AWARENESS OF CERVICAL CANCER RISK FACTORS AND UTILIZATION OF PAP SMEAR SCREENING AMONG PRIMARY SCHOOL FEMALE TEACHERS IN TESO NORTH SUB-COUNTY, KENYA

BY:

JAKAIT NANCY AKISA

A research thesis submitted to School of Public Health, Department of Epidemiology and Statistics in partial fulfillment of the requirement for the award of the

Degree of Master of Public Health,

Moi University, Eldoret.

JUNE, 2018

DECLARATION

RESEARCHER

This thesis is my original work and has never been presented for the award of any degree in any institution/university.

JAKAIT NANCY AKISA

SPH/PGH/05/12

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SUPERVISORS

“This thesis has been submitted to Moi University for examination with our approval as the university supervisors”.

PROFESSOR DAVID AYUKU PhD

Department: Behavioral Science

Signature ----------------------------Date ---------------------

Moi University, Eldoret, Kenya

DR. OMENGE ORANG’O (MMED)

Department: Obstetrics & Gynecology

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Moi University, Eldoret, Kenya

DEDICATION

I dedicate this thesis to my husband Mr. Machio, my parents and my son Ethan for their continuous support both emotionally and financially enabling me to complete my master’s degree.

ACKNOWLEDGEMENT

First of all I would like to thank the almighty God for the far he has brought me through my research process.

Secondly, I thank my family for their continuous support both financially and morally. Thirdly, I thank my lecturers for taking me through research methods course, my colleagues for their support and ideas and the entire community of Moi University.

I also wish to express my sincere gratitude to my supervisors for their commitment, guidance, support and encouragement towards my research work.

Last but not least, I also thank the people in the ministry of education Teso north for helping me with required information.

ABSTRACT

Background: Pap-smear, a cytological screening has been one of the most successful public health measures for preventing invasive cervical cancer since it enhances early detection of premalignant changes to cervical cells prompting treatment. Contributing factors to successful screening; thus reduction in morbidity and mortality of cervical cancer are people’s knowledge about the disease, its risk factors and prevention through screening. With the increasing burden of cervical cancer among women in the developing countries, it is important to ascertain people’s knowledge on cervical cancer and screening practices.

Objectives: To assess the level of knowledge of cervical cancer, its risk factors, and practices of Pap smear screening among female teachers in Teso North sub-county.

Methods: A cross-sectional study design was employed to conduct this research. Categorical variables were summarized as frequencies and the corresponding percentages. Continuous variables were violated the Gaussian assumptions thus summarized as median and the corresponding inter quartile range. Gaussian assumptions were assessed using Shapiro Wilk test for normality. Results were presented using tables and graphs.

Results: Cervical cancer and Pap smear awareness was 92.6% and 70.8% respectively with 35.3% identifying HPV as a predisposing factor to cervical cancer. Less than half of participants mentioned sexual contact as the means of transmission of HPV, 66.3% correctly identified the use of Pap smear and 16.8% had done Pap smear. More than half of the participants believed they were at risk of getting cervical cancer with 82.8% believing cervical cancer can be prevented.

Conclusion: Despite of adequate knowledge on cervical cancer and risk factors, uptake of Pap smear test was very low among primary school teachers. This resulted from inadequate information on pap-smear test itself.

Recommendations: More campaigns should be done on awareness of pap-smear and sensitization of women on importance of screening in order to attain the World Health Organization (WHO) recommended screening rate of >80%.

Ministry of health should ensure screening services are made locally available, accessible and affordable to all women country wide.

Research should be done on the general population to establish awareness of cervical cancer risk factors and uptake of pap-smear.

TABLE OF CONTENTS

DECLARATION	ii

DEDICATION	iii

ACKNOWLEDGEMENT	iv

ABSTRACT	v

LIST OF TABLES	ix

LIST OF FIGURES	x

ABBREVIATIONS	xi

OPERATIONAL DEFINITION OF TERMS	xii

CHAPTER ONE	1

1.0 INTRODUCTION	1

1.1 BACKGROUND OF THE STUDY	1

1.2 Problem statement	4

1.3 Justification of the study	4

1.4 Research question	5

1.4.1 Broad objective	6

1.4.2 Specific objectives	6

CHAPTER TWO	7

2.0 LITERATURE REVIEW	7

2.1 The burden of cervical cancer in Sub- Saharan Africa	7

2.2 Awareness of cervical cancer and its risk factors.	7

2.3 Awareness of cervical cancer prevention and practice of Pap smear screening	11

CHAPTER THREE……………………………………………………………………………..17

3.0 METHODOLOGY	17

3.1 Study area	17

3.2 Study population	17

3.3 Study design	18

3.4 Sample size determination	18

3.5 Sampling techniques	19

3.6 Study variables	19

3.6.1 Dependent variable: Pap-smear practice	19

3.6.2 Independent variable: Awareness of cervical cancer, its risk factors and preventive measures like pap-smear.	19

3.7 Data collection technique	19

3.8 Data processing and analysis	20

3.9 Inclusion criteria	20

3.10 Exclusion criteria	20

3.11 Ethical consideration	21

CHAPTER FOUR	22

4.0 RESULTS	22

4.1 Socio-demographic characteristics of respondents	22

4.1.1. Age groups	22

4.1.2. Marital status	23

4.1.3. Number of children	24

4.1.4. Age at first sexual contact, sexual partners, family planning, smoking and family type	25

4.2. Awareness of cervical cancer and its risk factors	27

4.3 Knowledge on Pap smear and locally available screening methods	32

4.4 Practices regarding Pap smear	33

CHAPTER FIVE:………………………………………………………………………………..47

5.0: DISCUSSION	47

5.1: Socio-Demographic factors	47

5.2: Awareness of cercial cancer and its risk factors	47

5.3: Knowledge of preventive measures and practice of pap smear	50

CHAPTER SIX	55

6.0: CONCLUSION AND RECOMMENDATIONS	55

6.1: Conclusion	55

6.2: Recommendations	55

REFERENCE	56

APPENDICES	64

APPENDIX I: INFORMED CONSENT	64

APPENDIX II: QUESTIONNAIRE	65

APPENDIX III:MAP OF TESO NORTH SUB-COUNTY	71

LIST OF TABLES

Table 1: Age at first sexual contact, sexual partners, family planning, smoking and family type	26

Table 2: Knowledge on cervical cancer	28

Table 3: Knowledge on signs and symptoms of cervical cancer	29

Table 4: Knowledge on the prevention of cervical cancer	30

Table 5: Knowledge on the available treatments options	31

Table 6: Knowledge on Pap smear among those who know about cervical cancer	32

4.4 Practices regarding Pap smear	33

Table 8: Recommended age for doing Pap smear screening	35

Table 9: Relationship between Knowledge of cervical cancer and demographic and clinical characteristics	36

Table 10: Knowledge on cervical cancer, and risk factors and symptoms of cervical cancer	37

Table 11: Relationship between Pap smear, and demographic and clinical characteristics	39

Table 12: Knowledge on Pap smear, and risk factors and symptoms of cervical cancer	41

LIST OF FIGURES

Fig 4.1: Distribution of participants by age groups	23

Fig 4.2: Distribution of participants by marital status	24

Fig 4.3: Distribution of participants by the number of children they have	25

ABBREVIATIONS

GAVI- Global Alliance for vaccine & immunization

HPV-Human Papillomavirus

HIV-Human Immunodeficiency virus

IEBC- Independent electoral and boundaries commission

WHO- World Health Organization

CIN- Cervical intraepithelial neoplasia

ICC- Invasive cervical cancer

MTRH- Moi Teaching & Referral Hospital

KNH- Kenyatta National Hospital

IREC- Institutional Research and Ethics Committee

OPERATIONAL DEFINITION OF TERMS

Cervix: The lower narrow part of the uterus connecting it the vagina.

Cervical cancer: This is a malignant disease characterized by progressive and abnormal growth of cervical cells. The disordered squamous epithelium resulting from disruption of the process of metaplasia is referred to as cervical intraepithelial neoplasia (CIN). CIN is a precursor to invasive cancer (Monga, 2006).

Cervical intraepithelial neoplasia (CIN): Refers to the disordered squamous epithelium resulting from disruption of the process of metaplasia.

Pap-smear: Pap-smear is a microscopic examination of cells taken from the cervix that detects premalignant changes to the cells that may lead to cervical cancer. It is a painless procedure where the cervix is visualized using a speculum and a layer of cells removed from the cervix for microscopic examination. It is recommended for all women aged 21 years and above. (Fraser et al, 2006).

Awareness: Having knowledge of or understanding of a subject, issue or situation (Macmillan dictionary).

Knowledge: Facts, information and skills acquired through experience or education; the theoretical or practical understanding of a subject. Correctly define cervical, identify risk factors, its treatment and prevention.

Practice: The actual performance of an activity in a real situation (Macmillan dictionary). Those who have done pap smear screening test.

Mortality: Relative death rate; the proportion of deaths at a particular time and place (Basavanthappa, 2008).

Morbidity: Relative disease rate expressed as incidence or prevalence of a disease (Basavanthappa, 2008).

Disease incidence: The number of new cases of a specified disease or condition (Basavanthappa, 2008).

Non-communicable disease: This is a disease that cannot be transmitted from one person to another (Basavanthappa, 2008).

CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Cervical cancer is the fourth most common form of cancer among women worldwide with 527,624 new cases diagnosed and the fifth leading cause of cancer-related deaths in females worldwide with an estimated 275,008 new deaths in 2012 (Ferlay et al, 2013). Cervical cancer comes fourth after breast, lung, and colorectal cancers and fifth leading cause of death after breast, lung, colorectal and stomach cancers (Torre et al, 2012).

Cervical cancer is the leading cause of cancer death among females in developing countries with 86% of the global burden and over 88% of the deaths representing 13% of all female cancers occurring in less developed regions (Ferlay et al, 2013). World Health Organization (WHO) projected that without changes in prevention and control measures, the global estimates of cervical cancer are expected to rise to 720,415 new cases and 394,905 deaths by 2025 due to cervical cancer in less developed regions meaning 36% & 44% global increment in new cases and deaths respectively (WHO, 2012). This should draw attention of all nations towards prevention and control of cervical cancer to prevent further increments. Nearly 60- 75% of women in Sub-Saharan Africa who develop cervical cancer live in rural areas whereby many of them are diagnosed at an advanced stage of the disease because of lack of awareness of early signs and symptoms and many go untreated with survival rate being 21% in 2002 compared with 70% & 66% in the united states and western Europe (Anorlu, 2008; Atara, 2012). Factors that contribute to the high incidence and mortality rate of cervical cancer in developing countries include; lack of awareness of cervical cancer among populations, absence or poor quality of screening programmes for precursor lesions and early-stage cancer; in women who have never been screened before cancer tends to be diagnosed in its late stages when it is less easily treatable, limited access to health care services and lack of functional referral systems (WHO, 2006).

The risk factors associated with cervical cancer include; Human Papillomavirus (HPV) infection, multiple sexual partners, early age at the time of first sexual intercourse, high parity, low socio-economic status, immunosuppression (HIV), family history, oral contraceptives and smoking (Fraser et al, 2006). HPV as the primary cause of cervical cancer accounts for 99.7% of all cervical cancer with about 70% of cases caused by HPV types 16 and 18 (National cervical cancer prevention plan, strategic plan, 2012). HPV infection is endemic in Africa due to the socio-cultural practices that women are exposed to e. g early marriages, polygamous marriages and high parity causing frequent exposure to the infection (Anorlu, 2008; Atara, 2012). The prevalence of HPV in Sub-Sahara Africa is estimated to be 24% ranging between 17.4% in South Africa to 33.6% in Eastern Africa (Adewole et al, 2013).

In Kenya, cervical cancer is the first most frequent cancer among women and the leading cause of cancer deaths in women of reproductive age (Bruni et al, 2016). The high cervical cancer mortality rate creates a heavy burden on the country depriving it of part of its workforce as women die at an early age. The Kenya cancer statistics & National Initiative report (2010), indicates that over 60% of Kenyans affected by cancer are younger than 70 years with the leading and commonest cancer in female being cervical cancer at 25 per 100,000 women. In general, cancer is the 3rd leading cause of morbidity in the country (7% of deaths per year) after infectious diseases & cardiovascular diseases (Kenya cancer statistics & National Initiative report, 2010). In 2006, around 2,354 women were diagnosed with cervical cancer and 65% of these died of the disease because 70-80% of cancers in the country are diagnosed at advanced stages. This is different from the situation in developed countries like America where most are diagnosed early when treatment is more effective (Kenya cancer statistics & National Initiative report, 2010). Annually, the number of cervical cancer cases diagnosed are 4802 with deaths of 2451 and cervical cancer screening coverage of 3.5% for all women 25-64years in 2012 (Bruni et al, 2016). The current screening coverage in Kenya is far much below the 70% screening rate aimed at by the ministry of health. The burden of HPV infection type 16 and 18 among women with cervical cancer in Kenya was found to be 61.4%. Other risk factors were as follows; Oral contraceptives 7.2%, HIV prevalence 5.2%, high parity 4.6% and smoking 2.2% (Bruni et al, 2016). Kenya like any other developing countries is faced with the challenges in the management of cervical cancer whereby patients present at late stage of the disease, low levels of knowledge of cervical cancer and screening services and poor attitude towards screening procedures (Kivuti et al, 2013). The implementation of national screening program in the country is still a challenge thus screening only occurs in few selected sites and disjointed projects rather than a fully-fledged national level program and Pap-smear which is commonly used in the country for cervical cancer screening is limited to urban areas only (National cervical cancer prevention plan, strategic plan, 2012). This statistics indicate that the burden of the disease is equally felt in Kenya as the rest of the world and calls for aggressive campaigns on cervical cancer awareness and its prevention and also increased coverage of screening services in order to help reduce the disease burden in the country

1.2 Problem statement

Cervical cancer is one of the non-communicable diseases that has become of great concern to public health. The factors contributing to cervical cancer being a major problem among females in the country may be due to inadequate knowledge about the disease and its risk factors and lack of access to preventive services such as screening with Pap-smear. Despite aggressive campaigns having been done around the country concerning cervical cancer awareness and its prevention, there is still a rise in number of cases being diagnosed annually. This implies that many women are still not knowledgeable about cervical cancer and its risk factors including preventive measures and those who have the knowledge do not practice or do not have access to preventive measures. It is documented that 80-90% of sexually active women have the probability of acquiring HPV infection of the genital tract at some stage in their life and the persistence of the infection is related to development of invasive cervical cancer (Monga, 2006) thus all women are at risk of developing the disease. In Kenya, coverage of only 3.5% screening for all women 25-64 years has been recorded (Bruni et al, 2016).

1.3 Justification of the study

Knowledge on the risk factors is of paramount importance as it leads to avoidance of the same and creates awareness on individual’s risk of acquiring the disease due to expose to the risks. This will prompt early screening leading to early detection and treatment of the premalignant lesions.

In most societies, it is rare to miss a teacher compared to other professions. Due to their position in the society as the elite/working group, they tend to be neglected assuming that they are knowledgeable in all aspects of life. This results from the fact that most of them are economically empowered and can afford to buy televisions, radio, phones ect thus assumed to be exposed to information through the media thus most health projects that are rolled out are not targeting teachers yet they are equally affected and continue to die from cervical cancer due to lack of knowledge. In order to answer this question, female teachers will be studied to ascertain their knowledge regarding cervical cancer, its risk factors practice of Pap smear screening. This study focused on female teachers rather than both male and female since cervical cancer affects the female population directly.

Knowing the teachers’ level of awareness on cervical cancer is of great importance because through the information obtained from this study, the concerned agencies and other organizations dealing with policy making shall be informed so as to formulate appropriate programs for the teachers to increase knowledge on cervical cancer and its prevention.

1.4 Research question

What is the level of knowledge of cervical cancer, its risk factors and uptake of pap-smear screening services among female teachers in Teso north sub-county?

1.4.1 Broad objective

The main objective of this study is to assess the level of awareness of cervical cancer risk factors, its prevention and uptake of Pap smear among primary school female teachers in Teso North sub-county.

1.4.2 Specific objectives

To assess knowledge of primary school female teachers in Teso north sub-county on cervical cancer and its risk factors.

To determine the level of knowledge of Pap smear screening and other screening methods available locally among female primary school teachers in Teso north sub-county.

To determine uptake of Pap smear screening of primary school female teachers in Teso north sub-county as a means of cervical cancer prevention.

CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 The burden of cervical cancer in Sub- Saharan Africa

Sub-Saharan Africa includes Eastern, Middle, Southern and Western regions of Africa. In Sub-Saharan Africa, 34.8 new cases of cervical cancer are diagnosed per 100,000 women annually and 22.5 per 100,000 women die from the disease compared with 6.6 and 2.5 women respectively in North America (GLOBOCAN, 2012). In a study done in the United States, HPV type detected in invasive cervical cancer were HPV 16 (53.2%), HPV 18 (13.1%) and HPV 45 (6.1%) (Wheeler et al, 2009). The high-risk of HPV infection is most common in young women with peak prevalence as high as 25-30% in women under 25years of age (WHO, 2006).

Many women are affected at the prime of their lives, thus affecting the socio-economic well-being of their families.

2.2 Awareness of cervical cancer and its risk factors.

Knowledge of cervical cancer and its risk factors is still poor among female populations in Africa contributing to the low uptake of preventive methods such as Pap smear screening.

Studies done among female teachers on awareness of cervical cancer and its risk factors revealed the following. A study done in Nigeria among secondary school teachers revealed their certainty that cervical cancer is common 44.5% (Adenkale et al, 2011). A study done among primary school female teachers in Kasarani Kenya indicated that 87% of respondents were aware of cervical cancer with 39% mentioning HPV infection as a risk factor to developing cervical cancer. Other risk factors mentioned were; multiple sexual partners, oral contraceptives, family history, early sexual debut, poverty and high parity (Ombech et al, 2012). 74.6% were aware of cervical cancer with only 30.2% mentioning HPV as a risk factor and commonest risk factors were multiple sexual partners and early age at first sexual intercourse. Main source of information was media (Ubajaka et al, 2015). Another study done among primary school female teachers in Nigeria revealed only 6.4% felt they were at risk of cervical cancer and 59.6% had no idea of any symptom of cervical cancer. Risk factors mentioned by a small proportion were HPV 8.5% and smoking 9.8% (Adogu et al, 2015). In India among college teachers revealed that the mostly identified risk factors were; smoking 53%, family history 45% and genital hygiene 36% with non mentioning HPV as a risk factor. Symptoms of cervical cancer were less known to the participants7% (Shankar et al, 2015).

Teachers are not the only ones affected but the problem of poor or inadequate information regarding cervical cancer cuts across the entire general population in developing countries. This has led to poor uptake of existing preventive measures resulting in increased burden of the disease. A study done at KNH in-patients revealed that patients who were aware of cervical cancer were more likely to have had a Pap smear test in the past (Gichangi et al, 2003).

A study done in ever-married Jordanian women, 33.3% had previously heard about cervical cancer (Amarin et al, 2008). A Cameroon survey on attitudes and knowledge revealed that only 28% of women had prior knowledge of cervical cancer (Tebeu et al, 2008). Another study done in South Africa among students clearly revealed that this population is at high risk due to indulgence in early sexual relationships with multiple sexual partners at 51.2% & 19.2% respectively. 42.9% had heard of cervical cancer and of these, 15.6% did not know any risk factors for cervical cancer, 58.6% who knew risks did not know that cervical cancer is preventable (Hoque, 2009). A study done among slum-dwellers in Lagos indicated that out of 4.2% who were aware of cervical cancer, none of them believed they were at risk of developing the disease (Balogun et al, 2011).

In a study done among Tanzanian women, 78.6% of the respondents had poor knowledge, 19.7% had satisfactory knowledge and 1.6% had good knowledge of cervical cancer. Risk factors identified among this population were multiple sexual partners, early sexual initiation HIV infection and smoking. This population was certain that cervical cancer can be prevented though screening and early treatment which includes surgery, chemotherapy and radiotherapy (John, 2011). In Kenya, a study done at Moi Teaching & Referral Hospital (MTRH) while assessing perceptions of risk & barriers to cervical cancer screening revealed that 22.8% felt that they were at risk of cervical cancer (Were et al, 2011). A study done in Qatar revealed 80% had heard of cervical cancer with main source of information being relatives and friends. Knowledge was higher among those aged 30-49, married > 15 years, parity >4 and university degree. P- 0.05 (Al-Meer et al, 2011). In a study done in Okada community among women, 91.1% had never heard of cervical cancer with only 6.5% felt they were at risk of cervical cancer (Igwilo et al, 2012). Another study done in Nigeria revealed that 50.9% reported having heard of cervical cancer with 12.6% believing the disease is treatable and it could be prevented 45.6%. Risk factors associated with cervical cancer among this population were multiple sexual partners, early sexual initiation, smoking, oral contraceptives, high parity and HIV/AIDS (Hyacinth et al, 2012).

In all of the above studies, none of them revealed HPV infection being mentioned by participants as a primary risk factor to cervical cancer. This leaves a gap in knowledge in association between HPV infection and cervical cancer in relation to other risk factors.

Recent studies have shown a great improvement in knowledge in terms of awareness of the disease and its risk factors. A study done by Ndlovu et al (2011) showed that 60.9% of the participants knew cervical cancer can be prevented and that they are at risk of the disease (60.8%). In a study done among Kenyan women by Sudenga et al ( 2013) showed that 92% of the participants believed that cervical cancer was curable if detected early with most women (65%) acknowledging that they were at risk for cervical cancer. Some of the risk factors mentioned in a study done among health professionals in Nairobi by Kanyori, 2014 were; HPV infection only 36%, family history 19%, multiple sexual partners 16%, immunosuppression 13%, smoking 8%, oral contraceptives 3%, early pregnancy 3%, and low socio-economic status 3%. In a study done among MTRH staff, participants acknowledged that cervical cancer can be prevented 90%, curable illness 64.9% and can be treated 76.7% (Bwombengi, 2014).

This information should raise an alarm across all continents on the target groups for cervical cancer awareness campaigns. All age groups should be involved to prevent young girls from early and frequent exposure to HPV infections due to indulgence in early sex which later may result in cervical cancer as earlier documented that 80-90% of sexually active women have the probability of acquiring HPV infection of the genital tract at some stage in their lives and persistence of genital HPV infection is specifically related to development of cervical cancer (Monga, 2006).

More work needs to be done on cervical cancer awareness in developing countries especially rural areas to ensure that all women have been reached with this important message on cervical cancer.

Kenya, being among the developing countries is quite disadvantaged in terms of resources and there might be some parts of the country where cervical cancer information has not reached especially the marginalized communities. This is why more research should be done to explore cervical cancer awareness.

2.3 Awareness of cervical cancer prevention and practice of Pap smear screening

The purpose of screening for cervical cancer is for early detection of premalignant changes to cervical cells thus initiation of early treatment leading to prevention of invasive cervical cancer. Most Sub-Saharan Africa countries have not embraced the idea of screening due to inadequacies thus are far much below the WHO recommendations of > 80% screening coverage, appropriate follow-up and management of patients with positive tests (Adewole et al, 2013). Knowledge on existing screening methods, its availability, accessibility and importance of screening may not have reached entire African populations resulting in low uptake of available screening methods. A comprehensive review of literature indicated that cervical cancer screening coverage in Sub-Sahara Africa ranges from 2.0% to 20.2% in urban areas and 0.4% to 14.0 in rural areas (Louie et al, 2009). In Kenya, the main challenges to increasing cervical cancer screening coverage include; low level of community awareness on importance of screening coupled with low knowledge on common risk factors, low knowledge on common symptoms of cervical cancer, inadequate skills among service providers, inadequate equipment and supplies, lack of treatment facilities when there is pre-cancer of cancer diagnosis (National cervical cancer prevention plan, strategic plan, 2012).

Several studies have been done among female teachers which have revealed very low uptake of Pap smear screening for cervical cancer. A study done among female teachers in Nigeria by Adenkale et al (2011) showed that only 5.4% had done pap smear with majority of participants mentioning lack of awareness of the test and not knowing where it could be done as the major reasons for not doing the test. Those with good knowledge, multiple sexual partners and polygamous marriages were more likely to screen. Another study done among female secondary school teachers showed 41.5% were aware of Pap smear with 20.5% having done Pap smear (Ubajaka, 2015). According to Adogu et al (2015) 75% of female primary school teachers studied had not heard of preventive measures to cervical cancer and only 0.4% had screened for cervical cancer. In Kenya, 41% had done Pap smear test with similar reasons for not doing the test being mentioned by teachers (Ombech et al, 2012). A study in Tanzania among primary school teachers revealed that only 21% reported ever being screened with multiparous and those with multiple sexual partner having the likelihood of screening more than others (Neema et al, 2015).

Teachers are not the only profession affected by low uptake of screening services like Pap smear. Naturally, health care providers are expected to be in the front line in the fight against cervical cancer by screening themselves first before even advising patients to do so but in developing countries it is not happening. Despite having adequate knowledge regarding risk factors, signs & symptoms and prevention of cervical cancer, there is still lack in utilization of Pap smear screening services. In a survey done among nurses in rural Turkey, 53.6% of the participants had never been screened. Reasons for this were forgetfulness, embarrassment and lose of virginity (Ertem, 2009). Another survey done among nurses in a regional hospital in Tanzania revealed that 116 of the 13 respondents had never done a pap smear reasons given were, 54.7% not knowing where to go for the test, 13.1% being afraid of the procedure and 7.3% being afraid of bad results (Urusa & Daris, 2011). Still in India, only 11% of the nurses surveyed had ever undergone a pap smear test on themselves reasons being, 61% did not feel they were at risk, 24% said they had no symptoms, 1% thought it would take away their virginity, 6% felt it was embarrassing and 3% were afraid of possible outcome (Ekta et al, 2012). In a study done in two hospitals in Nairobi, 44 % of health professionals had not done Pap smear test. Some of the barriers sited were; lack of time and forgetfulness, feeling shy and embarrassed, inhibiting cost, fear of outcome and procedure and lack of appropriate place to do the test (Kanyori, 2014). Among staff at MTRH, 42.9% female staff had screened and 30.9% male staff whose spouses had screened for cervical cancer. It also revealed that increasing age increased the chance of cervical cancer screening (Bwombengi, 2014).

Studies done among the general population showed no better results. In ever-married Jordanian women, 48.8% knew about Pap smear test, only 14.3% had ever done Pap smear of which 95.4% of them were opportunistic and only 5.6% reported having regular tests (Amarin et al, 2008). Another study done in Ethiopia among reproductive health clients showed that 81.2 % had never heard of Pap smear screening, only 0.5% had ever had a pap smear test reasons being no gynecological symptoms (41.2%), don’t know where it is done (32.4%), wait till older (14.7%) and consider it not important 11.8% (Yifru & Asheber, 2008). In Ghana, a study was done among college students which showed that out of 140 students interviewed; only 12% had done prior Pap smear screening. This population was unaware of any local screening initiatives and only 7.9% were aware of the link between HPV and cervical cancer (Abotchie & Shokar, 2009). A study done among Turkish women demonstrated that having knowledge of cervical cancer disease is influential on the habit of having Pap smear test; 68.5% of the participants had done Pap smear, 86.5% of those who had Pap smear had accurate knowledge of the disease (Aynur & Aylin, 2009). A study done by Hoque (2009) showed 41.9% of students had heard of pap smear, 38% correctly identified its use and 9.8% had done the test citing reasons for not doing the test as fear of procedure, cultural and religious reasons and not felt ill.

Another study in South Africa among rural women showed that only 18.8% of the respondents reported ever screening for cervical cancer, 71.4% who had never screened reported lack of information as a barrier to screening. Having educational background seemed to increase the likelihood to screen; twice if a woman had primary education (OR 2.0) and almost three times if a woman had secondary or higher education (OR 2.67); 93% of the respondents showed willingness to screen in the future and 60.3% considered themselves at risk for cervical cancer (Ndlovu, 2011). Among Zimbabwean women, 91% of rural female participants had never done Pap smear screening, 81% had no previous knowledge of cervical cancer screening while 80% expressed positive belief about cervical cancer screening (Mupepi et al, 2011).

In Tanzanian, only 14.2% had ever been screened with majority sighting lack of knowledge, fear of pain, feeling shy and test being expensive as reasons for not doing it and 55.7% of the respondents being positive about cervical cancer and screening for malignant cervical lesions (John, 2011). In a study done in Nigeria, Okada community among women, 3.2% had heard of Pap smear test, 6.6% felt they were at risk of and were willing to do Pap smear and take the vaccine if it was available. None had been screed for cervical cancer (Igwilo et al, 2012). In Kenya, a study done at Moi Teaching & Referral Hospital (MTRH) while assessing perceptions of risk & barriers to cervical cancer screening revealed that 12.3% had screened before, and 65% wished to be screened. Barriers included fear of bad results and lack of finances and increasing age increased the chances of screening (Were et al, 2011). In another study by Hyacinth (2012), 50% had heard of Pap smear and only 10.2% had done the test. Reasons cited for not doing the test were inability to locate the facility, not having information about the test, fear of bad results and not felt at risk of cancer. Another study done among Kenyan women by Sudenga et al, (2013) showed that only 6% of the respondents had ever been screened for cervical cancer. In Qatar, 39.4% had done Pap smear, 62.4% believed Pap smear can detect cancer and it could improve treatment outcome and 85.5 % would do Pap smear in future (AL- Meer et al, 2015).

The above cited figures for developing countries are far much lower than those in developed countries like United States where recent survey conducted to assess awareness and use of pap test among women revealed that 96.7% of respondents had heard of pap smear, 93.0% reported having received a pap smear test and over 80% who knew it is used to screen for cervical cancer (Hawkins et al, 2011). Even among the Vietnamese-American women who are considered to have low rates of Pap smear test awareness and practice there is still higher rates compared to women in developing countries, 74.0% had heard of Pap smear, 76% had done the test at least once with 42% of those who had not done the test considering obtaining one (Tung et al, 2002).

CHAPTER THREE

3.0 METHODOLOGY

3.1 Study area

This study was conducted in Teso north sub-county located in Busia County. Teso north sub-county has a population of 117, 947 with an area of 257.10 Sq. Km (IEBC, 2013), It has about 80 primary schools with a total population of about 400 female primary school teachers (Teso North sub-county education office data base, 2014). The main economic activity in the region is small scale farming with majority of the people taking education as a profession. The study area being on the border with Uganda, there are a lot of activities along the border leading to young girls engaging in early sexual activities and others engaging in extramarital affairs with multiple sexual partners. Teso north sub-County is one of the underdeveloped and poverty striken areas in the country with little resource directed towards medical research thus a lot of research has not been done in the region especially gynecological which include cervical cancer. The only sub-county referral hospital (Kocholyia) does not offer screening services for cervical cancer. Suspected patients are often referred to the county referral hospital or Moi Teaching & Referral hospital for further diagnosis and management.

3.2 Study population

The study population comprises of female primary school teachers in Teso north sub-county aged 21years and above.

3.3 Study design

A cross-sectional study design was adopted to look into knowledge of cervical cancer risk factors and practice of Pap smear.

3.4 Sample size determination

Data found on a similar study done in Kenya on awareness of cervical cancer risk factors and practice of Pap smear testing among female primary school teachers in Kasarani division Nairobi showed the level of awareness of cervical cancer to be 87% (Ombeche et al, 2012).

Given that Kasarani is an urban area we would assume that the level of awareness in the rural setting, Teso North sub-county, would be lower than that of Kasarani.

Thus in order to be 95% sure that the level of knowledge of cervical cancer risk factors, its prevention and practice of Pap smear among female teachers in Teso North sub-county is within plus or minus 5% of the assumed prevalence rate of 87% we estimated the sample size using the following formula (Cochran, 1963).

Where

P- Is the assumed level of awareness of cervical cancer, - is the margin of error equal to the 5% used in this case and - is the quantile of the standard normal distribution.

Correcting this sample size for a finite population size of 400 female primary school teachers, it results in the following number of participants to be studied.

3.5 Sampling techniques

A total of 122 subjects were randomly sampled. A list of all female primary school teachers was obtained from the ministry of education Teso north sub-county data base. Teachers were then sample using simple random sampling approach using their personal identification numbers. We think this number is sufficient based on representativeness, and resources available, including time

3.6 Study variables

3.6.1 Dependent variable: Pap-smear practice

3.6.2 Independent variable: Awareness of cervical cancer, its risk factors and preventive measures like pap-smear.

3.7 Data collection technique

Pilot study was done to test for the feasibility of the study and data collection tool.

Self-administered questionnaires were used for data collection. The questionnaires were administered to the randomly sampled female teacher who filled them and returned immediately. The questionnaire contained information on demographic data, knowledge on cervical cancer, its risk factors, Pap smear and other preventive measures and practices regarding Pap smear.

3.8 Data processing and analysis

The questionnaires were checked for completeness; data was coded and entered into STATA version 13 SE data base for analysis. Questionnaires were kept in a safe cabinet under a lock. Data analysis was done using STATA version 13 SE. Categorical variables were summarized as frequencies and the corresponding percentages. Continuous variables were violated the Gaussian assumptions. Therefore they were summarized as median and the corresponding inter quartile range. Gaussian assumptions were assessed using Shapiro Wilk test for normality. Association between categorical variables was assessed using Pearson’s Chi Square test while association between continuous and categorical variables was assessed using two sample Wilcoxon rank sum test. Results were presented using tables and graphs.

3.9 Inclusion criteria

All female teachers aged 21 years and above.

3.10 Exclusion criteria

Anyone diagnosed with cervical cancer prior to the study.

3.11 Ethical consideration

Approval from the institutional research and ethics committee (IREC) was obtained.

Permission from education officer in Teso north sub-county for conducting the study was obtained.

A consent form was provided for the participants. The purpose and benefits of the study to the participants was explained including potential risks to the participants if any. Rights of the participants in the study were explained which included right to privacy, confidentiality, anonymity and freedom to choose to participate in the study or refuse to participate and freedom to withdraw from the study at any time without any consequences. No participant was allowed to write their name on the questionnaire for purposes of anonymity.

Scientific ethics was upheld when referring to other author’s publications

CHAPTER FOUR

4.0 RESULTS

4.1 Socio-demographic characteristics of respondents

The information included; age, marital status, number of children, age at first sexual conduct, family planning methods, smoking and family type.

4.1.1. Age groups

The figure 4.1 below represents findings on distribution of participants by age groups.

Fig 4.1: Distribution of participants by age groups

Two thirds of the participants, 83 (68%), were aged below 40 years with only one tenth aged at least 51 years. Meaning the majority of the participants were young and energetic necessary for production and growth of the country’s economy.

4.1.2. Marital status

The findings below represent participants’ distribution in terms of marital status: Single, married, divorced, separated, widow and single parents. Figure 4.3

Fig 4.2: Distribution of participants by marital status

Over two thirds of the participants were married (72.1%) while the rest were either single, single parent, separated or widowed (14.8%, 0.8%, 4.9% & 7.4% respectively).

4.1.3. Number of children

High parity is among the risk factors for acquisition of HPV leading to the development of cervical cancer. The figure 4.4 below represents distribution of participants in terms of the number of children they have.

Fig 4.3: Distribution of participants by the number of children they have

Half of the participants had one to three children. 36.1% had more than three children which were still a higher figure considering the sample size imposing a greater risk to the population.

4.1.4. Age at first sexual contact, sexual partners, family planning, smoking and family type

The table below represents findings on age at first sexual intercourse, sexual partners, and family planning, smoking and family type.

Table 1: Age at first sexual contact, sexual partners, family planning, smoking and family type

Variable	Sample size	Levels	n(%) or Median (IQR)
Age at first sex	122	20.0 (18.0, 23.0)
None	9 (7.4%)
Number of sex partners	122	One	99 (81.2%)
More than one	14 (11.5%)
None	43 (35.3%)
Injection	43 (35.3%)
IUCD (Coil)	4 (3.3%)
Family planning	122	Pills	9 (7.4%)
Jadelle	14 (11.5%)
Withdrawal	5 (4.1%)
Condom	4 (3.3%)
Ever Smoked	122	1 (0.8%)
Type of family	103	Monogamous	74 (71.8%)
Polygamous	29 (28.2%)

The median age at first sex was 20.0 (IQR: 18.0, 23.0) years with a minimum and a maximum of 11 and 35 years respectively. Ninety nine or 81.2% of the participants had one partner.

Over half of the participants used some family planning method. Use of injection accounted for 35.3% while use of IUCD, pills or Jadelle accounted for 22.2%. Only 0.8% of the participants had ever smoked and majority had monogamous family.

4.2. Awareness of cervical cancer and its risk factors

This includes findings on participants who have heard of cervical cancer, source of information, gender affected by cervical cancer, perception of risk of getting cervical cancer, predisposing factors, signs & symptoms, prevention and treatment.

Table 2: Knowledge on cervical cancer

Variable	Sample size	n (%)
Heard about cervical cancer	122	113 (92.6%)
Source of information
Media	113	70 (62.0%)
Doctors/Nurses	113	35 (31.0%)
Friends	113	19 (16.8%)
Family member	113	6 (5.3%)
School	113	14 (12.4%)
CHW	113	18 (15.9%)
Posters and Adverts	113	12 (10.7%)
Gender affected by Cervical Cancer
Male	1 (0.8%)
Female	122	111 (91.0%)
Both sexes	5 (4.1%)
Don’t know	5 (5.1%)
Believe you are at risk of cervical cancer	122	90 (73.8%)
Believe cervical cancer can be treated	122	83 (68.0%)
Acquisition of cervical cancer
Sexual contact	58 (47.5%)
Curse	122	4 (3.3%)
Don’t know	60 (49.2%)
Predisposing factors to cervical cancer
Smoking	46 (37.7%)
HPV infection	43 (35.3%)
Early sex	122	51 (41.8%)
Multiple partners	92 (75.4%)
HIV Infection	49 (40.2%)
Don’t know	4 (3.3%)

There were 113 (92.6%) participants who knew about cervical cancer. Of this number, 70 (62.0%) got the information from media while 35 (31.0%) got information from the doctors or nurses. Others got information from friends, family members, school, and CHWs.

Five, 5.1%, had no knowledge on who is affected by cervical cancer. Ninety, 73.8% of the participants believed they were at risk of cervical cancer and 83 (68.0%) believed that cervical cancer can be treated.

Slightly less than 50% knew the mode of acquiring cervical cancer. The predisposing factors that were highly supported were smoking (37.7%), HPV infection (35.3%), early sexual intercourse (41.8%), having multiple partners (75.4%), and HIV infection (40.2%). Only 3.3% did not know the predisposing factors.

Nearly half of the participants, 60 (49.2%), did not know how cervical cancer can be acquired.

Table 3: Knowledge on signs and symptoms of cervical cancer

Signs and Symptoms of cervical cancer	Sample size	Strongly Agree	Disagree	Don’t know
Vaginal bleeding	122	81 (66.4%)	6 (4.9%)	35 (28.7%)
Lower abdominal pain	122	79 (64.8%)	10 (8.2%)	33 (27.1%)
Foul smelling vaginal discharge	122	68 (55.7%)	10 (8.2%)	44 (36.1%)
Pain after sexual intercourse	122	55 (45.1%)	14 (11.5%)	53 (43.4%)
Irregular menstrual periods	122	29 (23.8%)	35 (28.7%)	58 (47.5%)

Close to two thirds, 81 (66.4%) agree that vaginal bleeding could be a sign of cervical cancer. Seventy nine or 64.8%, and 68 (55.7%) agree that lower abdominal pain and foul smelling vaginal discharge respectively are symptoms of cervical cancer.

More than 40% and close to 50% did not know if pain after sexual intercourse and irregular menstrual periods respectively are signs or cervical cancer.

Table 4: Knowledge on the prevention of cervical cancer

Variable	Sample size	n (%)
Believe cervical cancer can be prevented	122	101 (82.8%)
Cervical cancer can be prevented through
Getting HPV vaccine	101	27 (26.7%)
Pap smear screening	101	74 (73.3%)
Avoid multiple partners	101	56 (55.5%)
Avoid smoking	101	35 (34.7%)
Early diagnosis and treatment	101	57 (56.4%)

Over 80% believed that cervical cancer can be prevented. Of this number, one quarter thought that getting HPV vaccine was one way to prevent cervical cancer, while 74 (73.3%) thought that Pap smear screening was one method of preventing cervical cancer. There were 56 (55.5%), 35 (34.7%), and 57 (56.4%) responses that showed believe on avoiding multiple partners, avoiding smoking, and early diagnosis respectively as the possible methods of preventing cervical cancer.

Table 5: Knowledge on the available treatments options

Treatment options for cervical cancer	Sample size	Strongly agree	Disagree	Don’t know
Chemotherapy	122	73 (59.8%)	5 (4.1%)	44 (36.1%)
Radiotherapy	122	61 (50.0%)	6 (4.9%)	55 (45.1%)
Surgery	122	65 (53.3%)	14 (11.5%)	43 (35.3%)
Traditional medicine	122	13 (10.7%)	56 (45.9%)	53 (43.4%)
Witch doctor	122	2 (1.6%)	75 (61.5%)	45 (36.9%)

Chemotherapy, radiotherapy and surgery were popularly known as the available treatment methods for cervical cancer.

Thirteen (10.7%) thought that traditional medicine could treat cervical cancer. On the other hand, over 60% disagreed that witch doctor could treat cervical cancer.

4.3 Knowledge on Pap smear and locally available screening methods

Table 6: Knowledge on Pap smear among those who know about cervical cancer

Variable	Sample size	n (%) or Median (IQR)
Ever heard of pap smear	113	80 (70.8%)
Source of information
Media	80	46 (57.5%)
Friends	80	13 (16.3%)
School	80	8 (10.0%)
Doctor/nurse	80	37 (46.3%)
Family member	80	1 (1.3%)
CHW	80	11 (13.8%)
Use of pap smear
Screening	80	53 (66.3%)
Don’t know	27 (33.2%)
Recommended persons to use pap smear
All women of reproductive age	26 (49.1%)
Sexually active women	53	5 (9.4%)
Any woman who is aged at least 21 years	22 (41.5%)
Aware of Health facility offering pap smear	80	29 (36.3%)
Distance to the facility	29	4.0 (1.0, 8.0)
Knew approximate cost of doing pap smear	19	7 (36.8%)
Know of any other method for cervical cancer screening	53	0 (0.0%)
Pap smear can be used for cervical cancer diagnosis	53	51 (96.2%)
Know of any other method for cervical cancer diagnosis	53	9 (17.0%)

More than two thirds of the participants knew about Pap smear. Of this number, 57.5% got the information through media, 16.3% through friends, and 10.0% from school. Thirty seven (46.3%) got the information from doctors or nurses.

Of those who knew of Pap smear, 53 (64.6%) knew that it is used for screening while the rest did not know its use and 26 (49.1%) recommended it for use among all women of reproductive age, 5 (9.4%) recommended it for use among sexually active women, and 22 (41.5%) recommended it for use among any woman aged at least 21 years.

Of those aware about Pap smear, 29 (36.3%) knew the health facility that was offering it and the median distance to the facility was 4.0 (IQR: 1.0, 8.0) kilometers. Only 7 (36.8%) of those who had heard of Pap smear and knew its use and facility offering it were able to approximate the cost of Pap smear screening.

None of the participants knew any other method for cervical cancer screening. More than 96% of those who knew the use of Pap smear said that Pap smear could be used for cervical cancer diagnosis. Nine, 17.0% of those who knew the use of Pap smear said that they knew of another method for cervical cancer diagnosis.

4.4 Practices regarding Pap smear

This includes information on those participants who have ever done pap smear and barriers to undertaking the test.

Table 7: Practice of Pap smear

Practice of pap-smear	Sample size	n (%)
Was advised to do Pap smear screening	113	49 (43.4%)
The person who advised
CHW	3 (6.1%)
Doctor	49	18 (36.7%)
Family	1 (2.0%)
Friend	19 (38.8%)
Nurse	7 (14.3%)
Parents	1 (2.0%)
Ever did Pap smear	113	19 (16.8%)
If yes what motivated you to do
Doctor’s advise	19	4 (21.1%)
Friends’ advise	19	2 (10.5%)
Own initiative	19	12 (63.2%)
Family history	19	1 (5.3%)
If No what motivated you NOT to do
The test is expensive	94	6 (6.4%)
Not available in the local health Centre	94	35 (37.2%)
Not aware of where to do the test	94	26 (27.7%)
Fear of bad results	94	17 (18.1%)
It is embarrassing	94	7 (7.5%)
Not felt to be at risk	94	10 (10.6%)
Have no information about the test	94	56 (59.6%)
Would advise someone to do Pap smear	113	73 (65.2%)
Would take Pap smear test in future if made available	113	109 (96.5%)
Think it is important to screen	113	103 (91.2%)
Frequency of doing Pap smear test
Yearly	34 (30.4%)
Every 3 years	8 (7.1%)
Every 5 years	113	4 (3.6%)
After 3 years if previous test was negative	7 (6.3%)
As recommended by doctor	57 (50.9%)
Don’t know	2 (1.8%)

Forty nine, representing 43.4% were advised to do Pap smear test. Majority of this number, 51.0%, were advised by either a nurse or a doctor followed by 38.8% who were advised by friends. Less than one fifth, 19 (16.8%), had ever done Pap smear. Majority of them, 63.2%, did so voluntarily. Reasons given for not taking pap smear test were; have no information about the test (59.6%), not available in the local health Centre (37.2%), not aware of where to do the test (27.7%), fear of bad results (18.1%), not felt to be at risk (10.6%), and it is embarrassing 7.5%).

Seventy three, representing 65.2%, would advise someone else to do Pap smear screening, 109 (96.5%) would take Pap smear test in future if made available, and 103 (91.2%) thought it was important to do Pap smear screening. Half of the participants thought that Pap smear should be done based on doctor’s recommendation. There were 8 (7.1%), and 7 (6.3%) who thought that Pap smear should be done every three years, and after three years if the previous test was negative, respectively. Others 34 (30.4%), and 4 (3.6%) thought that it should be done yearly and after every 5 years respectively.

Table 8: Recommended age for doing Pap smear screening

Recommended age for doing Pap smear test	Sample size	Strongly agree	Disagree	Don’t know
All sexually active	113	78 (69.0%)	3 (2.7%)	32 (28.3%)
12-25 years	113	40 (35.4%)	20 (17.7%)	53 (46.9%)
18-55 years	113	59 (52.2%)	11 (9.7%)	43 (38.1%)
21-60 years	113	61 (54.0%)	10 (8.9%)	42 (37.2%)
45 + years	113	28 (24.8%)	26 (23.0%)	59 (52.2%)

More than two thirds strongly agreed that Pap smear should be done among all sexually active women. Slightly less than half did not know whether age 12-25 years was the recommended age for doing Pap smear. On the other hand 52.2%, 54.0%, and 24.8% strongly agreed that age 18-55 years, 21-60 years, and 45 + years respectively were the recommended ages for screening.

Table 9: Relationship between Knowledge of cervical cancer and demographic and clinical characteristics

Have ever heard of cervical cancer
No (n=9, 7.4%)	Yes (n=113, 92.6%)
Variable	Sample size	Levels	n(%) or Median (IQR)	n(%) or Median (IQR)	P
Age (years)	122	>40 vs. ≤40	3 (33.3%)	36 (31.9%)	1.000
Married	122	Yes vs. No	6 (66.7%)	82 (72.6%)	0.708
Number of children	None	1 (11.1%)	15 (13.3%)
122	1-3	6 (66.7%)	56 (49.6%)	0.788
>3	2 (22.2%)	42 (37.2%)
Age at first sex (years)	109	20.0 (18.0, 21.0)	20.0 (18.0, 23.0)	0.773
Number of sex partners	122	More than one vs. one or none	1 (11.1%)	13 (11.5%)	1.000
Family planning	122	Injection, IUCD (Coil), pills, Jadelle, condom vs. withdrawal, none	7 (77.8%)	68 (60.2%)	0.480
Ever Smoked	122	Yes vs. No	0 (0.0%)	1 (0.9%)	1.000
Type of family	103	Polygamous vs. Monogamous	3 (37.5%)	26 (27.4%)	0.684

We reported the Fisher’s exact p-value for all the associations between categorical variables since the expected cell counts were <5, a violation of Chi Square assumption

Knowledge of cervical cancer was not associated with demographic characteristics. There was not sufficient evidence from the data to link age group, marital status, age at first sex, the number of sexual partners and the type or family planning method to knowledge of cervical cancer, p=0.773, 1.000 and 0.480 respectively.

Table 10: Knowledge on cervical cancer, and risk factors and symptoms of cervical cancer

Have ever heard of cervical cancer
No (n=9, 7.4%)	Yes (n=113, 92.6%)
Variable	Levels	n (%)	n (%)	P
Gender affected by cervical cancer	Male	0 (0.0%)	1 (0.9%)
Female	4 (44.4%)	107 (94.7%)	<0.0001
Both sexes	0 (0.0%)	5 (4.4%)
Don’t know	5 (55.6%)	0 (0.0%)
Believe to be at risk of cervical cancer	Yes vs. No	2 (22.2%)	88 (77.9%)	0.001
Believe cervical cancer can be treated	Yes vs. No	4 (44.4%)	79 (69.9%)	0.143
Acquisition of cervical cancer	Sexual contact	1 (11.1%)	57 (50.4%)
A curse	2 (22.2%)	2 (1.8%)	0.008
Don’t know	6 (66.7%)	54 (47.8%)
Smoking	2 (22.2%)	44 (38.9%)	0.481
HPV infection	1 (11.1%)	42 (37.2%)	0.158
Predisposing factors	Early sex	1 (11.1%)	50 (44.3%)	0.078
Multiple partners	3 (33.3%)	89 (78.8%)	0.007
HIV Infection	7 (77.8%)	42 (37.2%)	0.029
Don’t know	2 (22.2%)	2 (1.8%)	0.027
Symptoms of cervical cancer
Vaginal bleeding	Yes vs. No	4 (44.4%)	77 (68.1%)	0.162
Lower abdominal pain	Yes vs. No	2 (22.2%)	77 (68.1%)	0.009
Foul smelling vaginal discharge	Yes vs. No	2 (22.2%)	66 (58.4%)	0.076
Pain after sexual intercourse	Yes vs. No	1 (11.1%)	54 (47.8%)	0.040
Irregular menstrual periods	Yes vs. No	1 (11.1%)	28 (24.8%)	0.685
Believe cervical cancer can be prevented	Yes vs. No	4 (44.4%)	97 (85.8%)	0.008
Family member diagnosed of cervical cancer	Yes vs. No	1 (11.1%)	7 (6.2%)	0.469

We reported the Fisher’s exact p-value for all the associations between categorical variables since the expected cell counts were <5, a violation of Chi Square assumption

Compared to those who had no knowledge on cervical cancer, a higher proportion of those who had knowledge on cervical cancer said that female are the ones who get affected by cervical cancer, 107 (94.7%) vs. 4 (44.4%), p<0.0001. Those who had no knowledge of cervical cancer did not know who was affected by the cancer.

A significantly higher proportion of those who knew of cervical cancer believed that they were at risk of getting the cancer, 88 (77.9%) vs. 2 (22.2%), p=0.001, knew that cervical cancer is acquired through sex, 57 (50.4%) vs. 1 (11.1%), p=0.008, and knew that having multiple partners was one of the predisposing factors, 89 (78.8%) vs. 3 (33.3%), p=0.007. However, they did not think that HIV infection could be one of the predisposing factors of cervical cancer, 42 (37.2%) vs. 7 (77.8%), p=0.029.

A significantly higher proportion of those who had no knowledge of cervical cancer did not know the possible predisposing factors of cervical cancer, 2 (22.2%) vs. 2 (1.8%), p=0.027.

Those who had knowledge of cervical cancer knew that lower abdominal pain, and pain after sexual intercourse were the symptoms of cervical cancer, 77 (68.1%) vs. 2 (22.2%), p=0.009, and 54 (47.8%) vs. 1 (11.1%), p=0.040 respectively.

A significantly higher proportion of those who had knowledge of cervical cancer knew that cervical cancer can be prevented, 97 (85.8%) vs. 4 (44.4%), p=0.008.

Table 11: Relationship between Pap smear, and demographic and clinical characteristics

Aware of Pap smear
Yes (n=80, 70.8%)	No (n=33, 29.2%)
Variable	Sample size	Levels	n(%) or Median (IQR)	n(%) or Median (IQR)	P
Age (years)	113	>40 vs. ≤40	26 (32.5%)	10 (30.3%)	1.000
Married	113	Yes vs. No	60 (75.0%)	22 (66.7%)	0.366
Number of children	None	9 (11.3%)	6 (18.2%)
113	1-3	45 (56.3%)	11 (33.3%)	0.081f
>3	26 (32.5%)	16 (48.5%)
Age at first sex (years)	100	20.0 (18.0, 23.0)	21.0 (18.0, 23.0)	0.842
Number of sex partners	113	More than one vs. one or none	10 (12.5%)	3 (9.1%)	0.753f
Family planning	113	Injection, IUCD (Coil), pills, Jadelle, condom vs. withdrawal, none	51 (63.8%)	17 (51.5%)	0.291
Ever Smoked	113	Yes vs. No	1 (1.3%)	0 (0.0%)	1.000f
Type of family	95	Polygamous vs. Monogamous	18 (26.5%)	8 (29.6%)	0.801

f - Fisher’s exact p-value was reported because the expected cell counts were <5, a violation of Chi Square assumption

Knowledge of Pap smear was not associated with demographic characteristics (Table 11). Belief of being at risk of cervical cancer and belief of whether cervical cancer can be treated were not associated with knowledge on Pap smear, 66 (82.5%) vs. 22 (66.7%), p=0.082, and 60 (75.0%) vs. 19 (57.6%), p=0.075.

Table 12: Knowledge on Pap smear, and risk factors and symptoms of cervical cancer

Aware of Pap smear
Yes (n=80, 70.8%)	No (n=33, 29.2%)
Variable	Levels	n (%)	n (%)	P
Gender affected by cervical cancer	Male	0 (0.0%)	1 (3.0%)
Female	76 (95.0%)	31 (93.9%)	0.399f
Both sexes	4 (5.0%)	1 (3.0%)
Believe to be at risk of cervical cancer	Yes vs. No	66 (82.5%)	22 (66.7%)	0.082
Believe cervical cancer can be treated	Yes vs. No	60 (75.0%)	19 (57.6%)	0.075
Acquisition of cervical cancer	Sexual contact	48 (60.0%)	9 (27.3%)
A curse	0 (0.0%)	2 (6.1%)	0.001f
Don’t know	32 (40.0%)	22 (66.7%)
Smoking	28 (35.0%)	16 (48.5%)	0.207
HPV infection	32 (40.0%)	10 (30.3%)	0.395
Predisposing factors	Early sex	36 (45.0%)	14 (42.4%)	0.838
Multiple partners	71 (88.8%)	18 (54.6%)	<0.0001
HIV Infection	30 (37.5%)	12 (36.4%)	1.000
Don’t know	1 (1.3%)	1 (3.0%)	0.501f
Symptoms of cervical cancer
Vaginal bleeding	Yes vs. No	60 (75.0%)	17 (51.5%)	0.025
Lower abdominal pain	Yes vs. No	57 (71.3%)	20 (60.6%)	0.277
Foul smelling vaginal discharge	Yes vs. No	47 (58.8%)	19 (57.6%)	1.000
Pain after sexual intercourse	Yes vs. No	46 (57.5%)	8 (24.2%)	0.002
Irregular menstrual periods	Yes vs. No	23 (28.8%)	5 (15.2%)	0.155
Believe cervical cancer can be prevented	Yes vs. No	74 (92.5%)	23 (69.7%)	0.005f
Family member diagnosed of cervical cancer	Yes vs. No	5 (6.3%)	2 (6.1%)	1.000f
Use of pap smear	Screening vs. Don’t know	52 (66.3%)	3 (9.1%)	<0.0001
Health facility offering Pap smear	Yes vs. No	42 (52.5%)	2 (6.1%)	<0.0001
Advised to do pap smear	Yes vs. No	47 (58.8%)	2 (6.1%)	<0.0001
Have done pap smear	Yes vs. No	19 (23.8%)	0 (0.0%)	0.001

f - Fisher’s exact p-value was reported because the expected cell counts were <5, a violation of Chi Square assumption

A significantly higher proportion of those who had knowledge on pap-smear knew that cervical cancer can be acquired through sexual contact, 48 (60.0%) vs. 9 (27.3%), p=0.001, and knew that having multiple partners was a predisposing factors for cervical cancer, 71 (88.8%) vs. 18 (54.6%), p<0.0001

Those who had knowledge of Pap smear were significantly more knowledgeable about vaginal bleeding as one of the symptoms of cervical cancer, 60 (75.0%) vs. 17 (51.5%), p=0.025 and knew that pain after sex was a symptom of cervical cancer, 46 (57.5%) vs. 8 (24.2%), p=0.002.

A significantly higher proportion of those who had knowledge on Pap smear believed that cervical cancer can be prevented, 74 (92.5%) vs. 23 (69.7%), p=0.005, knew that Pap smear is used for screening cervical cancer, 52 (66.3%) vs. 3 (9.1%), p<0.0001, knew of a health facility that was offering Pap smear, 42 (52.5%) vs. 2 (6.1%), p<0.0001, had been advised to do Pap smear test, 47 (58.8%) vs. 2 (6.1%), p<0.0001, and had done Pap smear test, 19 (23.8%) vs. 0 (0.0%), p=0.001.

Table 13: Relation between Pap smear practice and demographic characteristics

Uptake of pap smear test
No (n=61, 76.3%)	Yes (n=19, 23.8%)
Variable	Sample size	Levels	n(%) or Median (IQR)	n(%) or Median (IQR)	P
Age (years)	80	>40 vs. ≤40	22 (36.1%)	4 (21.1%)	0.272
Married	80	Yes vs. No	47 (77.1%)	13 (68.4%)	0.546
Number of children	None	8 (13.1%)	1 (5.3%)
80	1-3	32 (52.5%)	13 (68.4%)	0.475
>3	21 (34.4%)	5 (26.3%)
Age at first sex (years)	71	20.0 (18.0, 24.0)	20.0 (19.0, 22.5)	0.851
Number of sex partners	80	More than one vs. one or none	8 (13.1%)	2 (10.5%)	1.000
Family planning	80	Injection, IUCD (Coil), pills, Jadelle, condom vs. withdrawal, none	40 (65.6%)	11 (57.9%)	0.591
Ever Smoked	80	Yes vs. No	60 (98.4%)	19 (100.0%)	1.000
Type of family	68	Polygamous vs. Monogamous	16 (30.8%)	2 (12.5%)	0.203

The findings did not give any evidence to link Pap smear use and socio-demographic characteristics (p > 0.05 for all the variables).

Table 14: Relationship between Pap smear uptake and knowledge of cervical cancer and risk factors

Uptake of Pap smear test
No (n=61, 76.3%)	Yes (n=19, 23.8%)
Variable	Levels	n(%)	n(%)	P
Gender affected by cervical cancer	Female vs. Male or Both sexes	58 (95.1%)	18 (94.75)	1.000
Believe to be at risk of cervical cancer	Yes vs. No	50 (82.0%)	16 (84.2`%)	1.000
Believe cervical cancer can be treated if found early	1`	42 (68.9%)	18 (94.7%)	0.031
Acquisition of cervical cancer	Sexual contact vs. Don’t know	33 (54.1%)	15 (79.0%)	0.064
Smoking	20 (32.8%)	8 (42.1%)	0.583
HPV infection	23 (37.7%)	9 (47.4%)	0.593
Predisposing factors of cervical cancer	Early sex	29 (47.5%)	7 (36.8%)	0.443
Multiple partners	53 (86.9%)	18 (94.7%)	0.678
HIV Infection	26 (42.6%)	4 (21.1%)	0.109
Don’t know	1 (1.6%)	0 (0.0%)	1.000
Symptoms of cervical cancer
Vaginal bleeding	Yes vs. No	45 (73.8%)	15 (79.0%)	0.768
Lower abdominal pain	Yes vs. No	47 (77.1%)	10 (52.6%)	0.048
Foul smelling vaginal discharge	Yes vs. No	38 (62.3%)	9 (47.4%)	0.292
Pain after sexual intercourse	Yes vs. No	34 (55.7%)	12 (63.2%)	0.607
Irregular menstrual periods	Yes vs. No	16 (26.2%)	7 (36.8%)	0.395
Believe cervical cancer can be prevented	Yes vs. No	56 (91.8%)	18 (94.7%)	1.000
Family member diagnosed of cervical cancer	Yes vs. No	1 (1.6%)	4 (21.1%)	0.010
Use of pap smear	Screening vs. Don’t know	40 (65.6%)	13 (68.4%)	1.000
Health facility offering Pap smear	Yes vs. No	24 (39.3%)	18 (94.7%)	<0.0001
Advised to do pap smear	Yes vs. No	28 (45.9%)	19 (100.0%)	<0.0001

The results did not find evidence to link knowledge of gender affected by cervical Pap smear use, P = 1.000. Participant’s own understanding to be at risk of cervical cancer was not associated with Pap smear utilization as well, p =1.000. Understanding that cervical cancer can be treated was associated with a higher rate uptake of Pap smear screening. Compared to those who had not utilized Pap smear, a significantly higher proportion of those who had utilized Pap smear believed that cervical cancer can be treated if found early, 94.7% vs. 68.7% p = 0.031, odds ratio: 8.14 (95% CI 1.01, 65.53).

There was no sufficient data to link knowledge on the ways of acquiring cervical cancer and Pap smear utilization (p = 0.064). There was however a higher proportion of those had utilized Pap smear who knew that cervical cancer can be acquired via sexual contact, 79.0% vs. 54.1%.

Knowledge of the predisposing factors of cervical cancer such as smoking, HPV infection, engaging in sexual intercourse at an early age, having multiple sexual partners, and HIV infection, were not associated with uptake of Pap smear. However results demonstrate that the participants who had utilized Pap smear were more likely to have knowledge of HPV as a risk factor for cervical cancer, 47.4% vs. 37.7%, and were more to be having multiple sexual partners, 94.7% vs. 86.9%. There was lack of evidence from the data to corroborate the association between uptake of Pap smear and symptoms of cervical cancer. A higher proportion of those who had utilized Pap smear were more likely to say that vaginal bleeding is symptom of cervical cancer, 79.0% vs. 73.8%, and were more likely to have endorsed that a pain after sexual intercourse was a symptom of cervical cancer, 63.2% vs. 55.7%.

Participants who had utilized Pap smear were less likely to endorse lower abdominal pain as a symptom of cervical cancer, 52.6% vs. 77.1%, p = 0.048, odds ratio: 0.33 (95% CI: 0.11, 0.97).

Compared to those who had not utilized Pap smear the participants who had utilized Pap smear were more likely to have had a family member diagnosed of cervical cancer, 21.1% vs. 1.6%, p = 0.010, odd ratio: 16.0 (95% CI: 1.66, 153.82), were more likely to know the health facility offering Pap smear, 94.7% vs. 39.3%, p < 0.0001, odds ratio: 27.75 (95% CI: 3.47, 221.72), and were more likely to have been advised to do Pap smear test, 100.0% vs. 45.9%, p <0.0001.

CHAPTER FIVE

5.0: DISCUSSION

5.1: Socio-Demographic factors

Findings from this study indicate that most of the participants were within the age bracket of 21-50 years which implies that this population is at the prime of their life, very energetic and dependable both by their families and the country for economy’s growth. This agrees with other studies whereby participants were below 50 years of age; Adogu et al, 2015, Neema et al, 2015 and Ombech et al, 2012.

Being an African setting polygamy is still being practice (28.2%) with majority of the women having more than three children. The minimum age of sexual initiation being 11 years with some women having multiple sexual partners, and only 3.3% were using condoms. This poses risks for cervical cancer to the population. These findings are in agreement with other studies where polygamy, early marriages, early sexual indulges, high parity and multiple sexual partners was practiced ; Adenkale et al, 2011, Al-Meer et al, 2011, John, 2011 and Neema et al, 2015 and Ndlovu, 2011, where condom use was very low.

5.2: Awareness of cercial cancer and its risk factors

Awareness level of cervical cancer in this study was found to be high with most teachers reporting having heard of cervical cancer. This is attributed to educational background whereby all the participants were primary school teachers with minimum educational attainment of college certificate and improvement in information technology as media is the common source of information mentioned. These findings agree with other studies; Al-Meer e al, 2011(80%), Ombeche et al, 2012 (87%) and Ubajaka et al, 2015 (74.6%).

In contrast, other studies have shown very low/ lack of awareness of cervical cancer; Amarin et al, 2008 (33.3%), Tebeu et al, 2008 (28%), Hoque, 2009 (42.9), Balogun et al, 2011 (4.2%), John, 2011 (1.6%), Igwilo et al, 2012 (8.9%) and Hyacinth et al, 2012 (50.9%).

Knowledge of risk factors is one of the preventive measures for cervical cancer. Most of those participants who were not aware of cervical cancer were not able to mention any risk factor and majority didn’t know how it is acquired. These findings are similar to those found in another study Hoque, 2009).

Common risk factors mentioned in this study were multiple sexual partners, early sexual initiation, HIV infection and smoking. HPV infection was the least mentioned yet it is the primary cause of invasive cervical cancer. These findings agree with those found in other studies where HPV was the least or not mentioned at all; Hyacinth et al, 2012, Ombech et al, 2012, Sudenga et al, 2013, Shankar et al, 2015 and Ubajaka et al, 2015). Awareness of the risk factors will lead to adoption of appropriate preventive measure thus help reduce disease incidences.

All women are believed to be at risk of getting cervical cancer in there life time. This study revealed that majority of the respondents believed they were at risk of cervical cancer which agrees with Ndlovu et al, 2011 and Sudenga et al, 2013 whereby 60.8% and 65% of the participants acknowledged that they were at risk of cervical cancer respectively. On the other hand, it contrasts other studies where by none or only a few of the participants believed they were at risk; Bologum et al, 2011 (none believed to be at risk), Were et al, 2011(22.8% felt at risk), Igwilo et al, 2012 (6.5% felt at risk) and Adogu et al, 2015 (6.4% felt at risk).

It is evident that most participants believed cervical cancer can be prevented (p-0.008) and that the disease can be treated if detected early compared to those who did not have knowledge on cervical cancer. This agrees with Sudenga et al, 2013 (treated 92%), Bwombengi, 2014 (treated 76.7%/prevented 90%), and Kanyori, 2014.

Nearly 60- 75% of women in Sub-Sahara Africa who develop cervical cancer live in rural areas whereby many of them are diagnosed at an advanced stage of the disease because of lack of awareness of early signs and symptoms and many go untreated with survival rate being 21% in 2002 compared with 70% & 66% in the united states and western Europe (Atara, 2012).

Mostly identified signs & symptoms of cervical cancer were vaginal bleeding, lower abdominal pain, foul smelling vaginal discharge and pain after sex which are the true signs & symptoms. This differs with Shankar et al, 2015 where symptoms of cervical cancer were less known to the participants.

Most participants strongly agreed that chemotherapy, radiotherapy and surgery were the available treatment options for cervical cancer which agrees with John, 2011.

There was no sufficient data to link socio-demographic data and knowledge on cervical cancer and risk factors. There was no sufficient data to link age, family type, smoking, family planning, number of children and multiple sexual partners to knowledge of cervical cancer and its risk factors as opposed to other studies; Al-Meer et al, 2011 and Were et al, 2011.

A significantly higher proportion of respondents who had knowledge on cervical cancer are the ones who believed they are at risk of cervical cancer (p-0.001) and that the disease can be prevented (p-0.008) compared to those who did not have knowledge on cervical cancer.

Majority of those who had no knowledge of cervical cancer are the ones who said it is acquired through a curse (p-0.008) with some participants mentioning traditional medicine and witch doctor as part of the treatment options.

This gap in knowledge of cervical cancer and its risk factors means that proper information needs to be channeled to the people so as to address the problem in order to attain a universal preventive health care. Education should be given on how risk factors like HIV infection and smoking weakens the body’s immunity paving way for HPV virus and also how multiple sexual partners, high parity, polygamous marriages and lack of use of condoms predisposes a woman to HPV infection. This is especially important as it is documented that 80-90% of sexually active women have the probability of acquiring HPV infection of the genital tract at some stage in their lives and persistence of genital HPV infection is specifically related to development of cervical cancer (Monga, 2006).

5.3: Knowledge of preventive measures and practice of pap smear

Knowledge on cervical cancer prevention is the key factor in curbing the diease. Sub-Saharan Africa has reported the lowest figures in terms of awareness and uptake of pap smear test, one of the preventive measures to cervical cancer. A comprehensive review of literature indicated that cervical cancer screening coverage in Sub-Saharan Africa ranges from 2.0% to 20.2% in urban areas and 0.4% to 14.0 in rural areas (Louie et al, 2009). This is true when we look at a study done in Nairobi in a similar population which is in urban setting with Pap smear awareness and uptake of 75% &41% respectively (Ombech et al, 2012) compared to Teso north which is in a rural setting with Pap smear awareness and uptake of 70.8% &16.8% respectively.

The leading preventive measure for invasive cervical cancer mentioned in this study were; Pap smear screening, early diagnosis and treatment and avoidance of multiple sexual partners which tallies with Ndlovu et al, 2011, John, 2011 and Hyacinth et al, 2012.

Knowledge of predisposing factors is influential on preventive measures that people will adopt as revealed in the study whereby most of those who knew smoking as a risk factor were more likely to avoid smoking compared to those who did not know p-0001. This was similar with HPV infection Vs HPV vaccine p-0.002, multiple sexual partners vs avoidance of multiple sexual partners p-0.004.

Knowledge of Pap smear among those who had ever heard of cervical cancer was found to be slightly high which agrees with Ombech et al, 2012. This contrasts other studies whereby awareness was found to be very low or none of the participants had ever heard of Pap smear (Amarin et al, 2008, Yifru & Asheber, 2008, Abotchie & Shokar, 2009, Hoque, 2009, Mupepi et al, 2011, Ndlovu, 2011, Adenkale et al, 2011, Hyacinth 2012, Igwilo et al, 2012, Ubakaja, 2015 and Adogu et al, 2015).

This study revealed that slightly more than half of the respondents were able to correctly identify the use of Pap smear as screening for cervical cancer 66.3%. These results tally with those of Al-Meer et al, 2015 (62.4%) and much lower than those found by Hawkins et al, 2011 in the United States where over 80% new pap smear is for screening for cervical cancer.

Only a few of the respondents knew that Pap smear screening is recommended for all women aged 21 years and above and any sexually active woman regardless of age and that regular check-up should be embraced. Majority said they will screen as long as the doctor recommends it. Similarly a study by Amarin et al, 2008 indicated that most of the tests done were opportunistic and only a few respondents reported having regular tests.

A lot of sensitization has to be done including opportunistic screening in our hospitals in order to capture a large population.

Information on alternative screening methods for cervical cancer (VIA/VILI) has not yet reached this population as none of the respondent knew any other method used to screen for cervical cancer.

There is still a gap in knowledge regarding information on the use of Pap smear, recommended age and frequency of taking the test, health facilities offering the test and other alternative methods for screening for cervical cancer. This hinders uptake of preventive measures for cervical cancer.

Pap smear uptake was found to be very low16.8%. other studies have also recorded similar findings in terms of low uptake of pap smear; Ndlovu, 2011 (18.8%), John, 2011 (14.2%), %), Mupepi et al (2011), Were et al, 2011 (12.3%), Hyacinth, 2012 (10.2%), Ekta et al, 2012 (11%), , Ubajaka, 2015 (20.5%), and Neema et al, 2015 (21%). Others studies recorded very low screening or none at all; Adekanle et al, 2011 (5.4), Igwilo et al, 2012 (none had screened), Sudenga et al, 2013 (6%) and Adogu et al, 2015 (0.4%). These findings were much lower than those of Ombech et al, (2012) (41%), Al-Meer et al (2015), Bwombengi, (2014) (42.9 &30.9%) and Kanyori, (2014) (66%).

The leading reasons for not screening as found in the study were; lack of information about the test, not available in the local health Centre, not aware of where to do the test, fear of bad results, not felt at risk, embarrassing procedure and financial constrain. Similar reasons were quoted in other studies also; Adenkale et al (2011), Ndlovu (2011), Were et al (2011), Urusa & Daris (2011), John (2011), Hyacinth (2012), Ekta et al (2012), Ombeche et al (2012) and Kanyori (2014). These barriers for cervical cancer screening should be dealt with through health education and proper sensitization in order to increase screening rate in Kenya.

It is evident from the findings that there was no association between Pap smear uptake and socio-demographic characteristic (p->0.05 for all variables) which contrasts other studies; Were et al (2011) and Bwombengi (2014) whereby increasing age increases the chance of cervical cancer screening. Another study by Ndlovu, 2011 revealed that older women are less likely to screen compared to younger ones below 35 years. Studies by Adenkale (2011) and Neema et al (2015) have also revealed that those with multiple sexual partners, multiparous and polygamous marriages were more likely to screen.

Pap smear uptake was more among those who believed cervical cancer can be treated if detected early p-0.031 OR 8.14(95% CL 1.01-65.5) and among those whose family members were diagnosed with cervical cancer p-0.01 OR 16.0 (95% CL 1.66-153.82). Being advised to do pap smear and awareness of health facility offering pap smear increased the chances of pap smear uptake among participants p-<0.0001.

There was no evidence from data to link Pap smear uptake and knowledge of cervical cancer risk factors as the p->0.05. However, compared to those who had not done Pap smear, the results demonstrate that participants who had utilized Pap smear were more likely to have had knowledge on HPV infection (47.4% vs 37.7%), smoking (42.1% vs 32.8%) and multiple sexual partners (94.7% vs 86.9%) as risk factors for cervical cancer.

More efforts should be geared towards stressing the importance of taking Pap smear test in developing countries since the uptake is very low compared to developed countries like the United States (Tung et al, 2002 and Hawkins et al, 2011).

With adequate knowledge and sensitization on pap smear and other locally available screening methods, availability and affordability of the tests, we will have majority of women being screened for cervical cancer hence help curb the deadly disease as many women in this study expressed willingness to screen. This compares with other studies also; Ndlovu (2011), John (2011), Were et al (2011), Mupepi et al (2011), Igwilo et al (2012) and Al- Meer et al (2015).

CHAPTER SIX

6.0: CONCLUSION AND RECOMMENDATIONS

6.1: Conclusion

Despite of adequate knowledge on cervical cancer and risk factors, uptake of Pap smear test was very low among primary school teachers. This resulted from inadequate information on pap-smear test and other screening services available locally.

This low uptake of Pap smear screening services among women will hinder early detection and treatment of cancer leading to the increased burden of the disease in the country.

6.2: Recommendations

More campaigns should be done on awareness of pap-smear and sensitization of women on importance of screening in order to attain the WHO recommended screening rate of >80%.

Ministry of health should ensure screening services are made locally available, accessible and affordable to all women country wide.

Research should be done on the general population to establish their awareness of cervical cancer risk factors and uptake of pap-smear.

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Were E., Nyaberi Z., & Buziba N., (2011). Perception of risk factors & barriers to cervical cancer screening at Moi Teaching & Referral hospital Eldoret, Kenya. African health science journal, 11(1), 58-64. Retrieved on 21/11/2013 from, www.ncbi.nlm.nih.gov/pmc/articles/PMC3092325

Wheeler C., Hunt W., Joste N., Key C., Quint W., & Castle P., (2009). Human papillomavirus genotype distributions: Implications for vaccination and cancer screening in the United States. Journal of the national cancer institute, 101(7), 475–487. Retrieved on April 5th, 2014 from; www.ncbi.nlm.nih.gov/pmc/articles/PMC2664090/

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APPENDICES

APPENDIX I: INFORMED CONSENT

I Nancy A. Jakait a student from Moi University School of public health would like to conduct a research on Awareness of cervical cancer risk factors and practices regarding Pap smear among female teachers in Teso north sub-county. Cervical cancer is a malignant disease characterized by progressive and abnormal growth of cervical cells that affects women. Pap-smear is a microscopic examination of cells taken from the cervix that detects premalignant changes to the cells that may lead to cervical cancer which is recommended for all women aged 21 years and above (Fraser et al, 2006). The purpose of this study is to assess women’s level of awareness of cervical cancer, its risk factors, prevention and practices regarding Pap smear. The information obtained from this study will provide a basis for designing programs that will benefit the entire population resulting in lowered burden of cervical cancer.

You are being asked to participate in this study by completing a questionnaire provided to you. Confidentiality and privacy shall be observed by you not indicating your name on the questionnaire and the information you give shall be kept private and confidential.

Participation in this study is completely voluntary meaning you choose to participate willfully & you can withdraw from the study at any time.

There are no risks and discomforts that are associated with the study. You will incur no cost since everything shall be provided for you during the study. If you have questions or concerns you can contact the researcher through contacts below.

Participant

I have read the content of this consent form and I give my consent to participate willfully.

Signature	Date

Researcher

Signature	Date

APPENDIX II: QUESTIONNAIRE

Section A: Socio-demographic characteristics

How old are you?

21-30	41-50

31-40	51 and above

Where do you stay?

Your marital status?

Single	Married	Divorced

Separated	Widow	Single parents

How many children do you have?

None	1-3

4 and above

What was your age at first sexual intercourse?

How many sexual partners have you had for the past one year?

None	One	More than two

What family planning method do you use?

None	Injection	IUCD (Coil)

Pills	Jadelle	Withdrawal	Condom

Have you ever smoked?

Yes	No

If yes, for how long have you been smoking and how often?

What is the type of your family?

Polygamous	Monogamous

Section B: Knowledge on cervical cancer and its risk factors.

Have you ever heard about cervical cancer?

Yes	No

If yes, where did you get the information from?

Media	Doctors/Nurses

Friend	Family member

School	Community health workers

Posters and advertisements

Others-------------

Who does it affect?

Male	Female

Both genders	Don’t know

Do you believe you are at risk of getting cervical cancer as a woman?

Yes, explain------

No, explain-------

Do you believe cervical cancer is like any other disease that can be treated if discovered early? Give your own opinion.

How is it acquired?

Sexual contact	A curse

Don’t know

Others---------

What are some of the risk/predisposing factors to cervical cancer? Tick as many

Cigarette smoking	HPV infection

Early sexual initiation	Multiple sexual partners

Immunosuppression (HIV infection)

Others----

7. Can you mention any signs & symptoms that can indicate that one may be having cervical cancer? Table 3

Strongly agree	Disagree	Don’t know
Vaginal bleeding
Lower abdominal pain
Foul smelling vaginal discharge
Pain after sexual intercourse
Irregular menstrual periods

8 .Can cervical cancer be prevented?

Yes

No

If yes, which of the following measures is part of the preventive measures?

Getting HPV vaccine

Pap smear screening

Avoiding multiple sexual partners

Avoiding cigarette smoking

Early diagnosis and treatment

Do you have anyone in your family who has been diagnosed with cervical cancer?

Yes

No

The following are some of the treatment measures for cervical cancer? Table 4

Strongly agree	Disagree	Don’t know
Chemotherapy
Radiotherapy
Surgery
Traditional medicine
Witchdoctor

Section C: Awareness of Pap smear screening and locally available screening methods

Have you ever heard of Pap smear screening?

Yes

No

Where did you get the information from?

Media	Doctors/Nurses

Friend	Family member

School	Community health workers

What is it used for? Give your own opinion

Who is recommended to do it?

All women of reproductive age

Younger women

Elderly women

Sexually active women

Any woman who is 21years and above

Do you know of any health facility that offers Pap smear test for women in your area?

Yes

No

If yes, how far is it from where you stay? -------

How much does it cost to do Pap smear screening at your local health centre?

Do you know any other screening method used for cervical cancer screening in your area?

Can Pap smear be used to diagnose cervical cancer?

Do you any other method used to diagnose cervical cancer? List them.

Section D: Practices regarding Pap smear

Has anyone ever advised you to do Pap smear?

Yes

No

Who advised you?

Have you ever done Pap smear?

Yes

No

If yes, what made you do it?

Doctor’s request

Advised by a friend

Own initiative

Having a family history of cervical cancer

If no, what are some of the reasons that made you not to do the test?

The test is expensive

Not available in the local health centre

Not knowing where the test is done

Fear of bad results

It is embarrassing

Not felt at risk

Not having information about the test

Will you advice someone else to do Pap smear? Explain.

Will you consider having the test in the future if made locally available?

Yes

No

Do you think it is important to do screening for cervical cancer? Explain.

The following are recommended ages that women should start screening for cervical cancer? Table 5

Strongly agree	Disagree	Don’t know
All sexually active women
12-25 years
18- 55 years
21-60 years
45 years and older

How often should it be done?

Yearly

Every 3 years

After 3 years in a previous negative report

Every 5 years

As recommended by a doctor

APPENDIX III:MAP OF TESO NORTH SUB-COUNTY