health Centre and the actual research Study
Ngombe Health Centre. She intends to interview women aged 35 years and above from
7th October to 7th November 2010.
Could you please assist her accordingly.
Yours faithfully,
LUSAKA URBAN
Q3*MANAGEMENT
DISTRICT HEALTH
TEAM
1
vf
Dr. C. Mbwili-Muleya
District Medical Officer
cc.
Nelly Kalonga.
2010 -10- 1 5
,-.„.„„., „„„»,„..,,]
DISTRICT
DIFtECTOR OF HEALTH
APPENDIX: IV
WORK PLAN
NO
TASK
TO
BE DATES
RESPONSIBLE PERSON/DAY
PERFORMED
1
Literature review
Continuous
2
Finalizing and hand in 24th
Researcher
Continuous
2010 Researcher
May
Collect first draft from 28th
September Researcher
1 day
2010
the supervisor
5
REQUIRED
25th October 20 10
research proposal
4
PERSON
and 8th October 2010
Researcher
1 day
th
Collect final copy from 11 October 2010 Researcher
2 day
Submit
second
final copy for making
6
supervisor
8
Conducting pilot study 7th October 2010
Researcher
2 days
of 11th October 2010
Researcher
30days
20thDecember
Researcher
21 days
Researcher
and 21 days
and pilot analysis
9
Data
collection
actual study
10
Data analysis
2010 to
10th January 20 11
11
Report writing
11th January 20 11
research
12
Submit first draft copy 3 1st January 20 11
84
Researcher
Iday
of report to supervisor
14
Collect first draft of 14mFebruary2011
Researcher
Iday
report from supervisor
15
Working on the final 21st
copy
February Researcher
2011
and 14days
research
supervisor
16
Submitting two bound 28th
19
Iday
coordinator
2011
copies for marking
18
February Supervisor/course
Collect comments from 08th march 20 11
Researcher
the supervisor
supervisor
Submit corrected copy 15th March 20 11
Researcher
1 day
to
supervisor
and Iday
for
approval
20
Final binding
29th April 20 11
Researcher
46 days
21
Submit five (5) bound 06th May 20 11
Researcher
1 day
copies
85
APPENDIX: V
GANTT CHART
TASK
RESPONSIBL
PERFORMED
E PERSON
MAY JUN
JUL
AU
SEPT
G
OC
NO
DE
T
V
C
JAN
FEE
MAR APR MAY
Finalizing research Researcher and
proposal
f
Literature review
supervisor
Pilot study
Researcher
Data collection
Researcher
researcher
*•
•*
4.
._, _
—
Data analysis
Researcher and
supervisor
Report writing
Researcher/supe
rvisor
Submission of
Researcher
research report
—
86
Final
corrections Researcher
and binding
^
and supervisor
Submission of five Researcher
-— •
copies
Dissemination
of Researcher
findings
r
—
87
APPENDIX: VI
BUDGET FOR A RESEARCH STUDY
NO
1
ITEM
QUANTITY
UNIT
COST
IN
TOTAL
KWACHA
COST
for 3 reams
K30,000.00
K90,000.00
3
K5,000.00
Kl 5,000.00
1
K 150,000.00
Kl 50,000.00
1 packet
K12,000.00
K12,000.00
1 packet
K6,000.00
K6,000.00
3
K3,000.00
K9,000.00
3
K2,000.00
K6,000.00
3
K7,000.00
K21.000.00
2
K5,000.00
Kl 5,000.00
1
Kl 8,000.00
Kl 8,000.00
1 packet
K45,000.00
K45, 000.00
1
K30,000.00
K30,000.00
1 box
K8,000.00
K8,000.00
1
K65,000.00
K65,000.00
STATIONARY
a) Bond
paper
typing
b)/ Notebook
c)/ Flash disk
d)/ Pens
e) Pencils
f) Sharpener
g)
o/ Eraser
h) Markers
i)/ Diskettes
j) Tipp-ex
k) Flip charts
1) Stapler
m) Staples
n) Calculator
o) Ruler
88
p) Box file
1
K3,000.00
K3,000.00
q) Cello tape
1
K25,000.00
K25,000.00
1
K10,000.00
Kl 0,000.00
r)
K528,000.00
SUBTOTAL
2
SECRETARIAL
SERVICES
a) Typing
research
50 pages
K2,500.00
K125,000.00
7 pages
K2,500.00
Kl 8,000.00
Kl,500.00x350
K525,000.00
90 pages
K2,500.00
K225,000.00
90 pages
K200 x 90 x 4 copies
K72,000.00
K20,000.00 x 4
K80,000.00
K60,000 x 4 copies
K240,000
proposal
b) Typing
research
questionnaires
c) Photocopying
of 7 pages x 50
questionnaires
d) Typing
of
the
research report draft
e) Typing
final
research report
f) Photocopying
of 3 reports
research report
g) Binding
research
K60,000 each
report
Kl,285,000.00
Subtotal
89
3
FIELD EXPENSES
a) Lunch
allowance 12 days
K50,000.00
K600,000.00
1 day
K50,000.00 x3 days
Kl 50,000.00
Iday
K20,000 x 3
K60,000.00
12 days
K20,000.00 x 12
K240,000.00
Iday
K20,000.00 x 3
K60,000.00
for the researcher
b) Lunch
allowance
for the assistants
c) Training
two
assistants
d) Transport
for
researcher
e) Transport for the
assistants
K200,
f) Dissemination
of
000.00
refreshments for
findings to the staff.
for K200,000.00
10
members.
Subtotal
Kl,310,000.00
SUB GRAND TOTAL
K3,120,000.00
CONTINGENCY FUND
K312,000.00
10%
K3,432,000.00
GRAND TOTAL
90
BUDGET JUSTIFICATION
FIELD EXPENSES
The researcher will need money to use for transport to and from the research setting as well as
money for lunch. The researcher will need money for training the research assistants for a day
and for dissemination of the research findings.
STATIONARY
The researcher will need stationary to conduct the research. Paper will be needed for printing,
pens and pencils for writing, Tipp-ex and erasers for making corrections, flip charts for drawing
up the data master sheet. The flash disc and diskettes will be used for storage of information.
The researcher will also need a stapler, staples for securing paper together and box files for
filling research documents.
SECRETARIAL SERVICES
Secretarial services will be needed for typing the research proposal, printing and photocopying of
the research proposal, research reports and appendices, the questionnaire and binding the five (5)
research reports.
10% CONTINGENCY OF TOTAL AMOUNT
10% of the total budget has been set aside to cater for unseen circumstances and possible
inflation increase.
*Property of UNZA Library