the perceived barriers restricting the uptake of cervical screening ...

FACULTY OF HEALTH AND LIFE SCIENCES

MASTER OF PUBLIC HEALTH

THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA.

BY

OYEWOLE VICTORIA ANUOLUWAPO 13043691

DATE: 17 DECEMBER, 2014

A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS OF THE DEGREE OF MASTERS OF PUBLIC HEALTH

LIST OF ABBREVIATIONS CC - Cervical Cancer CI- Confidence Interval. CRD- Centre for Reviews and Dissemination. CS – Cervical Screening. EBP- Evidence Based Practice HPV- Human Papilloma Virus. ICO- Information Centre on HPV and Cancer OR- Odd Ratio SA- Systematic Appraisal. SR- Systematic Review WHO- World Health Organization.

THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 1

TABLE OF CONTENTS ABSTRACT ..................................................................................................... 6 CHAPTER ONE .............................................................................................. 7 INTRODUCTION............................................................................................. 7 1.2 BACKGROUND .................................................................................................................... 8 1.3 EPIDEMIOLOGY OF CERVICAL CANCER (CC) ................................................................ 9 1.4 AETIOLOGY OF CERVICAL CANCER.............................................................................. 10 1.4.1 TYPES OF CERVICAL CANCER.................................................................................. 11 1.4.2 SIGNS AND SYMPTOMS OF CERVICAL CANCER ................................................... 11 1.5 ECONOMIC BURDEN OF CERVICAL CANCER ............................................................ 12 1.6 JUSTIFICATION FOR SYSTEMATIC APPRAISAL (SA) ................................................ 12 1.7 RESEARCH AIM ............................................................................................................... 13 1.8 RESEARCH QUESTIONS................................................................................................ 14 1.9 CHAPTER SUMMARY ..................................................................................................... 14

CHAPTER TWO............................................................................................ 15 LITERATURE REVIEW ................................................................................ 15 2.1 CHAPTER OVERVIEW ...................................................................................................... 16 2.2 LITERATURE REVIEW SEARCH METHODS ................................................................... 16 2.3 PUBLIC HEALTH INTERVENTIONS FOR CERVICAL CANCER PREVENTION AND CONTROL: A COMPREHENSIVE APPROACH...................................................................... 17 2.3.1. PRIMARY PREVENTION: HPV VACCINATION ........................................................... 18 2.3.2. SECONDARY PREVENTION: CERVICAL SCREENING. ............................................ 20 2.4 POTENTIAL BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN IN NIGERIA................................................................................................. 22 2.4.1 PRACTICAL BARRIERS. ................................................................................................ 22 2.4.2 EMOTIONAL BARRIERS. ............................................................................................... 22 2.4.3 SOCIOECONOMIC BARRIERS. ..................................................................................... 23 2.4.4 KNOWLEDGE AND UNDERSTANDING BARRIERS .................................................... 24 2.4.5 CULTURAL AND RELIGIOUS BARRIERS ..................................................................... 24 2.5 CHAPTER SUMMARY ....................................................................................................... 25

CHAPTER THREE ............................................................................................................... 26 THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 2

METHODOLOGY.................................................................................................................. 26 3.1 CHAPTER OVERVIEW ...................................................................................................... 27 3.2 METHODOLOGY................................................................................................................ 27 3.2.1 EVIDENCE-BASED PRACTICE...................................................................................... 27 3.3 SECONDARY DATA ANALYSIS ........................................................................................ 28 3.4 SYSTEMATIC REVIEW AND EVIDENCE-BASED PRACTICE (EBP) ............................. 30 3.5 STRENGTHS AND LIMITATIONS OF SYSTEMATIC REVIEW ..................................... 31 3.6 METHODS .......................................................................................................................... 32 3.6.1 SEARCH STRATEGY.................................................................................................... 32 3.6.2 CONDUCTING THE SEARCH ...................................................................................... 33 3.6.3 REFINING THE SEARCH................................................................................................ 34 3.7 INCLUSION AND EXCLUSION CRITERIA........................................................................ 35 3.7.1 INCLUSION CRITERIA.................................................................................................. 35 3.7.2

EXCLUSION CRITERIA ............................................................................................... 36

3.8.1 QUALITY ASSESSMENT ................................................................................................ 39 3.8.2 DATA EXTRACTION AND SYNTHESIS......................................................................... 41 3.9 CHAPTER SUMMARY ....................................................................................................... 42

CHAPTER FOUR .......................................................................................... 43 FINDINGS...................................................................................................... 43 4.1 CHAPTER OVERVIEW ...................................................................................................... 44 4.2.1 CODING OF RESULTS ................................................................................................... 44 4.3 RESULTS ............................................................................................................................ 52 4.3.1 CHARACTERISTICS OF THE STUDIES APPRAISED.................................................. 52 4.3.1.1 Study designs and methodology .................................................................................. 52 4.3.1.2 Location/context setting ................................................................................................ 52 4.3.1.3 Sampling and population .............................................................................................. 53 4.3.1.4 Data collection............................................................................................................... 54 4.3.1.5 Approaches to analysis................................................................................................. 55 4.3.1.6 Ethics........................................................................................................................... 55 4.3.1 OVERVIEW OF THE FINDINGS FROM THE SIX PRIMARY STUDIES ....................... 56 4.3.2.1 PRACTICAL BARRIERS .............................................................................................. 57 THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 3

4.3.2.2 SOCIOECONOMIC BARRIERS ................................................................................... 58 4.3.2.3 EMOTIONAL BARRIERS ........................................................................................... 59 4.3.2.4

KNOWLEDGE AND UNDERSTANDING BARRIERS .............................................. 59

4.3.1.5 RELIGIOUS AND CULTURAL BARRIERS .................................................................. 60 4.3 CHAPTER SUMMARY ....................................................................................................... 60

CHAPTER FIVE ............................................................................................ 61 DISCUSSION ................................................................................................ 61 5.1 CHAPTER OVERVIEW .......................................................................................................... 62 5.2 PROCESS OF APPRAISAL AND ITS LIMITATIONS ...................................................... 62 5.3 DISCUSSION OF RESULTS .............................................................................................. 63 5.3.1 PRACTICAL BARRIERS ................................................................................................. 63 5.3.2 SOCIOECONOMIC BARRIERS ...................................................................................... 64 5.3.3 EMOTIONAL BARRIERS ................................................................................................ 66 5.3.4 KNOWLEDGE AND UNDERSTANDING BARRIERS .................................................... 66 5.3.5 CULTURAL AND RELIGIOUS BARRIERS ..................................................................... 67 5.4 DISCUSSION WITH REFERENCE TO MAIN RESEARCH QUESTION AND OBJECTIVE ................................................................................................................................................... 69

CHAPTER SIX .............................................................................................. 72 CONCLUSION .............................................................................................. 72 6.1 CHAPTER OVERVIEW ...................................................................................................... 73 6.2 SUMMARY OF THE REVIEW ............................................................................................ 73 6.3 GAPS IN THE EVIDENCE AND IMPLICATION FOR FUTURE RESEARCH .................. 74 6.4 IMPLICATIONS FOR PRACTICE AND POLICY MAKING ................................................ 75 6.5 REFLEXIVITY ..................................................................................................................... 76 6.6 CHAPTER SUMMARY ....................................................................................................... 77

REFERENCES.............................................................................................. 78 APPENDIX..................................................................................................... 89


TABLES Table 1: Summary of search result ……………………………………………………..35 Table 2: Selected studies for the appraisal……………………………………………..38 Table 3: Methodology……………………………………………………………………....41 Table 4: Standardized quantitative (survey) data extraction…………………………..43 Table 5: Data extraction for paper 1……………………………………………………..46 Table 6: Data extraction for paper 2……………………………………………………..47 Table 7: Data extraction for paper 3……………………………………………………..48 Table 8: Data extraction for paper 4……………………………………………………..49 Table 9: Data extraction for paper 5……………………………………………………..50 Table10: Data extraction for paper 6…………………………………………………….51

FIGURES Figure 1: The incidence of cervical cancer in women compared to other cancers in women of all ages in Nigeria (estimations for 2012)………………………………….11 Figure 2: Overview of programmatic interventions over the life course to prevent HPV infection and cervical cancer……………………………………………………………18 Figure 3: Study identification flow charts…………………………………………….. 39 Figure 4: Pie chart showing the percentage of most occurring barrier restricting the uptake of cervical screening…………………………………………………………… 56 Figure 5: Conceptual map of perceived barriers to cervical screening uptake among women (15-60years) in Nigeria…………………………………………………………70


ABSTRACT Background: Globally, Cervical Cancer (CC) is the second most common cancer and the fourth cause of female cancer deaths in women aged 15 to 44 years (WHO, 2014b; Bruni et al., 2014b). Every year, over 270 000 women die of CC, 85% of them occur in the developing countries (WHO, 2014b). This may be due to limited access to effective screening and inequality in the developing countries ( WHO, 2014b). CC is a major public health burden worldwide because it is a preventable life threatening disease, with long-term morbidity, mortality and premature death (Arulogun and Maxwell, 2012). Cervical screening (CS) is effective in preventing the morbidity and mortality of CC (Abiodun et al., 2014). However, in many developing countries, the uptake of CS is still unsatisfactory. Aim: The aim of this study was to carry out a systematic appraisal on the perceived barriers restricting the uptake of CS among women (15-60years) In Nigeria. Objectives: To explore the perceived barriers to CS uptake among women in Nigeria and to draw a conceptual map of a perceived barriers influencing CS uptake among women (15-60years) in Nigeria. Methods: A comprehensive literature search from 2004 onwards was performed using Applied Social Sciences Index and Abstracts (ASSIA), Web of knowledge, Medline, Science Direct, Pub-MED. A total 2525 articles were initially identified. Finally, six peer reviewed quantitative studies that fit into the inclusion criteria of this systematic appraisal were selected. Data extracted from articles included: study aims, design/participants; sampling method, intervention; variables; primary outcome; key findings. Study quality was assessed using a checklist appropriate to the study design. Results: This SA showed that knowledge and understanding barriers (33%) was the highest barrier to the uptake of CS. The other barriers follow this order: socioeconomic barriers (26%), emotional barriers (16%), practical barriers (16%) and cultural and religious barriers (10%) respectively. Conclusion: An enhanced public health education is recommended, through increased mass media campaigns, public enlightenment on CC and evidence based health promotion strategies to increase CS uptake. In addition, there is a need for policy development on CS in Nigeria, as well as the establishment of an effective national CS program sponsored by the government to support practices and improve uptake among women.


CHAPTER ONE INTRODUCTION


1.1 CHAPTER OVERVIEW This chapter provides an introductory platform into the topic area ‘perceived barriers restricting the uptake of cervical screening among women (15-60years) in Nigeria’, by providing a brief background to cancer and cervical cancer, defining the terms used, providing justification for the study, outlining the research questions, and objectives, as well as the application of the topic area to public health. The systematic appraisal (SA) approach will be used for this research.

1.2 BACKGROUND According to the World Health Organization [WHO] (2014a), Cancers are the leading cause of morbidity and mortality worldwide, with approximately 14 million new cases and 8.2 million cancer related deaths in 2012. The burden of cancers continues to rise globally due to aging, world population growth and increased adoption of high risk behaviours such as tobacco use, alcohol use, unhealthy diet and physical inactivity (WHO 2014a; Jemal et al., 2011). Over 60% of the world’s total cases of cancer occur in Africa, Asia, and Central and South America (WHO, 2014a). These regions account for about 70% of the world’s cancer deaths (WHO, 2014a). The reasons may be due to lack of early detection and limited access to treatment (WHO, 2014a; WHO. 2014b). Nigeria is the most populous country in Africa with a population of 47.72 million women (aged 15years and above) as at 2012 who are at risk of developing cervical cancer (Bruni et al., 2014a; Information Centre on HPV and Cancer (ICO) 2014). Cervical Cancer (CC) is a major public health burden affecting Nigerian women because it is the commonest malignancy of the female genital tracts (Anorlu et al., 2007). It affects mostly the poor, the uneducated women living in disadvantaged areas, reflective of poor access to health care, gender and health inequality (Anorlu et al., 2007).


1.3 EPIDEMIOLOGY OF CERVICAL CANCER (CC) Globally, CC is the second most common cancer and the fourth cause of female cancer deaths in women aged 15 to 44 years (WHO, 2014b; Bruni et al., 2014b). Women in the developing world die of CC than women in wealthier countries (WHO, 2014b). This may be due to limited access to effective screening and inequality in the developing countries (WHO, 2014b). Every year, more than 270 000 women die of CC, 85% of them in low and middle-income countries (WHO, 2014b). In a recent study conducted by Yang et al. (2004) on cancer and years of life lost, CC was found to be responsible for 2.7 million (age-weighted) years of life lost worldwide, with 2.4 million of the years of life lost occurring in developing countries. The reasons attributed to the high mortality include health inequality, lack of awareness, limited access to effective screening, poor socio-economic status and increasing levels of poverty (Witteta and Tsua, 2008; Anorlu, 2008).

Nigeria is one of the low income countries where women face a lot of challenges socially and health wise (Kolawole, 2008). Women in Nigeria bear the brunt of illiteracy and poverty, in addition to the consequences of their sexuality and childbearing (Kolawole, 2008). Nigeria ranks top among countries with high burden of CC in developing countries, because CC is the 2nd most common female cancer in women and a major contributor of death in women of reproduc tive age in Nigeria (Bruni et al., 2014a; ICO, 2014). [As shown in Figure1]. In addition, Nigeria recorded 14,089 new CC cases and 8,240 CC deaths in 2012 (Bruni et al., 2014a; ICO, 2014). The high burden of CC in Nigeria may be attributed to high prevalence of Human Papilloma Virus (HPV) infection, less comprehensive Cervical Screening (CS) program, and also partly due to low awareness and poor health seeking behaviour (Arulogun and Maxwell, 2012).


.

Figure 1: The incidence of cervical cancer in women compared to other cancers in women of all ages in Nigeria (estimations for 2012) Source: Bruni et al., (2014a).

1.4 AETIOLOGY OF CERVICAL CANCER In medical parlance, the “Cervix” is the neck of the uterus (womb); it is the lower and the narrow part of the uterus (Medical dictionary, 2011). CC is a disease arising in cells of the cervix that can become abnormal and can grow uncontrollably, usually between 1015years (Olumide et al., 2014). This disease is caused by infection with persistent oncogenic sexually transmitted Human Papilloma Virus (HPV); most commonly Serotypes 16 and 18 (Muñoz et al., 2006; WHO, 2014b). Skin-to-skin genital contact is a well-recognized mode of transmission, such as sexual intercourse (WHO, 2014b). Approximately, 3.5% of women in the general population are estimated to


harbour cervical HPV-16/18 infection at a given time, and 66.9%of invasive cervical cancers are attributed to HPVs 16 or 18 in Nigeria (ICO 2014; Bruni et al., 2014a). Cervical cancer occurs more often in women older than 30 years, although it also occurs in younger women (Kolawole, 2008). The risk for CC depends on the sexual history of a woman, immune system, health status, and lifestyle (WHO, 2014b). These risk factors include: early sexual debut, having multiple sexual partners or having sex with someone who has multiple sexual partners, having sex at an early age especially for women younger than 18 years (Muñoz et al., 2006; WHO, 2014b). Women with immune system problems are at increased risk of CC, particularly if they have been exposed to HPV (Bosch and de Sanjosé, 2007; WHO, 2014b). Factors that compromise the immune system and increases the risk of CC include smoking, Human Immunodeficiency Virus (HIV) infection, history of sexually transmitted-infections (STIs), a family history of CC, ageing, and poverty (Bosch and de Sanjosé, 2007; WHO, 2014b). 1.4.1 TYPES OF CERVICAL CANCER There are two types of CC; the squamous cell cancer and adenocarcinoma, which were named according to the cell types that become cancerous (Muñoz et al., 2006; WHO, 2013a). The squamous cell cancer is the commonest type , but they are both treated in the same way (Bosch and de Sanjosé, 2007). In addition, the squamous cell cancers of the cervix occur in 85% cases and about 99.7% of these cases are associated with one or more HPV strains (Muñoz et al., 2006; Kolawole 2008) 1.4.2 SIGNS AND SYMPTOMS OF CERVICAL CANCER The pre-cancerous cervical lesions and CC are often asymptomatic (WHO, 2013a; WHO 2014b). By the time symptoms appear, the cancer cells could already have spread. However, when symptoms do occur, the first signs may include vaginal bleeding, moderate pain during sexual intercourse and vaginal discharge (WHO, 2014b). Advanced CC clinical features may include weight loss, fatigue, pelvic pain,


back pain, leg pain, swollen legs, heavy vaginal bleeding, bone fractures, leakage of urine or faeces from the vagina and loss of appetite (WHO, 2014b).

1.5 ECONOMIC BURDEN OF CERVICAL CANCER The development of CC occurs between the fourth and sixth decades of life which is preceded by precancerous changes about 10-20years (WHO, 2006). It usually affects women above 30years, which is usually the period they contribute to economic productivity (WHO 2013b). Thus, the mortality arising from CC cause significant economic loss to households, communities and nations (Kolawole, 2008). Further, the disease also places a huge financial burden on the economy (Kutikova et al., 2005). This is because CC patients compared to those without CC have higher utilization of health care service, higher costs of hospitalization, more radiological and laboratory procedures and require more pharmacy-dispensed drugs, more emergency room and outpatient office visits (Kutikova et al., 2005). Further, the disadvantaged women with CC may not even have access to any of these health care services due to health disparity. Thus, a cost-effective intervention such as Cervical Screening (CS) could potentially save numerous lives.

1.6 JUSTIFICATION FOR SYSTEMATIC APPRAISAL (SA) Cervical cancer is a major public health burden worldwide because it is a preventable life threatening disease, with long-term morbidity, mortality and premature death (WHO, 2006). Most cases of CC die at their prime age when raising children, caring for their family and contributing to their social and economic environment (Kolawole, 2008). Such demise brings personal tragedy, pain and avoidable loss to their society (Arulogun and Maxwell, 2012). Unfortunately, Nigeria lacks a national CC control program which has been identified as a basic requirement for national intervention (Arulogun and Maxwell, 2012). Tackling CC is therefore important in achieving the WHO Millennium Development Goal (MDG) 5 which is to reduce by three quarters the maternal mortality ratio by 2015 (WHO, 2014c). In addition, CC control will also contribute to the eradication of poverty, promotion of gender equity and indirectly contribute to the THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 12

achievement of universal primary education and reduction of child mortalit y (Kolawole, 2008) which is in line with the MDG 1, 2, & 3 because of the impact of CC on poverty, education and gender inequality (Witteta and Tsua, 2008). In order to achieve a successful outcome in the fight against CC, there is need to review the barriers responsible for the low uptake of CS and develop a framework on these barriers within Nigeria context, as it is crucial for determining policies and interventions. A good research study starts with a literature review of some sort (Kitchenham, 2004). However, unless a literature review is thorough and fair, it is of little scientific value, this is the main rationale for undertaking SA (Kitchenham, 2004). According to Glasper and Rees (2013) SA is a way of identifying, evaluating and interpreting all available research relevant to a particular research question, or topic area, or phenomenon of interest. While a SA itself is a form of a secondary study, individual studies contributing to a SA are called primary studies (Payne and Payne, 2004) SA is the best fit for this study because primary research has been carried out in a bid to discover the barriers to CS in Nigeria. To the best of the author’s knowledge, a SA has not been carried out on this topic. Therefore there is a need to carry out a SA, in order to update research and add to the existing body of knowledge. SA enables researchers to establish what he/she knows. Further, they are excellent tools for documenting knowledge gaps in the literature which can be used to shape future research agendas (Copper et al., 2009).

1.7 RESEARCH AIM This study aims to carry out a SA on the potential barriers restricting the uptake of CS among women (15-60years) In Nigeria. Identifying these barriers is a step to enabling holistic, effective interventions, if the components of the intervention can target the various factors that act as barriers to uptake of CS. The objectives of this study are as follows: I. To explore the perceived barrier to CS uptake among women (15-60years) in Nigeria.


II. To draw a conceptual map of perceived barriers influencing CS uptake among women (15-60years) in Nigeria.

1.8 RESEARCH QUESTIONS The research questions to be answered are: 1. What are the preventive measures available for CC and how effective are they? 2. What are the perceived barriers restricting the uptake of CS among women (1560years) in Nigeria? 3. What are the possible ways to improve access to CS in order to reduce the perceive barriers in Nigeria?

1.9 CHAPTER SUMMARY This chapter provided a brief summary on the burden of CC among women globally and in Nigeria, the rationale for the study and why SA is best fit for this research. The next chapter presents information from the review of literature in the topic area.


CHAPTER TWO LITERATURE REVIEW


2.1 CHAPTER OVERVIEW This chapter provides a comprehensive review of literature on the preventive measures of CC, the effectiveness of these measure and the barriers to CS uptake among women in Nigeria. This chapter will begin by giving a brief account of the search methodolog y.

2.2 LITERATURE REVIEW SEARCH METHODS In order to search for relevant numbers of literature for this research, an extensive literature search was carried out on these electronic databases: NORA, Pub-Med, CINAHL, Cochrane library and Grey literatures such as unpublished MPhil and PhD Thesis were also included in the search. The searched keywords were developed using the Population (P), Intervention, (I), Comparison (C), Outcome (O) (Khan et al., 2011). Below are the key search terms and their alternatives used. Key terms P

Women

Alternative terms used Female, ladies, married women, female nurses, market women, single mothers, female workers, female students.

I

Cervical screening and HPV Pap smear, cervical cytology, Visual inspection vaccination

C

of cervix, HPV diagnostic and HPV vaccine

Not applicable to this SA as Not applicable to this SA it is not comparing anything

O

Barrier to cervical screening

(Limitation, factors, restriction, attitude,) to (Pap

uptake

smear, cervical cytology, Visual inspection of cervix, HPV diagnostic) utilize, access


2.3 PUBLIC HEALTH INTERVENTIONS FOR CERVICAL CANCER PREVENTION AND CONTROL: A COMPREHENSIVE APPROACH WHO recommends a comprehensive approach to CC prevention and control (WHO 2013a). The recommended set of actions includes multidisciplinary interventions across the life course as shown in Figure 2 (WHO, 2013b). Some of these include community education, social mobilization, vaccination, screening, treatment and palliative care (WHO, 2013a). Other recommended preventive interventions are: health education on healthy lifestyle, safe sexual practices and health promotion message on smoking cessation, on healthy diet rich in vitamins, abstinence, mutual monogamy, male circumcision and condom use (WHO 2013a). Implementation of CC prevention and control program contributes to the attainment of the MDG 5 (universal access to sexual and reproductive health services to improve women’s health) (WHO 2013b).

Figure 2: Overview of programmatic interventions over the life course to prevent HPV infection and cervical cancer. Source: WHO, (2013b)


2.3.1. PRIMARY PREVENTION: HPV VACCINATION One of the most effective public health interventions for combating infectious diseases is the introduction of vaccines (Chauke -Moagi and Mumba, 2012; Levine et al., 2011). Numerous recent developments have highlighted HPV vaccine as an important prevention strategy (WHO, 2013b). For example, the 2009 WHO position paper on HPV vaccines recommended that HPV vaccination should be included in the routine national immunization programs as a public health priority (WHO, 2009). Notably, the primary prevention of HPV infection is through HPV vaccination (WHO 2013a). [As shown in Figure 2]. There are two types of vaccine, presently administered against HPV infection; the Gardasil and Cervarix which is licensed in most countries (WHO, 2013b). These two vaccines protects against 95% of HPV infections caused by HPV type 16 and 18 (WHO, 2013b; WHO, 2014b), which causes 70% of CC (De Vuyst et al, 2009; WHO, 2014b). The HPV vaccination policy as recommended by WHO should target girls 9 to13 years old who have not yet become sexually active , as both vaccines work best if administered prior to exposure to HPV (WHO, 2013b).This gives an opportunity to catalyse a life course approach to CC prevention and control from childhood (WHO 2013b). Girls who have had sex and have had the available current vaccine will still need to be screened, as it will not protect them from some oncogenic HPV types that still contribute to about 30% of all HPV in women (WHO, 2009). However, effective, affordable and equitable delivery strategies to reach girls 9–13 years of age three times, within a period of six months are required for a successful HPV vaccination program (WHO, 2013b). Notably, the government of most developed countries like United Kingdom have demonstrated that they could effectively incorporate the HPV vaccination into their routine immunisation programme (Hughes et al., 2014). Unfortunately, lack of required local infrastructure (HPV vaccine requires refrigeration and maintenance of a cold chain) poor service delivery, logistics needed for multiple injections, cultural acceptability, public support and political will have posed a major challenge to the achievement of HPV vaccination programs in most developing countries like Nigeria (WHO, 2013b). More so, the current market prices of HPV THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 18

vaccines range from more than US$10 to below US$100 a dose, which does not include the operational costs for delivery (WHO, 2013b). Although there has been support and donation programs from industries (such as; Gavi alliance) which provides opportunity for some of the poorest countries to access HPV vaccine (WHO, 2010; Perlman et al., 2014). Not many low- and middle-income countries are able to benefit from these support programs due to the substantial additional financial resources which countries need to secure (WHO, 2013b). Thus, the high cost of vaccine and vaccine delivery pose a major barrier to HPV vaccination program in most developing countries (Agosti and Goldie, 2007). Furthermore, the fear of safety and side effect of HPV vaccine has posed a unique challenge in the acceptance of the vaccine (WHO, 2013b) in some African countries such as Rwanda and Cameroon (Perlman et al., 2014). These unproven rumours about the side effects or adverse outcomes of the vaccine may influence public trust and adversely influence HPV immunization programming which may lead to suspension of the program overall in some countries, as lately experienced in Japan (WHO, 2013b) and India (Gilmour et al., 2013). Hence, this calls for more health education and promotion and stakeholder’s involvement, most especially the vital demographics, (adolescents, parents and healthcare professionals); in order to influence the level of willingness and acceptability of HPV vaccine and to also achieve successful implementation of HPV vaccination programs (Perlman et al., 2014). Further, due to the ethical issues involved, there is need for informed consents from parents and other care givers before administering the vaccine (WHO, 2013b). Finally, different approaches are required to reach girls not in school and who may be particularly vulnerable e.g. street children, migrants and so on (WHO, 2013b). Although these may require special efforts, reaching these girls offers a huge opportunity to provide them with other health interventions (WHO, 2013b).


2.3.2. SECONDARY PREVENTION: CERVICAL SCREENING. Cervical screening is the systematic application of a screening test in order to identify cervical abnormalities in an asymptomatic population (WHO, 2013b; WHO, 2014d). The worldwide efforts towards the prevention of CC have focused on screening sexually active

women

using

cytology

smears

and

treating

precancerous

lesion

(Sankaranarayanan et al., 2001; WHO, 2014d). The WHO has acknowledged screening coverage to be a crucial factor of providing effective prevention of CC (WHO, 2006). Thus, the WHO policy recommends screening for every woman from aged 30 to 49 at least once in a lifetime and preferably more frequently (WHO, 2014b; WHO, 2014d).There are various test used for CS; the Papanicolaou test (cytological screening tests) usually called ‘pap smear’ is the most commonly used and often considered as the most successful CS test (WHO 2006; WHO, 2014d). It looks at the morphology of cells in the cervix to check for early signs of change within 1-3 yearly screening; this varies in different countries depending on their local policies (WHO, 2013b). Other tests such as visual inspection of cervix and HPV diagnostics, Loop Electrical Excision Procedure (LEEP), and conisation seems promising, but there is not yet enough evidence of their effectiveness (WHO 2014b; WHO 2014d). In the 1960s and 1970s, the incidence rates in developed countries were similar to what is seen today in the developing world; the significant decline in the incidence and mortality of CC in developed countries has been largely attributed to effective screening programs (Franco et al., 2002; WHO, 2013b). Furthermore, evidence of pap screening effectiveness and its wide spread acceptance has been proven by observational epidemiologic studies, such as case-control and cohort investigations (Franco et al., 2002). Even though the impact has not been proved through randomised trials; it has been shown to be effective in reducing incidence and mortality from CC. (Franco et al., 2002; WHO, 2014d). CS has been identified to be cost effective, safe and has the potential of saving numerous lives if done on time (Franco et al., 2002; WHO, 2013b). Sherris et al., (2001), reported that CC incidence can be reduced up to 90% where screening quality and coverage are high. For example, CS THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 20

program has been introduced, tested and proven in some developed countries such as; United Kingdom, United States of America and

in Nordic countries; like Iceland,

Finland, Sweden, where National screening programs have been responsible for sharp fall in incidence and mortality of CC (Levi et al., 2000; Nygard, 2011) [see appendix 3]. However, the competing health care priorities, insufficient financial resources, weak health systems, and limited numbers of trained providers have made hi gh coverage for CS in most low- and middle-income countries difficult to achieve (Sankaranarayanan et al., 2001; WHO, 2013b). Therefore, national intervention and promotion strategies that will increase women’s number of visits to the clinic for screening should be considered.

2.3.3 TERTIARY PREVENTION: TREATMENT OF INVASIVE CANCER. New cases of CC are diagnosed worldwide every year that need treatments; invasive CC is usually treated either by surgery and or/radiotherapy; however, chemotherapy can complement the treatment regimes in late stages (WHO, 2014b). Unfortunately, many countries, particularly, the developing countries face the challenges of insufficient ability to provide these services which led to inaccessibility and the unaffordability of service to women affected (WHO, 2013b). Hence, it is expedient to be aware of intergovernmental arrangements and assistance for referral to neighbouring countries for countries that do not have the capacity to provide this treatment service, so as to avail this arrangement (WHO, 2013b).


2.4 POTENTIAL BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN IN NIGERIA 2.4.1 PRACTICAL BARRIERS. Ndikom and Ofi, (2012) found out that women do not attend screening service because of practical barrier such as ‘not getting around to do it’ or ‘difficulty in booking an appointment’ (Ndikom and Ofi, 2012). This finding corroborates with a Swedish Study that reported that non-attendance to CS was positively associated with time-consuming and economic barriers (Eaker et al., 2001). Time constraint is a problem because women have so many obligations and sometimes women, particularly in the rural areas who are the bread winners believe that time used to attend CS may be used to farm and market their goods to fend for their daily living; thus, CS could be given less priority in demanding real life settings (Nygrd et al., 2006). Long distance to health centre also contribute to this, as most centres offering CS are usually in tertiary hospitals which in most cases are far particularly for women living in the rural settlement (Arulogun and Maxwell, 2012). 2.4.2 EMOTIONAL BARRIERS. One of the primary reasons for opting out of CS was emotional reasons which are based on the fear of the result and anxiety about how the screening will be done; positive result is sometimes seen as a death sentence and hence, screening is avoided (Ndikom and Ofi, 2012; Chigbu and Aniebue , 2012 ). This supports the finding of Were et al., (2011) who reported that key barrier to access to CS in Kenya was the fear of positive screening (or abnormal pap smear) result. The reasons given for low uptake of CS such as fear of the results and not being a candidate for CC have been highlighted in earlier studies in Uganda (Mutyaba et al., 2006) and Owerri, Nigeria (Ezem, 2007). More so, for some women, Pap smear test procedure is embarrassing or traumatic, which may be one of the reasons why high risk groups are not reached (Arulogun and Maxwell, 2012). Furthermore, some women perceive the screening test to be painful; thereby avoiding screening (Chigbu and Aniebue, 2012). It is therefore important to THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 22

ensure high quality care at screening centre, where women are being treated with respect. Magawa et al., (2012) hypothesized that women will not attend preventive care services if they will not be respected and treated properly. 2.4.3 SOCIOECONOMIC BARRIERS. Poverty remains a major problem in low resource countries like Nigeria (Anorlu, 2008). Also poor health awareness, insufficient health centres with pap screening facilities, poor referral system and lack of a national screening program has been identified as one of the major socioeconomic barriers that hinders uptake of CS in Nigeria (Ezechi et al., 2013; Kolawole, 2008). Ndikom and Ofi, (2012) highlighted that most screening programs rely on pap smear which are complex and costly to run, especially, in developing countries where health systems and infrastructures are weak. Although some CS efforts have been carried out by government organizations and some nongovernmental organizations in very few designated medical facilities across the country, their impact has been limited with only tiny proportion of eligible women accessing the free screening services (Kolawole, 2008). Barriers to using these services include great physical distance to these facilities and shortage of skilled staff (Cronje, 2005). Ezechi et al., (2013) reported that women attributed financial constraint (cost of screening) as the major reason for their refusal to take the test, as the available services for them are not free. The unbearable health cost prevalent in the country, especially for rural women means that a day away from the farm, shop or work will mean a huge loss to their family income (Awodele et al., 2011). In addition, lower socioeconomic group women have been observed to be less likely to attend CS (Ezechi et al., 2013) and access other health services in relation to their need, an observation widely defined as the ‘inverse care law’ (Adam et al., 2004). Evidence also showed that people from deprived communities are less likely to use palliative care services (Rachet et al., 2010), due to less available services in such area with increased rate of health deprivation and low level of awareness of available services among such communities (Rachet et al., 2010). THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 23

2.4.4 KNOWLEDGE AND UNDERSTANDING BARRIERS A number of studies have identified low awareness and poor knowledge as one of the major factors hindering the uptake of CS in Nigeria (Ezechi et al., 2013; Kolawole, 2008; Awodele et al., 2011). Ndikom and Ofi (2012) pointed out that some women think that CS is for educated people. Also, many people are non-chalant to their health, especially when they are healthy; they tend not to bother about preventive services as they have other contending problems. Hence, it is seen as generally not important (Ndikom and Ofi 2012). A similar finding was also observed from the study in Ghana, where 47% of women felt they were not at risk of CC (Abotchie and Shokar, 2009). Furthermore Akujobi et al. (2008) reported that lack of knowledge of CC and CS and where to obtain screening services were reasons for the low uptake of Pap smear in a study carried out among women in south eastern Nigeria. Literacy level among women in rural communities in Nigeria is low, which has a negative impact on their total quality of life, ranging from health care access to health seeking behaviour (Denny et al., 2006). According to Witteta and Tsua (2008), lower level of female education is associated with decreased maternal and infant health. While the availability of statistics on knowledge, awareness and practice is limited in developing countries like Nigeria, evidence suggests that awareness among poor women on the existence and importance of screening is extremely low (Arulogun and Maxwell, 2012). In rare cases where services do exist women are not aware of them (Arulogun and Maxwell, 2012). There is an urgent need to increase awareness as well as provide affordable CS services in health centres. 2.4.5 CULTURAL AND RELIGIOUS BARRIERS In some African communities, low awareness is aggravated by the belief that cancer is linked to ‘witchcraft’ and can be cured using traditional medicine, posing a further obstacle to prevention and treatment (White et al., 2012). Also, Denny, (2005) revealed that, most CS tests involve pelvic examination, which is culturally and religiously not accepted for many women in some communities in Nigeria, thus hindering CS uptake. This concurs with the studies by Were et al., (2011) and Wright et al., (2010) who found THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 24

out that some women belief that diseases are only from the devil and the children of God cannot have it; this is what they are made to believe by some religious leaders in Nigeria. Furthermore, in most developing countries like Nigeria, women cannot take a decision whether to participate in a life-saving test due to socio-cultural and religious impediment, hence the need for partner’s permission before uptake. This is a major challenge to a woman’s health and needs to be addressed (Ndikom and Ofi , 2012). Other barriers to uptake of CS include language barrier and unhelpful attitudes of health professionals (Ndikom and Ofi, 2012).

2.5 CHAPTER SUMMARY This chapter has broadly reviewed existing literature on the preventive strategies for CC and also identified the barriers to CS. It has also given insight on policies set up to fight CC. Quite a number of barriers to CS were pointed out from the literature, some of which include fear, cost, low and poor awareness, ignorance, time constraints, culture and religious belief. The next chapter will give detailed information on the methodology used for the SA.


CHAPTER THREE METHODOLOGY


3.1 CHAPTER OVERVIEW This chapter presents underpinning philosophy for this SA which is evidence based practice (EBP). It follows on with a discussion of secondary data analysis and systematic review (SR) as well as its strengths and limitations. This chapter describes the methods and stages used in the SA, which are; i) search strategy, including relevant search terms; ii) applying inclusion and exclusion criteria to refine the search; iii) study identification flow chart; iv) conducting quality assessment of studies selected for the appraisal; and v) data extraction.

3.2 METHODOLOGY 3.2.1 EVIDENCE-BASED PRACTICE ‘Evidence-based practice’ (EBP) was one of the health and social care practice slogans in the 1990s, which was established in the 1980s at McMaster University medical school as a method of relating a process of problem-based clinical teaching and learning that involved students and clinicians, searching for and evaluating the evidence for clinical practice (Sackett et al., 1996; Evidence Based Medicine Working Group, 1992). Its philosophical origins, however, can be found in mid-nineteenth-century in Paris (Sackett et al., 1996). EBP remains an important topic and has progressively drawn the attention of policy makers, public health practitioners, clinicians as well as the public (Petticrew and Roberts, 2006; Sackett et al., 1996). Sackett (1997) stated that EBP is being practiced by different disciplines of health, such as evidence -based surgery, evidence-based dentistry, evidence-based nursing and evidence-based public health (Sackett, 1997).The aim of EBP is to do the right thing, at the right time, for the right person; in other words, ensuring quality care for the individual client. This is achieved by evaluating ideas, practices and previous events and applying the learning achieved to future practice (Cluett and Bluff, 2006). According to Trinder, (2000) there is an essential need for the philosophy of EBP in professional practice. This may suggest the reason why EBP, among health care in all spheres and many other domains such THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 27

as education, management and social work has been so widely and promptly adopted. Due to the worldwide acceptance of EBP, it has been considered the gold standard of health care (Sackett et al., 1996). Sackett et al., (1996) defined evidence-based medicine as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’. According to Cluett and Bluff, (2006), there are five steps to EBP process which are; ask practice-focused questions, frame the questions to find an answer, search, identify and access the potential evidence, evaluate the quality of evidence and decide what is the best evidence, apply the best evidence to the specific case evaluate the EBP care provided, and the processes by which care decisions were reached. An important feature of EBP is dynamism and openness to continuous review, with the purpose of constantly updating practice (Cluett and Bluff, 2006). EBP is not limited to a particular study design/methodology such as randomized control trial and meta-analysis (Sackett, 1997). It involves applying the best available external evidence that will solve problem identified (Sackett, 1997). One of the major concerns identified about EBP is that, it becomes dogmatic and may be used as cost cutting and ‘cookbook’ practice (Sackett et al., 1996). In other words, it may become a cheap intervention for a specific problem (Sackett et al., 1996). For this systematic appraisal, EPB is not used as a cookbook but rather, as the underpinning philosophy for this research.

3.3 SECONDARY DATA ANALYSIS There are several definitions of secondary data analysis found in different literature, many of which have subtle differences which together imply a lack of consensus about what is meant by the term. However, Boslaugh, (2007) defined secondary data analysis as a methodology for doing research using pre-existing statistical data. Payne and Payne (2004) also stated that, secondary data analysis is the re-analysis of qualitative, quantitative data as well as mixed data sets which were previously collected from a study by an independent researcher with the aim of addressing a new research question. Usually, researchers start their careers conducting analysis of existing datasets; this can be a key foundation to successfully starting a research career (Smith THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 28

et al., 2008). Therefore, it is always wise to begin any research activity with a review of the secondary data (Smith et al., 2008). There are several strengths and limitation of secondary data analysis (Smith, 2008; Smith et al., 2011a; Payne and Payne, 2004) some of the strengths include: (a) Secondary data analysis can be carried out rather quickly compared to the way primary data gathering and analysis is being done (b) Researchers save time and mo ney where good secondary data are available by making effective use of available data rather than collecting primary data, thus avoiding duplication of effort. (c) Secondary data analysis allows trend analysis depending on the level of data aggregation, thereby creating a relatively easy way to monitor change over time. Some of the limitations are; a) It is often difficult to determine the quality of the primary data used in secondary data analysis; in addition, the sources of the finding may also conflicts each other. This SA used a Strengthening the Reporting of observational Studies in Epidemiology (STROBE) checklist and Rees 2011 generic model for critiquing quantitative research to determine quality of each of the selected studies (Glasper and Rees, 2013; Von Elm et al., 2008). b) The goals and purposes of the original researcher can potentially bias the study as secondary data is usually not collected for the same purpose which the original researcher had. Six studies that best answer the research questions of this SA were used c) Since the data used in secondary research, were collected by other researchers, of which they decide what to collect and what to omit, thus, all the desired information may be unavailable. Peer reviewed articles were used for this SA to overcome this limitation.


3.4 SYSTEMATIC REVIEW AND EVIDENCE-BASED PRACTICE (EBP) Systematic review (SR) has it history as far back as 1753, from the work of James Lind on scurvy where Lind recognized the need to systematically review 20 existing literature on scurvy and thrust aside weaker evidence (Booth et al., 2012). Steven, (2001) highlighted that SR is the heart of the new EBP. Systematic reviews (SRs) give a strong evidence to underpin EBP (Khan et al., 2011). SRs in EBP provide practitioners a medium to gain access to pre-filtered evidence (Schlosser, 2007). According to Guyatt & Rennie, (2002) pre-filtered evidence is established when an expert has reviewed and presented the methodologically strongest data in the field of a substantive area. Schlosser, (2007) highlighted that pre-filtered evidence can considerably save practitioners time, especially when they rely on someone else’s expertise. Basically, SR seeks to amalgamate the results of several original studies by using strategies that delimit bias (Cook et al., 1997).

Systematic review differs from the traditional narrative review. In a narrative review, an expert who is contented writes concerning a particular field, condition, or treatment (Garg et al., 2008). It also relies on the author’s preference as the author(s) pick which ever criteria and search any databases; methods are often not specified and cannot be imitated (Booth et al., 2012; Petticrew and Roberts, 2006). However, in contrast to narrative review, systematic review adhere to a set of scientific methods intimately which explicitly aim to limit systematic error (bias), mainly attempting to identify, appraise and synthesize all relevant studies (of whatever design) in order to answer a particular question or set of questions (Petticrew and Roberts, 2006). It also adheres to a thorough scientific design based on definitive, pre-specified and duplicable methods (Khan et al., 2011). Although narrative reviews have a wide range of benefit of being a broad overview of relevant information gathered from years of practice of an experienced author (Garg et al., 2008). SRs significantly reduce the time it would take to locate and subsequently appraise and synthesize individual studies (Schlosser , 2007). Furthermore, SRs can be used to determine exposure or risk factor; exposure is THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 30

considered to be effective predictors of negative outcomes (Schlosser, 2007). Awareness of such risk factors could serve as a towards for the development of better technology (Schlosser, 2007), thus, SR has the potential to offer data-based rationales needed to pursue certain development projects and also provides rationales for the need to establish a particular research project (Schlosser, 2007). In addition, SR is not only helpful for implementation of EBP but also for taking stock-relative to a particular set of question as well as for the shaping of future research (Booth et al., 2012). Despite these various benefits, SR may differ greatly in quality and as well as in the trustworthiness of the yielded outcomes and recommendations (Booth et al., 2012; Schlosser, 2007).

3.5 STRENGTHS AND LIMITATIONS OF SYSTEMATIC REVIEW The major advantage of SR is that they provide information about the effects of some phenomenon across a wide range of settings and empirical methods (Glasper and Rees, 2013). If studies give consistent results, SR provides evidence that the phenomenon is robust and transferable. If the studies give inconsistent results, sources of variation can be studied (Garg et al., 2008; Kitchenham, 2004; Mulrow, 1994). Another strength of SR, in the context of quantitative studies, is that, it is possible to combine data using meta-analytic techniques; this increases the likelihood of detecting real effects that individual smaller studies are unable to detect (Kitchenham, 2004). However, increased power can also be a disadvantage, since it is possible to detect small biases as well as true e ffects (Garg et al., 2008). In addition, SR can study rare events by accruing events from all original studies (Leibovici and Reeves, 2005). Further, issues and questions that are important to patients and public health can be focused on in SR rather than a single drug or intervention, thus pointing out areas where evidence is lacking (Loannidis and Lau, 1999). Furthermore, SR adopts a scientific method that limits random and systematic errors of bias that might be intrinsic in the primary research and reports (Mulrow, 1994; Leibovici and Reeves, 2005). This is THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 31

another well acknowledged strength of SR. For policy makers, SR may provide robust and reliable summaries of evidence in which decision on policies can be drawn (Petticrew and Roberts, 2006). Despite the aforementioned strengths, SR has some limitations. Bias has been identified as a major limitation of SR; some of which includes language and publication biases (Petticrew and Roberts, 2006; Centre for Reviews and Dissemination (CRD) 2008). Language bias occurs when primary studies reviewed has been restricted to only those published in English language, thus, studies with positive findings are more likely to be accessed because searches are limited to English language (Mulrow, 1994; Petticrew and Roberts, 2006). Garg et al., (2008) highlighted that studies with negative findings from non-English speaking countries are usually published in journals with local language. Likewise, publication bias is another form of selection bias in which the research that appears in the published literature is systematically unrepresentative of the totality of the completed research work (Rothstein et al., 2005; CRD 2008), this leads to a selective underreporting of research studies in order to increase the chances of getting the paper published. While SR adopts systematic approaches that help to identify defects in the literature, it does not conquer the problems that are innate in the design and execution of the primary studies nor the errors that occur in the several methodological shortcomings of each of the primary studies (Garg et al., 2008). SR focus only on the methods used to evaluate the effect of interest in the primary studies by a group of researcher while SA is by a lone researcher (Garg et al., 2008).

3.6 METHODS 3.6.1 SEARCH STRATEGY Bias reduction is a significant advantage of SR, in which conducting a meticulous search of the literature to identify relevant studies is a major factor in reducing bias (CRD, 2008). The guidelines for carrying out reviews in health care developed by the Centre for Reviews and Dissemination (CRD) of the University of York guided the search for relevant studies in this research. The key search terms and strategy were THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 32

carried out based on the aims and questions of this SA

with all the basics of the

research questions included using the Population (P), intervention, (I), comparison (C), Outcome (O) model (Khan et al., 2011). The concepts include barrier to uptake, cervical screening and women. Furthermore, these concepts were broadened using several synonyms as well as other related words that some researchers might have used in literatures. Electronic databases of different types were searched to find relevant studies. Bibliographies and references from other articles were also carefully scanned to identify and extract information from relevant papers. 3.6.2 CONDUCTING THE SEARCH The following were the electronic databases searched for primary studies: 1) Applied Social Sciences Index and Abstracts (ASSIA) 2) Web of knowledge 3) Medline 4) Science Direct 5) Pub-MED In search of the relevant literatures, the following were the key words used separately and combining the keywords with the words: “cervical screening*” OR pap smear, cytological screening, screening of the cervix, visual inspection of cervix and HPV diagnostics; “barriers to uptake*” OR Limitations to utilization, restriction to use, and hindrances to uptake; “women*” OR mothers, married women, female workers, ladies, female student. The asterisk denotes the special symbol to abbreviate a search term in order to search for all the diverse word of the terms. With women*, for example, search engine showed all words with ‘women’, that is women’s, female, ladies, female student, married women, market women, urban and rural women, single mothers, female workers, single ladies. The use of the Boolean operator ‘OR’ was integrated as a search engine to retrieve studies with any other synonyms. Excluder tabs were further used in Medline search THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 33

database so as to narrow down the search results. In order to limit the result to Nigeria, the country of focus in this SA, the geography excluder tab was used. Furthermore, the age excluder tab was used to filter down the search results to limit it to the population of interest, which are women of reproductive age. Alternatives used from the age excluder tab were women, mothers: 15 years above; females:15 -60years; market women: 1560years; ladies: 15-60years, married women: 15years-60years, single mothers: 1560years. Major topics and abstracts that were clearly not relevant to the aims of this appraisal were excluded, some of which include abstracts on breast screening, colorectal screening and HPV vaccination. Table1. Summary of search results No

Databases

Number of Hits

1

ASSIA

953

2.

Science direct

1168

3

Web of knowledge

112

4

Medline

78

5

PUB-MED

214

Total

2525

3.6.3 REFINING THE SEARCH All the articles retrieved were exported to Endnote Web Reference Management Software and duplicate records were removed. An initial screening of titles and abstracts was conducted and those that were not relevant to the aim and research questions were excluded. A more detailed review of the remaining abstracts was undertaken to ascertain their eligibility. Full texts of potentially eligible studies were obtained (either directly from the database or by request from the Library) and reviewed to determine whether they merited inclusion.


3.7 INCLUSION AND EXCLUSION CRITERIA SA draws on the use of scientific methods which decreases random and systematic errors of bias, defining a set of inclusion and exclusion criteria forms a major component of the appraisal process (CRD, 2008). According to CRD (2008), it is essential that decisions about the inclusion of studies are made according to predetermined written criteria stated in the protocol. In this research, essentials of the review questions were developed in order to establish the specific inclusion and exclusion criteria for selecting studies for this review. 3.7.1 INCLUSION CRITERIA The studies included in the SA were studies conducted in Nigeria, this because CC is the 2nd most frequent cancer and major contributor of death in women of reproductive age in Nigeria (ICO, 2014). Studies that highlighted CS has a mode of prevention of CC were included because this is the intervention that addresses the research aim and the focus of this SA; also cross sectional quantitative studies that identified barriers to CS uptake were included. Cross sectional quantitative research is a major element in EBP as it lays emphasis on accuracy of data collection methods which is critical to answering the research question (Glasper and Rees, 2013). Further quantitative studies are the research method that concentrates on the describing and analysing phenomena by using numerical data and empirical models (CRD, 2008); this has been chosen for this research as it will best answer the research questions posed by this SA. Studies with a study population of women (15-60years) comprising of both married and single women were further included. This age band was chosen because women age 15years and above are at risk of CC in Nigeria (ICO, 2014; Bruni et al., 2014). Peer reviewed primary research papers were the only selected type of papers for this SA, as this study aims to identify methodologically sound studies. Peer reviewed papers were selected as they have been appraised for its quality by experts in this particular area of study. In addition, only peer reviewed studies published in English were included as it is a requirement that meets the examination regulation of Northumbria University. Studies with full text published from January 2004 onwards were included as this will provide recent THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 35

information on the research topic. Full text articles will give a full detail of the selected studies.

3.7.2

EXCLUSION CRITERIA

Studies that used HPV vaccination as prevention of CC were excluded. HPV vaccination is only recommended for girls ages 9-13year who are not sexually active, thus the focus of this study is on prevention of CC for women 15-60years of age which is CS. Studies that excluded barriers preventing the uptake of CS and focused only on the level of awareness and knowledge of CC alone were excluded as they do not answer the questions posed by this SA. Publications in foreign languages, due to the cost and time involved in translating materials were excluded; papers prior to 2004 were also excluded, as studies prior to that period were considered obsolete. Also, some studies such as SRs, non-peer review literatures, editorials, commentaries, expert opinions and policy documents were also excluded as these are not peer review studies [see appendix 1 for excluded studies].

3.8

SEARCH RESULTS

Across the five databases, the search for primary result yielded a total of 2525 ‘hits’. 2500 was excluded after the initial screening of the title using the inclusion and exclusion criteria. This resulted in the filtering and detection of duplicated and repetitive studies by using the Endnote Web Reference Management Software. The abstract of 25 relevant papers were examined further and 10 studies were excluded as these did not. This serves as the first stage of the appraisals where a total of 15 studies were selected; finally 6 quantitative studies were selected and considered eligible as it fits into the inclusion criteria of this SA.


Table 2. Selected studies for the appraisal Authors and publication date

Title of studies

Labelled

Utoo, B. T., Ngwan, S. D., & Anzaku, A. S. Utilization of screening services for cancer of the S1 (2013). cervix in Makurdi, Nigeria. Oche, M. O., Kaoje, A. U., Gana, G., & Ango, Cancer of the cervix and cervical screening: J. T. (2013). Current knowledge, attitude and practices of female health workers in Sokoto, Nigeria. Nwankwo, K. C., Aniebue, U. U., Aguwa, E. Knowledge, attitudes and practices of cervical N., Anarado, A. N., & Agunwah, E. (2011). cancer screening among urban and rural Nigerian women: a call for education and mass screening.ecc Eze, J. N., Umeora, O. U., Obuna, J. A., Cervical cancer awareness and cervical screening uptake at the Mater Misericordiae Egwuatu, V. E., & Ejikeme, B. N. (2012) Hospital, Afikpo, Southeast Nigeria. Owoeye, I. O. G., & Ibrahim, I. A. (2013). Knowledge and attitude towards cervical cancer screening among female students and staff in a tertiary institution in the Niger Delta . Awodele, O., Adeyomoye, A. A. A., Awodele, A Study on Cervical Cancer Screening Amongst D. F., Kwashi, V., Awodele, I. O., & Dolapo, Nurses in Lagos University Teaching Hospital, D. C. (2011). Lagos, Nigeria.

S2

S3

S4

S5

S6


Figure 3. Study identification flow charts Potentially applicable citations from an electronic database search; ASSIA+ Science direct+ Web of knowledge+ Medline + Pub-med + list of references from other studies. N= 2525

Studies with different topic, different aim, different study population and different intervention were excluded.

Excluded

N=2500

Retrieval of electronic copies of potentially applicable studies. N= 25 Excluded Studies excluded after evaluation of abstracts N= 10

Retrieval of full text of potentially applicable studies to be included. N= 15 Studies excluded after critical appraisal of full text using the inclusion criteria N=9

Excluded

Studies selected for the final appraisal N=6 THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 38

3.8.1 QUALITY ASSESSMENT In SR, quality assessment is used as a tool for weighing and excluding studies using quality scores (Harden et al., 2004). Quality assessment of individual primary study helps the researchers to assemble studies based on their quality before any synthesis or interpretation of results. This allows the researcher to scrutinize and identify areas where there are systematic differences between primary studies in dissimilar quality group (Kitchenham, 2004). A thorough quality assessment is often based on quality instruments, which serves as checklists derived from a consideration of factors that could bias study results, in which each study can be assessed (Harden et al., 2004). However, numerical assessments of quality can be obtained if quality items within a checklist are assigned numerical scales (Kitchenham, 2004). According to CRD (2008), the main aim of assessing quality is to ascertain how the results from a study are liable to be and how vital they are to the target population of interest. Although primary studies are sometimes poorly reported, it may not be possible to establish how to assess a quality criterion. However, it may be possible to assume that due to lack of reporting on a research method study, it can be assumed that it was not done; which may not be right (Kitchenham, 2004). Therefore, as a researcher, it is vital to attempt to obtain more information from the authors of the primary study if a vailable.

In SR, a critical appraisal framework for experimental studies such as RCT, quasi experimental are well developed and readily available, unlike non-experimental research, such as observational studies (Harden et al., 2004). Thus, a need for frameworks for reporting and critically appraising such studies was required. In 2004, strengthening the Reporting of observational Studies in Epidemiology (STROBE) initiative was developed. This is a set of checklist and guidelines for standard reporting of observational research using the STROBE initiative (Kumar and Bala, 2011). According to Von Elm et al., (2008) the STROBE statement was set up to help authors and researchers carrying out analytical observational study and to help editors and


reviewers when considering such articles for publication as well as readers who deem it fit to critically appraise articles. Applying the elements from the STROBE checklist and Rees 2011 generic model for critiquing quantitative research (Glasper and Rees, 2013; Von Elm et al., 2008). A seven (7) scoring system quality assessment checklist was developed, to evaluate the quality of the studies used for this SA. This scoring system enables the researcher to evaluate if the study met the criteria or not. In the scoring system, ‘completely’ denotes (2 points), ‘partially’ denotes (1 point) or ‘not at all’ denotes (0 point). For a study, the maximum score of 14 points was achievable. Table 3 below shows the methodological quality assessment for each individual study in details. Table 3. Methodological quality of included studies NO

Criteria

S1

S2

S3

S4

S5

S6

1

Coherent title and abstract with an objective summary of the whole research Introduction: good theoretical framework and literature review, rationale and specific objectives clearly indicated Methods: study design, setting, study population, eligibility criteria and data collection tools clearly indicated Variables: well defined variables of interest (dependent and independent variables), data measurements, statistical methods and reliability and validity of methods The results: descriptive data, outcome data and main results explicitly indicated Discussion: key results discussed linking to objectives and wider evidence, study limitations and generalizability (external validity) discussed. Ethical approval or informed consent explicitly indicated Total score/14

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

1

2

2

2

1

1

2

2

2

2

2

2

1

1

2

1

1

1

1

2

2

2

2

0

11

13

14

13

12

10

2

3

4.

5. 6.

7.

Criterion key: Completely met – 2 points; partly met – 1 point; not met – 0 point THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 40

The result from the quality evaluation above showed that all the primary quantitative six studies have met a reasonably satisfactory eminence standard. Among the six studies the least score gotten by a study was 10/14 (N=1) while the highest score achieved was 14/14 (N=1). On the whole, all the six studies met the first three criteria completely, which are: clearly stated title and objectives, good theoretical framework and literature review, sampling made clear, data collection methods and clearly stated variables of interest. However, five of the studies only partly met Criteria 6 on the checklist, indicating that these studies did not state the limitations and generalizability of their studies. In addition, one of the studies did not meet Criteria 7 at all and one other study partly met Criteria 7; indicating that these studies did not pay attention nor stated their ethical considerations. Finally, three of the studies partly met Criteria 4, as the other studies did not indicate the reliability and validity of their findings.

3.8.2 DATA EXTRACTION AND SYNTHESIS In SRs, data extraction precedes data synthesis. Data extraction is the process whereby necessary information about the study characteristics and findings from the included study are obtained by the researcher. Although this varies from review to review, the review question is used to tailor the extraction forms (CRD, 2008). Data extraction is an essential part of SRs because there are different layouts and styles of reporting in primary studies, thus a need to highlight and collate main data rudiments of interest and provide standardization (Social Care Institute for Excellence (SCIE), 2006). Table 4 presents the standardized data extraction structure used for quantitati ve survey in this SA. This data extraction structure was used to gather information needed for description and analysis.

Data synthesis involves the collation, combination and summary of the findings of individual studies included in the SRs (CRD, 2008). For data synthesis in this SA, narrative synthesis was used. Narrative synthesis involves the adoption of a documentary approach which presents an analysis of the relationships within and THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 41

between studies with an overall assessment of the robustness of the evidence (CRD, 2008). The findings from the primary studies were extracted (data extraction) and then synthesized (data synthesis) in order to generate themes relevant to the aims and questions of this SA. The next chapter presents the themes of the synthesized findings.

Table 4. Standardized quantitative (survey) data extraction Study title

Sampling

Intervention

and aim(s)

Outcome

Results

Comment

measure

3.9 CHAPTER SUMMARY This chapter highlighted the underpinning philosophy of this SA, secondary data analysis and the strengths and limitations of SRs. It further examined the search strategy and methodology adopted for the SA including electronic databases, search terms and quality assessment. The next chapter will discuss in details the findings from the selected primary studies.


CHAPTER FOUR FINDINGS


4.1 CHAPTER OVERVIEW This chapter highlights the process and analysis of data extraction of the six papers selected for this SA. For each of the six studies a tabular presentation will be used for highlighting the results of the data extraction. In addition, the criteria for analysis will be consistent throughout the studies. The general quality of the six studies will be appraised by assessing the methodology, theoretical issues, sampling method, analysis process, ethical issues and considerations as well as the findings of the studies.

4.2 DATA EXTRACTION AND SYNTHESIS This SA used a consistent form of data extraction to evaluate the six studies selected for this SA. The process of data extraction is essential in SA, as this serves as a surrogate for synthesis of the study’s findings which is the deconstruction and reconstruction of the finding from each study and as well as synthesis of result from this SA. This will be discussed later in this chapter. Tables 5 - Table10 below depicts the data extraction of each of the six studies. The following information were presented on the table; aim of study, study design, sampling methods, intervention, variables, outcome measures, results and an extra column for observation and general comments. 4.2.1 CODING OF RESULTS After the data synthesis, results were generated in line with the research question. A coding system was designed to generate results , after the barriers restricting the uptake of CS were extracted. These barriers were categorised into five themes. Thereafter these barriers were checked for in each of the individual study. If barriers appeared in the study it was coded 1 and when it does not appear it was coded 0. All generated data were imported into Microsoft Excel 2007 to presents in a systematic manner result and to identify the highest occurring barrier restricting the uptake [as shown in Figure 3 below]


Table 5. S1- Utoo, B. T., Ngwan, S. D., & Anzaku, A. S. (2013) ‘Utilization of screening services for cancer of the cervix in

Makurdi,

Nigeria,’ Journal

of

Reproductive

Biology

and

Health, vol1

(1),

pp.

2.

[Online].

Available:

http://www.hoajonline.com. Study and study aim(s) Study Location/context: Makurdi, Nigeria/ urban setting Study design: Cross sectional study , interviewer administered questionnaire

Study aims: To determine the awareness and utilization of screening services for cancer of the cervix amongst women in Makurdi.

Sampling Method

Intervention

Primary outcome measures Barriers to cervical screening uptake

Participant’s Cervical average age: screening women, 35±11.2 years Dependent variable: Sampling ●Knowledge method: ●Attitude convenience sampling, Independent Structured variable: administered ●Socioquestionnaire demographic Reliability and =parity validity: not Sample size: stated 172 Data analysis: EPI Consent: Ethical INFO approval not statistical stated software informed consent version 3.2.2. obtained from participants

Results

Main themes Socioeconomic barrier: ●Cost ●Absence of screening centres

Commen t No clear approval stated

ethical

Issues relating to study limitations, reliability and validity

Knowledge barrier: ● Ignorance ●perceived non necessity Issue of sampling bias ●physician non and systematic bias due recommending to non-random sampling Cultural and Religion barrier: ●Faith in God


Table 6. S2- Oche, M. O., Kaoje, A. U., Gana, G., & Ango, J. T. (2013). Cancer of the cervix and cervical screening: Current knowledge, attitude and practices of female health workers in Sokoto, Nigeria. International Journal of Medicine and Medical Sciences, vol 5(4), pp.184-190. [Online]. Available at: http://www.academicjournals.org. Study and study aim(s)

Sampling method

Intervention

Study Location/context: Sokoto, Nigeria/ urban setting

Participant’s average age: Female health worker, 20-60 years

Cervical screening (pap smear)

Study design: descriptive cross sectional study Study aims: To assess the knowledge, attitude and practices of female health workers at Usman Danfodiyo University Teaching Hospital, Sokoto with respect to cervical cancer Pap smear screening

Sampling method: multistage sampling method, structured selfadministered questionnaire Sample size: 240

Dependent variable: ●Knowledge ●Awareness Independent variable: ●Sociodemographic ●life style

Data analysis: EPI Consent: Ethical INFO approval stated statistical informed consent software obtained from version 3.3.2 participants

Primary outcome measure Barrier to cervical screening uptake

Reliability and validity: pretest of study instrument

Result

Comments

Main theme

Reliability and validity well established by using pretested questionnaires and repeat measurements

Knowledge barrier: =Not at risk ● lack of awareness Emotional barrier: ●Afraid of experiencing pain ● Fear of the result.

Ethical stated

approval

clearly

Cultural/religion barrier: ●Do not want to be exposed to male doctor


. Table 7. S3- Nwankwo, K. C., Aniebue, U. U., Aguwa, E. N., Anarado, A. N., & Agunwah, E. (2011) ‘Knowledge attitudes and practices of cervical cancer screening among urban and rural Nigerian women: a call for education and mass screening,’ European journal of cancer care, vol 20(3), pp.362-367. [Online]. Available at: http://onlinelibrary.wiley.com. Study and study aim(s) Study Location/context: Enugu, Nigeria/ urban/rural setting Study design: cross sectional study Study aims: to ascertain the knowledge of the women in Nigeria to cervical cancer, their practice of cervical cancer screening and factors hindering the use of

Sampling method

Intervention

Participant’s average age: women, 1860years

Cervical screening(visual inspection)

Dependent Sampling variable: method: ●Knowledge convenience ●Attitude sampling method, ●Practice structured administered questionnaire Independent variable: Sample size: ●Socio1000 demographics ●Environmental Consent: Ethical ●Socioeconomic approval stated informed consent obtained from participants Data analysis:

Primary outcome Results measure Barrier to cervical Main themes: screening uptake Knowledge barrier ●lack of knowledge about cervical cancer ●No complaint =screening unnecessary ●Never thought Reliability and of it validity: pre-test of questionnaire Socioeconomic and repeating barrier measurement ●Cannot afford cost Practical barrier ●Cannot locate facility

Comment Issues of sampling and systematic bias due non random sampling method Study reliability and validity was well established by using pretested questionnaires and by repeating measurements External validity and representativeness of sample ensured due to large sample size, with sample from three different town of both urban and rural community thus, enhancing generalizability Ethical consent well carried out and stated.


available screening services

SPSS version 11 statistical programme

Emotional barrier ●Fear of outcome

Table 8. S4- Eze, J. N., Umeora, O. U., Obuna, J. A., Egwuatu, V. E., & Ejikeme, B. N. (2012) ‘Cervical cancer awareness and cervical screening uptake at the Mater Misericordiae Hospital, Afikpo, Southeast Nigeria,’ Annals of African medicine, Vol 11(4), pp.238.[Online].Available at: http://www.ncbi.nlm.nih.gov. Study aim(s)

and

study Sampling method

Study Location/context: Ebonyi, Nigeria/ rural setting Study design: descriptive cross sectional study The study aims: to assess the perception of cancer of the cervix among Igbo women who live in a rural community in Ebonyi State, Southeast Nigeria, and evaluates their predisposition and attitude to cervical cancer screening as a

Participant’s average age: women, 36.2years Sampling method: convenience sampling method, structured questionnaire

Intervention

Cervical screening Dependent variable: ●Knowledge ●Awareness

Independent variable: Sample size: ●Demographi 500 cs ●Socioecono Consent: Ethical mic status approval stated ●Lifestyle informed consent obtained from participants Data analysis: SPSS version

Primary Results outcome measure Barrier to Main themes cervical Knowledge and screening understanding barrier uptake =lack of awareness

Comment

Issues relating to sampling bias and systematic bias might occur due to non-random sampling. Study reliability and validity was well established by pre-testing questionnaire.

Socio-economic barrier ● Cost Reliability ●Non availability of Large study sample size, thus and validity: screening centres generalization and transferability pretesting of of findings. questionnair Practical barrier e ●Time constraint The study was carried out over a long period of time, thus ensuring thoroughness; however, selection bias might have occurred in the process of participant recruitment due to non-random sampling. Ethical approval and consent


means of preventing the disease

15

gotten.

Table 9. S5- Owoeye, I. O. G., & Ibrahim, I. A. (2013) ‘Knowledge and attitude towards cervical cancer screening among female students and staff in a tertiary institution in the Niger Delta,’ International Journal of Medicine and Biomedical Research, vol 2(1), pp.48-56. [Online]. Available at: http://www.ijmbr.com. Study and study aim(s) Study Location/context: Niger delta, Nigeria/ urban setting Study design: descriptive cross sectional study

Sampling method Participant’s average age: Female student and staff, 1645year

Sampling method: multistage The study aims: Sampling This study assessed method, the knowledge, level structured of perception and Questionnaire the attitude of female staff and students of Sample size: the Niger Delta 400 University, Nigeria, towards cervical Consent: cancer screening Ethical approval stated Informed

Intervention Cervical screening

Dependent variable: ●Knowledge ●Attitude

Independent variable: ●Sociodemographic

Primary outcome Results measure Barrier to cervical Main themes screening uptake Emotional barrier: ● It is painful ●It is embarrassing

Comment Ethical approval consent gotten.

and

Large sample size.

Socioeconomic barrier: ● It is expensive

Adequate primary data Reliability and to mediate between Validity: not stated Knowledge and results and findings. understanding barrier: ● Feels healthy Issues relating to reliability and validity of tools and results.


consent Data analysis: obtained from SPSS version 11. participants Table 10. S6- Awodele, O., Adeyomoye, A. A. A., Awodele, D. F., Kwashi, V., Awodele, I. O., & Dolapo, D. C. (2011) ‘A study on cervical cancer screening amongst nurses in Lagos University Teaching Hospital, Lagos, Nigeria ,’ Journal of Cancer Education, Vol 26 (3), pp. 497-504.[online]. Available on: http://link.springer.com. Study and study aim(s) Study Location/context: Lagos, Nigeria/ urban setting Study design: descriptive cross sectional survey

Sampling method Participants Average age : Female nurses, 2050years

Intervention Cervical screening

Dependent variable: ●Knowledge ●Attitude ●Awareness

Primary outcome Results measure Barrier to cervical Main themes screening uptake Practical barrier: ● Time constraints

Sampling method: Reliability systematic Validity: The study aims: random stated This investigated the sampling knowledge, attitude method, closed Independent and practice of ended variable: nurses in Lagos questionnaire ●socioUniversity Teaching demographics Hospital (LUTH) Sample towards cervical size:200 cancer screening Data analysis: Consent: EPI INFO ethical 2002 software

Socioeconomic barrier: ●Screening costly and ● Financial constrain Not Knowledge barrier: ● Lack of awareness ●The belief of being too young ●Not thought about it ●Ignorance

Comment Informed consent and ethical approval not stated by the author

Issues relating to reliability and validity of tools and results


approval not stated in the study


4.3 RESULTS This SA presented the results from the studies in two main themes: I) studies characteristics; and II) summary of the primary findings of the individual studies. However, these two main themes were further divided into sub-themes to enhance comprehensive narrative synthesis. 4.3.1 CHARACTERISTICS OF THE STUDIES APPRAISED This section explains the methods reported in each of the six primary studies. Nevertheless, these six studies have a uniform study design (cross sectional quantitative study), although some studies presented more detailed information about their sampling process, the process of data collection, method of analysis, consent and ethical issue. This may be due to the fact that some of these studies were published in journals, with higher restrictions on word limits leading to provision of limited detailed information provided even if they were carried out in the study. The six studies selected were carried out in different part of Nigeria (that is, Northern, Southern, Western and Eastern Nigeria), thus enhancing generalization. 4.3.1.1 Study designs and methodology All the six studies included in this SA used cross-sectional survey designs. Quantitative research methodology has the survey approach used scientific/positivism as the research underpinning philosophy (Creswell, 2013). Survey is a useful research design for describing the characteristics of a large population and also provides empirical data about real life situation, thus the likelihood of representation of data (Bryman, 2012). However, surveys are prone to errors. For example, sampling error could occur due to non-random sampling (Creswell, 2013). All of the six studies were descriptive as they seek to identify the barriers to CS uptake. 4.3.1.2 Location/context setting All the six primary studies selected for this SA were conducted in Nigeria. S1 was conducted in Markurdi the capital of Benue state, east central Nigeria using urban populations. S2 was conducted in Sokoto state, North-western Nigeria, using the urban THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 52

populations. S3 and S4 were conducted in South-eastern Nigeria (Enugu and Ebonyi state). While S3 was conducted among both rural and urban populations, S4 was conducted strictly among the rural population. S5 was conducted in Niger delta region in South- south Nigeria among the urban population and S6 was conducted among urban populations in Lagos state, South-western, Nigeria. The location settings for these six studies included both urban and rural population drawn across a diverse ethnic mix in Nigeria. This increases the confidence of gaining more detailed information and picture about the barriers being studied. 4.3.1.3 Sampling and population All the six primary studies used a study population that meets with the age inclusion criteria which is women between 15-60years. Furthermore, the lowest sample size was 172 in S1 followed by 200 for S6, 240 for S2, 400 for S5, 500 for S4, and the highest sample size was 1000 for S3. However S1, S6 and S2 did not give detailed information about how the sample size was determined although the sampling method used was stated. S3 and S4 gave robust and detailed information on how they arrived at the sample size used for their study.

Sampling and sample size are essential part of quantitative research as it gives essential information on the statistical generalization adducible from the result of the study to the wider population (Fox et al., 2009). The sample sizes used in the six studies were considered to be large enough although desirable sample size depends on the expected variation in the data (Creswell, 2013). Large sample size is very important as it helps to draw an accurate and correct conclusion as well as increase confidence and reduce error in the result (Nayak, 2010). Two of the six studies, (S2 and S5) used a multistage sampling. Multistage sampling is when some individuals are selected within some areas such as towns, local government areas and a random sampling is further used to select just a proportion of individuals within the selected areas (Fox et al., 2009). S1, S3, and S4 made use of convenience sampling to select participants into their studies. Convenience sampling is a non-probability sampling method where THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 53

participants are selected because of their convenient accessibility and proximity to the researcher (Creswell, 2013). However, this is prone to sampling error due to nonrandom sampling of participants in the study, making the sample size not to representative of the general population size (Fox et al., 2009). Nevertheless, convenience sampling, which is also non-random sampling are cheap, easily accessible and the subject are readily available (Creswell, 2014). S6 used a systematic random sampling method. This sampling is a probability type of sampling method where the participants of a study are selected randomly from the larger population based on a random starting point and a fixed, periodic interval (Bryman, 2012). This gives assurance of an evenly sampled population that is representative and whose result can be generalized to a larger population (Creswell, 2014), thus enhancing the study’s external validity. Non-random sampling of S1, S3 and S4 indicate limited external validity, as the researcher used a convenience sampling, which is often criticized for its limitation in generalization since the sample size may not be representative of the entire population. Hence, the finding from the studies may not speak for the entire population. 4.3.1.4 Data collection All the six studies have similarity in their data collection method as they used structured questionnaire for collecting information on the independent and dependent variables. Data reliability and validity are crucial measuring tools in data collection as well as analysis as it is used to ascertain the credibility of the study findings (Creswell, 2014). All excluding S1, S5 and S6 ensured validity and reliability by conducting pilot studies and pre-testing the questionnaire, making use of research assistants who can speak the local dialect of study participants. This was done to eliminate the language barrier. All with the exception of S3 did not state the reliability and validity by repetitions of measurements and consistency checking. Furthermore none of the studies showed nor stated how confounders were controlled for. S1, S5 and S6 did not state reliability and validity of their study. Hence the credibility of the results may not be justified.


4.3.1.5 Approaches to analysis S1, S2 and S6 used EPI INFO statistical software for data analysis while S3, S4 and S5 used SPSS statistical data analysis although they used different versions of this software. EPI INFO software helps to generate output files from the analysis, checks the survey data for inconsistencies and outliers, and conducts a descriptive analysis of survey data together (WHO 2013c). All the six studies used chi-square test and the significance association between the independent and dependent variables by testing for the p-value. S5 used t-test to determine the difference between means. S3 used multi logistic regression significant predictor. S1 and S4 used Odds Ratio (OR) and corresponding Confidence Interval (CI) where applicable. Odd ratio is the measurement of association between an exposure (independent variable) and the outcome (dependent variable) (Szumilas, 2010). In this case, independent variable is the barrier to CS uptake while the dependent variable is the uptake of CS. Usually Odd Ratio is used to establish if an exposure is a potential risk factor of the outcome / dependent variable (Szumilas, 2010). The Confidence Interval is used to give an estimated precision of the odd ratio and also depicts how reliable the result is (Szumilas, 2010). Chi-square is used to test the strength of association of two categorical variables; the exposure and outcome variable (McHugh, 2009), for example, the level of awareness of CS and uptake of CS. The P-value is used to ascertain whether the findings from a research are statistically significant or not a nd to indicate if the results of the research occurred by chances or by error. A finding is said to be statistically significant when the P-value0.05(greater than 0.05) (Davies and Crombie, 2009). 4.3.1.6 Ethics Ethics consideration in research is very important as this ensures the protection of the rights and welfare of participants, minimize the risk of physical and mental discomfort, harm and/or danger that may arise from the research procedures (Creswell, 2014). Of the six studies S2, S3, S4 and S5 obtained ethical approval from the necessary board of committee and informed consent from the participants. S1 obtained informed consent THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 55

from participants but did not state if ethical approval was collected while S6 did not state whether there was ethical consideration nor informed consent from participants. S1 and S6 overall has an acceptable methodological quality even though they did not fulfill the aspect of ethics. For this SA, there was no need for ethical approval for any part of this dissertation because this is a secondary study and also all the sources of the secondary data used in this dissertation were all properly referenced.

4.3.1 OVERVIEW OF THE FINDINGS FROM THE SIX PRIMARY STUDIES This section highlights the finding of the SA after the critical appraisal; data extraction (deconstruction) and synthesis of the data (reconstruction) for the SA were carried out.

Cultural and religion barrier 10%

Knowledge and understanding barrier 32%

Pratical barrier 16%

Emotional barrier 16%

Socioeconomic barrier 26%

Figure 4: Pie chart showing the percentage of most occurring barrier restricting the uptake of cervical screening

From the above, the result of this SA showed that knowledge and understanding barriers (33%) was the highest barrier to the uptake of CS. The other barriers follow this order: socioeconomic barriers (26%), emotional barriers (16%), practical barriers (16%) and cultural and religious barriers (10%) respectively.


These findings are discussed under these themes below. 1. Practical barriers 2. Socioeconomic barriers 3. Emotional barriers 4. Knowledge and understanding barriers 5. Religious and cultural barriers

4.3.2.1 PRACTICAL BARRIERS Time constraints and inability to locate a screening centre has been identified as barriers to uptake of CS. This was reported in S3, S4 and S6 that time constraint is a major barrier that limit women from going for CS. S6 indicated that the occupation of participants contributed to the reason why women do not go for screening. For example, participants in S6 and S2 were female health practitioners (mainly nurses). Despite working in health centres where screening facilities were available, the shift-oriented nature of their job was identified as a key hindrance towards attending screening. Nurses on day shift were particularly affected by this shift pattern. In S4, over 59% of participants were self-employed (including traders and farmer) while the rest were employed in the organized public and private sectors, unemployed or retirees. A number of these may be bread winners in their homes; thus, a day off for screening centre from work place or shop may cause a huge loss to the family income and feeding. S1 reported that single women are more likely to screen than the married women, although this finding was found not be statistically significant. This may be due to the fact that married women have more obligations in the home which may restrict the time to attend CS. However, this finding is contrary to the findings of S4 which hypothesised that there is a significant association between uptake of CS and being married. However, this was justified by the fact that married women of reproductive age are more prone to CC than the single unmarried women and older married women who have passed reproductive THE PERCEIVED BARRIERS RESTRICTING THE UPTAKE OF CERVICAL SCREENING AMONG WOMEN (15-60YEARS) IN NIGERIA. (VICTORIA OYEWOLE) Page 57

age, hence, may increase the level of uptake. S6 further revealed that the observed low uptake among predictors (health workers) shows an unsafe sign as low uptake among predictors (health workers) of its use might have a negative influence on the general population towards the uptake of screening. 4.3.2.2 SOCIOECONOMIC BARRIERS Low socioeconomic status was reported in five of the studies (S1, S3, S4, S5 and S6) as a barrier to CS uptake. All the five studies reported cost, financial constraint and absence of screening centre and facilities as key barriers to CS uptake. In S1, about 60% of the respondents were either self-employed or unemployed while less than 60% had either primary or secondary education which perhaps might have led to low socioeconomic status, as a result, cost of CS may be difficult to afford. In S3 about 70% were low income traders, farmers and housewives, who generally find it difficult to pay the cost of screening, as the money derived from their economic activities are primarily used to cater for their family. S1 further reported that women do not make use of hospital services because they are not readily available and ineffective health system in the country. This observation is consistent with S4 that showed that among the participants; with low skilled job were mostly low income earners who may not be able to afford cost of screening. Housewives or women with very low income are often very poor and very dependent on their husbands for financial support and sustenance. Consequently, money for CS might be difficult to source as the husband, who is often the sole provider in the home, may not be able to afford such expenses. Furthermore, findings from S6 showed that socioeconomic status played an important role in the demand of CS as17% of the respondents stated their inability to attend screening due to its high cost. Consequently, this has shown that there is a need for women to be encouraged to take up health insurance so as to ease payment for their health services such as CS regularly.


4.3.2.3 EMOTIONAL BARRIERS Emotional barriers such as fear of the result, embarrassment and fear of experiencing pain were reported as barriers to uptake of CS. This was reported in S2, S3, S5, and S6. From these studies, women reported their reluctance to attend CS as they presume that screening is painful and would always lead to a positive result which majority of them consider as a death sentence. In addition, findings from S5 revealed that one of the major reasons why respondent had not been screened is the embarrassment ensuing from the exposition of their genitals to either a male doctor who is not their husband or lover or to a female health worker who is a stranger. S3 reported that some health workers did not recommend CS for people because it is painful and is risky.

4.3.2.4

KNOWLEDGE AND UNDERSTANDING BARRIERS

This major barrier was identified and reported by almost all the six studies. Low level of awareness and poor level of knowledge was identified in almost all the six studies. Similarly, poor knowledge was reported in S3 and S4 to have a significant association with the low uptake of CS. Although S1 reported a high level of awareness (65%) among its respondents, this may be due to the fact that the study population were women, who attend the gynaecological clinic and have most probably being educated by the health worker during their frequent visit to hospital. Nevertheless, the finding revealed that education significantly (p-value=0.0002) affected awareness of both CC and utilization. This corroborates findings from S2 and S6 that reported a high level of awareness and good knowledge among respondents, which was not unexpected considering that they were health workers and coupled with their educational background of the subject. However, the high level of awareness did not translate to the proper uptake of screening in these respondents. Apart from the time hindrance reported earlier, the respondents in S2 and S6 perceived themselves not to be at risk of contracting the disease, thus affecting their screening behaviour.


In S6, it was highlighted that the study population had a good knowledge of CS, but had a limited understanding of the types of CS. It was further reported that there is a significant association (p