KNOWLEDGE AND ACCEPTABILITY OF CERVICAL CANCER SCREENING AMONG FEMALE PART-TIME STUDENTS IN UNIVERSITY OF BENIN

CHAPTER ONE
INTRODUCTION
BACKGROUND OF STUDY
Cervical cancer is the most common malignancies among females worldwide especially in women of 20–39 years of age. Its contribution to cancer burden is significant across all cultures and economies. Cervical cancer also accounts for over 270,000 deaths worldwide, an overwhelming majority of which occur in the less developed regions (Imam, 2008). Globally there are over 500,000 new cases of cervical cancer annually and in excess of 270,000 deaths, accounting for 9% of female cancer deaths. 85% of cases occur in developing countries and in Africa (Campbell, 2008). Cervical cancer remained the second leading cause of cancer deaths after breast cancer and the fifth most deadly cancer in women, accounting for approximately 10% of cancer deaths (Okonofua, 2007).  The developing countries have carried a disproportionate share of the burden and 80 % of the 250,000 cervical cancer deaths in 2005 occurred there (WHO, 2007; Uysal & Birsel, 2009). Cervical cancer is the malignant cancer of cervix uteri or cervical area. This happens when normal cells in the cervix change into cancer cells (Arbyn, 2005). 
Human Papilloma Virus (HPV) infection is a necessary factor in the development of nearly all cases of cervical cancer. Sexually transmitted human papilloma virus infection leads to the development of cervical intraepithelial neoplasia and cervical cancer (Colgan, 2006).  HPV is spread through sexual contact and although most women’s bodies can fight the infection, sometimes the virus leads to the development of cervical cancer. HPV types 16 and 18 cause 70% of cervical cancer cases, whereas types 6 and 11 cause 90% of genital warts cases. During persistent HPV infection, precancerous changes may be detected in the cervix, that is, readily detectable changes occur in the cells lining the surface of the cervix, therefore early detection and treatment of these changes is an effective strategy for the prevention of cervical cancer and forms the basis of cervical screening programmes (Stephen, 2006). Women with many sexual partners, and those whose partners have had many sexual consorts, or have been previously exposed to the virus, are most at risk of developing the disease (WHO, 2007).
In developed countries of Europe and America that have organized national cervical screening programs, early detection and treatment of precancerous cervical lesions have resulted in a dramatic reduction in the incidence of and mortality from cervical cancer (WHO, 2007). Pap smear screening can identify potentially precancerous changes. Treatment of high grade changes can prevent the development of cancer. Cervical cancer is a major risk in women today especially at the age of 20years and above. Awareness of screening programme, preventive vaccination and diet are preventive measures that reduce the incidence of cervical cancer. In developed countries, the widespread use of cervical screening programmes has reduced the incidence of invasive cervical cancer by 50% or more (Population Reference Bureau, 2005).
Cervical cancer is the most common genital tract malignancy of women living in poor rural communities of developing countries (Ferlay, 2006). Such populations lack cervical screening facilities and other basic infrastructural and human resources essential for effective primary healthcare delivery. Symptoms of cervical cancer include; vaginal discharge containing blood, abnormal vaginal bleeding, pelvic pain, blood in urine, bowel symptoms, blood in stool, painful sex, unusual vaginal bleeding, unusual vaginal discharge, contact bleeding, vaginal mass, moderate pain during sexual intercourse, loss of appetite, weight loss, fatigue. Others are loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, swollen leg, heavy bleeding from the vagina and leaking of urine or faeces from the vagina in advanced cases (Duncan, 2005).
Cervical cancer incidence and mortality rates have declined substantially in Western countries following the introduction of screening programmes. The ideal ages of women for screening are 30– 40 years owing to high risk of precancerous lesions due to being sexually active; and a precancerous lesion is detectable for 10 years or more before a cancer develops (Olamijulo, 2005). Although it has been already proven that the efficiency of regular pap tests reduced the mortality rate of cervical cancer, its application in the developing countries is less compared with the developed countries. 
The lack of knowledge concerning cervical cancer may be related to this fact (Yaren, 2008). In developed countries, the widespread use of cervical screening programmes has reduced the incidence of invasive cervical cancer by 50% or more. Cervical cancer is one of the most preventable of all cancers through primary and secondary prevention, prophylactic Human Papilloma virus (HPV) vaccination and cervical screening (Ezem, 2006) 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 / Institute Catald'' 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).The hardest - hit regions are 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.  
Furthermore, WHO 2008 asserted that 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).  More 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, Lacoste, McCormick, 2005). Possible reasons for a low participation in cervical cancer screening include; ignorance of the existence of such test, ignorance of importance of screening or lack of risk awareness and the risk factors to the development of cervical cancer, absence of symptoms and lack of awareness of centers where such services are obtainable, and lack of motivation to get screened (Aniebue & Aniebue 2010)          
STATEMENT OF THE PROBLEM
The level of awareness and utilization of cervical cytology services among women in the country is unclear as there is no reliable population – based cancer registry or prevention program databases, and very few regional – based studies have been reported in the country. (Gharoro & Ikeanyi, 2006).  Cancer prevention program in UBTH has recorded various degrees of successes, and limited to opportunistic screening until the establishment of Centre for Disease Control (CDC) in UBTH in 2006. What has been the norm is that women are screened when they attend for other gynaecological complaints during clinic visits and consultations. (Gharoro & Ikeanyi, 2006). A search of literatures revealed that there are little evidence studies done on knowledge and acceptability of cervical cancer screening in the university of Benin community. One of such studies is the study carried out by Gharoro and Ikeanyi in 2006 on appraisal of the level of awareness and utilization of the pap smear as a cervical cancer screening test among female health workers in University of Benin Teaching Hospital. The study revealed that a large number of the female health workers were aware of the disease, cervical cancer and pap test availability in the hospital, yet, the screening uptake was abysmally poor. Base on this gap in studies done on cervical cancer screening, the situation warrants a detailed study on the knowledge and acceptability of cervical cancer screening among Female Part- Time Students in University of Benin.    
OBJECTIVES OF THE STUDY
Specific objectives
1.     To determine the knowledge of cervical cancer screening among  Female Part-       Time Students in University of Benin.
2.     To determine the acceptability of cervical cancer screening among  Female Part-     Time Students in  University of Benin.
3.     To identify barriers to cervical cancer screening service.        
SIGNIFICANCE OF THE STUDY
Center for Disease Control (CDC) in University of Benin Teaching Hospital has recorded low utilization of cervical cancer screening service since the inception of the programme; 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 are little evidence studies done on knowledge and acceptability of cervical cancer screening in University of Benin Community. 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 Female Part- Time Students in University of Benin. 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.
RESEARCH QUESTIONS
1.      What is the level of cervical cancer awareness among the respondents?
2.      What is the level of acceptability of cervical cancer screening?
3.      What are the barriers to cervical cancer screening?
HYPOTHESIS
There is no relationship between knowledge of cervical cancer and acceptability of cervical cancer screening.
LIMITATIONS OF THE STUDY
1.   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.
2.   There was limited published literature on knowledge of cervical cancer and cervical cancer screening in Nigeria, as a result much of the literature review was from other countries
SCOPE OF STUDY
Research setting is the physical location and conditions in which data collection takes place in the study, (Polit & Beck, 2008). The research setting can be seen as the physical, social, and cultural site in which the researcher conducts the study (Bhattacharya, 2008).The area of study is the University of Benin, Benin City, Edo state. University of Benin, Benin City, is geographically located at Ugbowo Community, in Ovia North East Local Government Area of Edo State. University of Benin is situated on 1,748 hectares of land along Benin – Lagos Highway. It shares a main boundary with University of Benin Teaching Hospital and Isiohor community. University was founded in the year 1970; her motto is “knowledge for service”. It is made up of 10 faculties namely; Agriculture Arts, Education, Engineering, Law, Life Science, Management Science, Pharmacy, Physical Science, Social science and School of Basic Sciences, College of Medicine and Dentistry.    
CONCEPTUAL DEFINITIONS OF TERMS  
Cervical cancer: Cervical cancer is a cancer of the cervix or neck of the uterus (Altaian & Sarg, 2006).
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 & Beer, 2007).
Pap smear: Pap smear is the cytological gynecologic test that examines the structure, function, pathology and chemistry of the cell (Black & Hawks, 2005)
Knowledge: Information, understanding, or skill that you get from experience or education.
Awareness of something: the state of being aware of something (Merriam _ Webster Dictionary).
Acceptability: Acceptability is a state of welcoming something or acknowledging something (Geddes and Crosset, 2006).      
OPERATIONAL DEFINITION TERMS
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.
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.
Cervical cancer: In this study, cervical cancer means a growth or a sore on the cervix or uterus.