|Year : 2015 | Volume
| Issue : 1 | Page : 34-38
Awareness and utilization of Papanicoloau smear among health care workers in Maiduguri, Nigeria
Maisaratu Bakari1, Idris Usman Takai1, Mohammed Bukar2
1 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
|Date of Web Publication||8-May-2015|
Idris Usman Takai
Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Context: Cervical cancer is the leading cause of cancer related deaths among women in developing countries. Lack of awareness and comprehensive cervical cancer screening programmes offered in most developing countries are partly responsible for the high burden of disease. In developed countries, routine use of Papanicoloau smear, in part, has led to a decline in cervical cancer incidence and mortality. Objective: To determine the level of awareness, utilisation and factors associated with awareness of Pap smear test as a tool for cervical cancer screening among health care workers (HCW) in Maiduguri north-eastern part of Nigeria. Subjects and Methods: This was a cross-sectional questionnaire based study conducted among 150 health care workers in Maiduguri, between January and March 2010. Simple descriptive statistics was employed in the analysis of data. Results: A total of 150 participants were recruited for the study. The majority (141) of respondents were aware of Papanicolaou smear and 23.3% of the female respondents had done the test previously. Majority (90.8%) of the men were willing to pay for their spouses to do the screening; some of them (20.0%) were indifferent if their spouses perform the cervical screening without their consent. The major reason given for carrying out the test was for prevention of the disease. The major source of information was the hospital (84.7%). Majority of the women were willing to do the test if offered the opportunity either free (70.6%) or with payment (29.4%). A number of socio-demographic variables played crucial roles in awareness and utilisation of Pap smear. These included higher level of educational status ( P = 0.000) of the respondents, increased maternal age ( P = 0.001) and high parity ( P = 0.003). Conclusion: There is poor utilisation of Pap smear among HCW despite high level of awareness and availability of screening services. A number of socio-demographic variables play crucial roles in awareness of Pap smear. The reasons for the low utilisation among health care workers, who are the custodians of health care need to be investigated to improve their utilisation of Pap smear.
Keywords: Knowledge, pap smear, utilisation
|How to cite this article:|
Bakari M, Takai IU, Bukar M. Awareness and utilization of Papanicoloau smear among health care workers in Maiduguri, Nigeria. Niger J Basic Clin Sci 2015;12:34-8
|How to cite this URL:|
Bakari M, Takai IU, Bukar M. Awareness and utilization of Papanicoloau smear among health care workers in Maiduguri, Nigeria. Niger J Basic Clin Sci [serial online] 2015 [cited 2019 Dec 13];12:34-8. Available from: http://www.njbcs.net/text.asp?2015/12/1/34/156682
| Introduction|| |
Cervical cancer remains a major health issue among women in developing countries especially in sub-Saharan Africa. It is the second most common malignancy in women worldwide ,, ; however it is the most common cause of cancer related morbidity and mortality in women in the developing countries.  Worldwide, there are over 500,000 new cases and 250,000 deaths each year, 80% of which occur in developing countries. ,,,,
Cervical cancer is the commonest malignancy of the female genital tract in Nigeria, accounting for 70.5% of gynaecological malignancies in Maiduguri, 59.2% in Kano, 77% in Zaria, 60% in Ilorin, 74% in Jos, and 74.6% in Benin. ,,,,, Data from Kenya  , Zimbabwe  and Ghana  have shown that cervical cancer accounted for 57.8%, 70-80% and 80% of gynaecological cancers respectively. Cervical cancer is a preventable, detectable and curable disease which develops from pre-existing, slow growing intraepithelial precursor lesions known as cervical intraepithelial neoplasia (CIN). The association between cervical cancer and human papilloma virus (HPV) has been established and nearly all cervical cancers are directly linked to previous infections with one or more of the oncogenic types of HPV. 
The prolonged phase of pre-malignancy and the accessibility of the cervix provide the opportunity for screening to effectively detect the disease during the pre-invasive phase, thereby allowing for early treatment and cure. Cervical cancer death rates therefore remain very high in developing countries like ours due to limited access to health care and cervical cancer screening facilities, and where such facilities are available studies have shown that they are poorly utilized. 
Various screening methods are available for detecting the pre-invasive lesions of the cervix. These include cytological screening, human papilloma virus DNA testing, visual inspection (down staging), visual inspection with acetic acid or Lugol's iodine, cervicography, speculography and polar probe. , The Papaniculoau (Pap) cervical smear is the gold standard and has become the main stay of population based prevention programmes. , It is a highly specific screening test with estimates in the range of 98-99%, and sensitivity of 50-80%. , The Pap test is the only test known to reduce cervical cancer incidence and mortality in programmes, especially organized screening programmes. It is the most effective prevention technique available today and is used worldwide. ,
Regular screening with Pap smear reduces the mortality from cervical cancer. Systematic screening programmes being implemented by developed countries have resulted in the reduction of morbidity and mortality from cervical cancer ,, It has been reported that both organized and opportunistic cytological screening tests have lowered the incidence rates of cervical cancer.  Various factors like non availability, poor accessibility, poor quality of care provided, lack of adequate information to the women, as well as cultural and behavioural barriers are responsible for the very low level of cervical screening up-take in developing countries. , Studies have reported high level of awareness of cervical cancer and cervical cancer screening tests amongst health workers in Nigeria, as seen in Abuja, Ilorin, Jos, and Enugu. ,,, However surveys among non-health workers showed poor knowledge and utilisation of cervical screening. ,,
In view of the very high incidence of cervical cancer and its associated morbidity and mortality in the general population and Maiduguri in particular, this study Was done to explore the level of awareness and utilisation of Pap smear test as a screening test for cervical cancer among health care workers in Maiduguri, a locality where facilities and personnel exist for the detection and treatment of the pre-invasive stage of cervical cancer. This will help in improving the available health preventive campaign in the state and the country at large. The aim of the study was to determine the level of awareness, utilisation and factors affecting awareness of Pap smear tests among health care workers in Maiduguri north-eastern part of Nigeria.
| Subjects and methods|| |
This cross‐sectional study was conducted in Maiduguri metropolitan council in Borno state, among HCW, from January to March 2010. The study protocol was approved prior to the implementation of the study by the ethical committee of Borno state ministry of health. HCW refers to all professional health staff like doctors, pharmacists, nurses, laboratory scientists and non- professionals such as medical records, cleaners and porters. A total of 150 HCW who accepted to participate in the study were recruited from four hospitals. A validated structured questionnaire was used for this study. The questionnaire contained questions which sought to determine the socio-demographic characteristics of the respondents, knowledge of Pap smear, attitude towards, as well as utilisation of Pap smear test. Help was given to some of the women in the interpretation and administration of the questionnaires especially to those who could not read and/or write well. Methodology, purpose of the study and assurance of confidentiality were fully explained to the participants and the research assistants who assisted in data collection before administration of the questionnaires. A minimum sample size was calculated using a standard formula for known population size for a cross sectional study (Yamane Formula)  , and was found to be 135. However, to overcome risks of non-responses or poorly answered questionnaires and since convenience sampling was used to interview the participants 15 extra questionnaires were distributed, and this brought the sample size to 150 participants.
The data were analysed using SPSS (Version 16 Inc., Chicago, USA 2006). The initial analysis was by generation of frequency of various variables. Further analysis involved the use of cross tabulations to explore statistical relationships between variables. The level of significance was put at P ≤ 0.05. Results are presented in tabular form.
| Results|| |
A total of 150 HCW who accepted to participate in the study filled the questionnaires giving a response rate of 100%. There were 85 (56.7%) females and 65 (43.3%) males. One hundred and forty one (94.0%) were aware of Pap smear as a screening test but only 35 (23.3%) of the female respondents had done the test previously. A number of socio-demographic variables play crucial roles in awareness and utilisation of Pap smear. Higher level of education (P = 0.000), increased maternal age (P = 0.001) and high parity (P = 0.003) were significantly associated with increased level of awareness and utilisation of Pap smear tests. [Table 1] describes the socio-demographic characteristics of the respondents. The respondents were within the age range of 21-60 years with highest number (24.0%) of the respondents in the 31-35 years age‐group. One hundred and twenty four were married (82.7%) with 82 (54.7%) in a monogamous setting while 42 (28%) in polygamous setting. Twenty three (15.3%) were single, 1.3% (2 respondents) were divorced and 0.7% (1 respondent) widowed. Thirty three (22%) of the respondents were multiparous. Fifty (33.3%) of the male respondents and 70 (46.7%) of the female respondents had tertiary education. Majority (74%) were Muslims.
[Table 2] details the cadres of the HCW. Forty seven (31.3%) were nurses, 33 (22.0%) doctors, 19 (12.7%) lab scientists, 6 (4.0%) were pharmacists. Forty five (30.0%) of the respondents were other cadres of HCW including porters, medical records, cleaners, nurse assistants and X-ray technicians.
[Table 3] shows willingness to the utilisation of Pap smear tests by the HCW. Among those HCW who were able to screen themselves, 18 (51.4%) had actually gone to have the test done on their own, while the remaining were done on physician request. The major reasons given for carrying out the test were for prevention of the disease. Sixty (70.6%) will avail themselves for Pap smear if offered free and only 25 (29.4%) will avail themselves for Pap smear if they have to bear the costs of the test.
| Discussion|| |
The key to success of cervical cancer screening programme is awareness and utilisation. Unfortunately, this study shows that the vast majority (94.0%), of the respondents were aware of cervical cancer screening but utilisation was poor. The finding on awareness is in keeping with 93.5%, 87%, 79.8%, 72.9%, 69.8% and 64% reported among health workers in Abuja, Ilorin, Nnewi, Jos, Zaria, and Benin respectively. ,,,,, It is however higher than 32% reported from Nairobi  , 18.7% reported from Ibadan  , and 19% reported from Jos.  These differences may probably be because health care workers are expected to have no barrier access to medical information at all times. This study showed that the Pap smear utilisation was very low, despite the high levels of awareness as only 23.3% of the female health care workers had undertaken the test previously. Although our data showed that 51.4% of those who had the test were self-referred there could have been low and/or poor referral by the attending physicians. This is in keeping with a study from Abuja  among health care workers in which 62.5% of respondents requested for the test and the most frequent reasons given by the women for not doing the test was lack of physician referral. Similarly, the reality in most developing countries especially in sub-Saharan Africa is that the populace are still unaware of cervical cancer screening, and even among those who are aware, previous studies have reported a wide disparity between knowledge and utilisation of Pap smear screening test even among health personnel. ,, The 23.3% utilisation of Pap smear in our study is comparable with the 22% reported from Nairobi  , but is higher than 9.6% reported from the Abuja series  , 0.3% from Ilorin  , 5.7% from Nnewi  , 19% from Jos  , 5.2% from Ibadan  and 11.5% from Maiduguri.  Lack of physician request and lack of awareness were the major reasons advanced for not doing the test in those series. There is therefore the need for proactive reproductive health campaigns on the need for health care workers to improve on opportunistic screening of women and improve referral.
A number of socio-demographic variables play crucial roles in awareness of Pap smear. Higher level of Education, increased maternal age and high parity of the HCW were significantly associated with increased level of awareness and utilisation of Pap smear tests when compared with those that did not. Awareness and utilisation was significantly higher among respondents who were above 30 years and among those with tertiary education. This is in keeping with previous reports. ,,,,,,,, There was no significant difference with respect to cadre of HCW, marital status, sex, religion or nature of marriage between those who had previously done Pap smear screening test and those that did not.
While majority of the female health care workers in our series did the test for preventive reason, various reasons for not doing the test were advanced in previous reports including lack of awareness, not susceptible to the disease or gave no reason for not taking the test. ,,,, This will have negative consequences for screening to effectively detect the disease during the pre-invasive phase, therefore patients may present in advanced stage making treatment or cure difficult. Most of our female respondents were willing to have Pap smear screening if offered the opportunity to do so. This contrasts with studies among health workers in Ilorin where majority (77.4%) would not like to be screened.  Some have recommended risk scoring in selecting women for cervical cancer screening in developing countries with many competing health needs.  This study was limited by its cross-sectional nature and convenience sampling. It was also limited by the fact that reasons for non-utilisation of Pap smear were not explored. The study was conducted in an urban area and among HCW where socio-economic status of the respondents is better. Community based study in these regards is recommended and this should include rural arrears. There is need for an aggressive awareness campaign about cervical cancer and its prevention as well as the establishment of well‐organised screening programmes in Nigeria.
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[Table 1], [Table 2], [Table 3]