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��ࡱ�>��	.1����+,-������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	���bjbjW�W�	4$5�5��o,�������_'_'c(c(c(����w(w(w(8�(�s)�w(�R�G+��+�+�+,�4�4�4�Q�Q�Q�Q�Q�Q�Q$VW��YF�Qic(�4�2��4�4�4�Q_'_'�+,�`RH9H9H9�4�_'��+c(,�QH9�4�QH9H9��N�(JiP�+,�����=Iv$#�w(28�=O�QvR0�RUO>Z9F>Z0iP>Zc(iPT�4�4H9�4�4�4�4�4�Q�QH9�4�4�4�R�4�4�4�4��������������������������������������������������������������������>Z�4�4�4�4�4�4�4�4�4	%&:	TITLE: 	WILLINGNESS TO UTILIZE CERVICAL CANCER SCREENING SERVICES AMONG ANTENATAL CLINIC ATTENDEES IN SELECTED HEALTH FACILITIES IN IBADAN, NIGERIA   

Authors: Chizoma Ndikom*1, Bola A. Ofi1, Folashade Omokhodion2 

1Department of Nursing, University of Ibadan, 
2 Department of Community Medicine, University of Ibadan
*correspondence: Email: HYPERLINK "mailto:cmndikom@gmail.com"cmndikom@gmail.com
                              Phone: +2348023529101  

		ABSTRACT

INTRODUCTION: Women of childbearing who are sexually active are at risk for Cervical Cancer (CC), since they may have been exposed to Human Papilloma Virus. Majority of the women with invasive cervical cancer were never screened for this disease which is known to be a major cause of cancer deaths among women, especially in developing nations. The study sought to determine awareness and willingness utilize of CCS services among Antenatal Clinic (ANC) attendees in selected health facilities in Ibadan. 
METHODS: This cross-sectional study was conducted in selected health facilities in Ibadan. Systematic random sampling was used to select 846 women attending ANC in the facilities. Data were collected from the women using validated structured questionnaire. Data were analysed using Chi square at Pd"0.05.
RESULTS: The women s mean age was 27.9(5.8 years. Majority, 94.8% were married, 49.1% had secondary school education, 64.2% were traders and majority (68.0%) earned less than 10,000 naira/month. Awareness of CC was quite low as (84.4%) had never heard of cervical cancer while only (15.6%) were awareness of it. Over 73.6% of the women were willing to utilize CCS services but Uptake of CCS was 2.1%. Contributory factors to low uptake were non-availability of CCS services, lack of information on CCS and cost of services among others. There was a significant association between awareness and willingness to utilize CCS services (P=. 0.000) as well as educational level and willingness to undergo screening (P =0.019). There was no significant association between age and willingness to utilize CCS services (P=. 0.834).
CONCLUSION: There was low awareness and poor utilization of CCS among the women despite their high level of willingness to utilize the CCS services. There is need to provide more information on cervical cancer screening as well as make the services available at reduced cost.
 
Key Words:	Cervical cancer screening, willingness, Women�s awareness, utilization

Word Count: 297


INTRODUCTION 
Mortality and morbidity arising from non communicable diseases like cancer have posed a threat to the life of women. Cervical cancer is one of the common cancers in women. It is responsible for the death of many women. Carr and Sellors (1) stated that Cervical cancer screening based on cytological examination is largely unavailable in developing countries or made available to a small, select group of women in private facilities, maternal child health sites, or family-planning clinics, missing the age groups at highest risk for precancerous lesions�. Anecdotal evidence has shown that utilization of cervical cancer screening for the prevention of the disease is poor in Nigeria (2). The major cause for the continuing high mortality due to cervical cancer in the developing world is the scarcity of well-organized, high-quality screening programs in those regions(3). It was from a study among nurses in Lagos that majority understood that Pap smear could be used to detect precancerous state of cervical cancer, while 18.5% (37) respondents felt that Pap smear could be used to prevent cervical cancer (4). 
                 Many young women in Nigeria are not aware of their being at risk of cervical cancer. Study among Female Undergraduates in Ibadan by (5) revealed that Sexual experience before the age of 20 years occurred in 51.7 % of their respondents. Early sexual exposure has been known to be a risk factor for cervical cancer especially when precautionary measures were taken. 
          A study of influences on uptake of reproductive health services in Nsanger Community on uptake of cervical cancer screening in Uganda by (6) revealed that knowledge about cervical cancer among Ugandan women was very low. The quantitative data from a study by (7) indicated an association between Pap test use and access to preventive care. It was stated by (8) stated that it is apparent that much of the anxiety associated with cervical screening results from ignorance among lay woman and the provision of insufficient information or magnification by health professionals. 
             There are many barriers to cervical cancer screening uptake as shown in a Swedish Study which reported that non attendance to cervical screening was positively associated with time-consuming and economic barriers (9). Time is a problem because women have so many responsibilities thus cervical cancer screening could be given less priority in demanding real life settings (10). 
 Most screening programmes that rely on Pap smear are complex and costly to run and have failed to reach a significant proportion of women in developing countries where health systems and infrastructures are weak (11). Other barriers to prevention and treatment may include lack of awareness of cervical cancer, and of ways to prevent the disease, difficulty getting to clinics and hospitals, the need for multiple visits and high cost associated with screening.
           A number of the factors that could influence pose as barriers to CCS were identified by (12) and they are poor knowledge, underlying health and cultural beliefs, attitudes, language and unhelpful attitudes of health professionals to be important barriers to CCS. According to (13) Barriers to screening include increased age, nonwhite race/ethnicity, low educational level, low income, decreased access, in sufficient funding, and unfavourable attitudes towards screening. The barriers identified by (6) were ignorance about cervical cancer, cultural constraint/beliefs about illness, economic factors, domestic gender power relations, alternative authoritative sources of reproductive health knowledge and unfriendly health care services. 
	Uptake of cervical cancer screening has remained low. Various barriers influencing screening uptake in previous studies have been identified. Cervical cancer screening is one of the reproductive health services that should be provided for women. Are the women ready to utilize cervical cancer screening services? This study sought to determine wiliness to utilize cervical cancer screening services among antenatal clinic attendees in selected health facilities in Ibadan, Nigeria.   

Theoretical Model
The theoretical model utilized for this study is The Andersen�s Behavioral Model of Health Care Utilization.

 








Figure 1: Adapted Andersen�s Behavioral Model of Health Care Utilization (14)

The Andersen�s Behavioral Model of Health initially developed in the late 1960s is one of the most frequently used frameworks for analyzing the factors that are associated with patient utilization of healthcare services (14). The model suggests that people�s use of health services is a function of their predisposition to use services, factors which enable or impede use, and their need for care, thus providing a way to conceptualize these variations in utilization rates and consumption of medical resources (15). In this model, utilization of services is determined by three major elements: need, enabling, and predisposing factors. 
Need factors, which have been shown to account for the majority of the explained variability in provider use, include the individual�s perceived health care need and other indicators of their health status (15) 
Enabling factors include items such as the individual�s income, health insurance status, and access to a source of regular care. 
Predisposing factors include demographic variables, socioeconomic status, attitudes, and beliefs. This model shows various factors that influence utilization of health services which could apply to utilization of cervical cancer screening services (15). 
Women� awareness, social demomographic variables and their perceived need for cervical cancer screening services could influence their willingness to utilize CCSS but some barriers like non-availability of services, fear of being diagnosed of the disease could impede actual uptake. 

Method 
A Cross-sectional design was used for this study. The respondents were all women within child bearing age utilizing Antenatal Clinic Services in selected health facilities Ibadan, Oyo state in South West Nigeria. The choice of the health facilities was informed by the availability of MCH services and client turnover. All the facilities included in the study had high patient turnover. The health facilities include four secondary health facilities and four Primary Health Centers (PHCs). The total population of women attending the clinic during the period of the study was 2,120. Data was collected from 846 using systematic random sampling method. 
Instrument for the study was a structured questionnaire designed from reviewed literature. The final tool was translated to Yoruba by a research expert and a Yoruba translator as Yoruba is the common language spoken in Ibadan. Permission for the study was obtained from Oyo State Ethical Committee and Oyo State Hospital Management Board, Ibadan. Institutional approval was obtained from the various facilities and Units studied. Informed consent was obtained from participants after being duly informed about the details of the study. Interviewer administered questionnaire was used to obtain information from the respondents. Descriptive and inferential statistics was used to analyze the data using Statistical Package of the Social Sciences. Chi square statistics was used to test association between variables for categorical data. 
. 
Results

Socio demographic characteristics of women

Table 1: shows the distribution of socio demographic characteristics of the respondents. The majority (62.6%) were aged between 21-30 years. Their mean age was 27.87+5.75 years. Majority (94.8%) were married, 49.1% attained secondary school level of education, 64.2% were traders and 68% earned less than N10, 000 as monthly income. Their husbands were mainly traders (64.7%).  

Table 1: Women�s socio-demographic data 
VariablesN=846 Frequency (%)Age
20 and below
21-30
31-40
41 and above

75(8.9)
530(62.6)
234(27.7)
7(0.8)Mean age score/SD27.87+5.75Marital status
Single
Married
44(5.2)
802(94.8)Educational status
Primary
Secondary
Above secondary
No response
107(12.6)
415(49.1)
324(38.3)
0(0.0)Occupation
Civil servants
Unemployed
Traders
Public servants
No response
153(18.1)
124(14.7)
543(64.2)
26(3.1)
0(0.0)Husbands occupation
Civil servant
Traders
Public servants
Unemployed
No response
139(16.4)
547(64.7)
64(7.6)
13(1.5)
83(9.8)Income
<10,000
11000-20000
21000-30000
>31000
No response
575(68.0)
135(16.0)
69(8.2)
67(7.9)
0(0.0)





 Awareness of cervical cancer among the women 
Table 2 below shows the awareness of women on cervical cancer 132 (15.6%) while 714 (84.4%) had never heard of cervical cancer.  Similarly, 113 (13.3%) received information from the clinic. The sources of information on cervical cancer indicated by the respondents in figure 3 include: Health worker137 (40.55%), Media 57(18.6%), Read about it 39(10.4%), Friend 27(7.9%), School 20 (5.8%), Family member15 (4.7%), Seminar16 (5.4%) and Internet 8(2.3%).

Table 2: Women�s awareness of cervical cancer and sources of information
Awareness and Source of Information on Cervical CancerFrequencyPercentageAwareness of cervical cancer 
Yes
No132
71415.6
84.4Received Information on cervical cancer in clinic
Yes
No
113
733
13.3
86.7Source of informationFamily member
Yes
No
15
317
4.7
95.3Friend
Yes
No
27
205
7.9
92.1Health worker
Yes
No
137
195
40.5
59.5Seminar
Yes
No
16
320
5.4
94.6Read about it
Yes
No
39
296
10.4
89.6Internet
Yes
No
8
324
2.3
97.7Media
Yes
No
57
275
18.6
81.4School
Yes
No
20
312
5.8
94.2Knowledge of women on cervical cancer

Figure 4 shows the overall knowledge of women on cervical cancer. Majority of the respondents 749 (88.6) had poor knowledge, 92 (10.8%) had fair knowledge while only,
5 (0.6) high 




Figure 2: Level of knowledge of women of cervical cancer



















Women�s utilization of cervical cancer screening services

Table 3 shows that the majority 828 (97.9%) of the women have never been screened for cervical cancer but only 18(2.1%) had under gone it. However, 612 (73.6%) of the respondents were willing to utilize cervical cancer screening services only 132 (15.5%) of the women indicated their awareness of where to go for cervical cancer screening and 132 (15.5%) knew a relative that has been screened.  

Table 3:	Women�s utilization of cervical cancer screening
VariablesFrequencyPercentage Ever had cervical cancer screening test
Yes
No
18
828
2.1
 97.9Willingness to screen
Yes
No
612
219
73.6
26.4Awareness of where to screen
Yes
No
132
714
15.5
84.5Relation who had been  screened
Yes
No
44
802
5.2
94.8





































Perceived factors that influence utilization of cervical cancer screening services 

The possible hindrances to the uptake of screening by women are presented on Table 4.   Unavailable services, 374 (44.2%) was the most critical factor, followed closely by lack of information 336(40.7%). Other factors include: lack of decision making ability 289 (34.2%), cost of obtaining services 255 (30.1%), Lack of support from husband 240 (28.4), fear of being infected 218(25.8), Distance from screening centre 199 (23.5) and Invasion of one�s privacy158 (18.7). 

Table 4: Perceived factors that influence utilization of cervical cancer screening services 

VariableFrequencyPercentageUnavailable services
Yes
No
374
472
44.2
55.8Cost of obtaining service
Yes
No
255
591
30.1
69.9Lack of decision making ability
Yes
No
289
557
34.2
65.8Invasion of one�s privacy
Yes
No
158
688
18.7
81.3Lack of information about screening
Yes
No
336
501
40.7
59.3Lack of support from husband
Yes
No
240
606
28.4
71.6Fear of being infected
Yes
No
218
628
25.8
74.2Distance from screening centre
Yes
No
199
647
23.5
76.5










Table 5: 	Relationship between respondents� characteristics and willingness to uptake screening services






Willingness to Uptake Screening ServicesYes (%)No (%)Total (%)�2P valueAwareness of screening service
Yes
No
126(20.6)
486(79.4)
4(1.8)
215(98.2)
130(15.6)
701(84.4)
43.02
0.000Age (years)
<20
21-30
31-40
>41
55(9.0)
385(62.9)
166(27.1)
6(1.0)
20(9.1)
134(61.2)
64(29.2)
1(0.5)
75(9.0)
519(62.4)
230(28.1)
7(0.5)
0.862
0.834Educational level
=<primary
Secondary 
Above secondary
83(13.6)
314(51.3)
215(35.1)
22(10.0)
97(44.3)
100(45.7)
105(11.8)
411(47.8)
315(40.4)
7.902
0.019
Hypotheses testing

Table 5 shows there was a significant association between awareness and willingness to utilize cervical cancer screening services (P= 0.000).  Also there was no significant association between age of respondents and willingness to utilize cervical cancer screening (P=. 0.834). The association between level of education and women�s willingness to utilize cervical cancer screening services was significant (P = 0.019).

DISCUSSION
This study is limited by the fact that it was carried out using self report among antenatal clinic attendees in Ibadan metropolis. All respondents were pregnant women and sexually active. The women had access to modern health care facilities. It was important to study this group of women. Majority of the women were aged between 21-30 years, were married, traders, earned less than N10, 000.00 per month and mainly had secondary education and their husbands were mainly traders. These women in the study were not really empowered financially. 
Only, 15.6% of respondents have heard about cervical cancer. A study among women attending gynaecology clinics in a tertiary level medical care centre in South Eastern Nigeria by (16) affirmed that Twenty-five (12.6%) of the women were aware of the cervical cancer screening test. Of the 25 respondents who were aware of the cervical cancer screening test, 15 (60.0%) had received at least a Pap smear test (16). Although these women have access to health care facilities yet they were not given information on cervical cancer screening. 
The sources of information on cervical cancer mentioned by the few respondents who had ever heard about it were mainly health workers and Media.  This underscores the need for regular information dissemination in our health care facilities especially Antenatal clinics as this will help the target group receive information that will be of benefit to their female children aged nine years and above before exposure to sexual intercourse . This finding was similar to those of (16) who reported that Twenty-one (84.0%) of those women who were aware of the cervical cancer screening test got their information from healthcare providers, 3 (12.0%) from television and 2 (8.0%) from radio, furthermore 80 (57.1%) of the women agreed that they would like to undertake cervical cancer screening, while 60 (42.9%) would decline the cervical cancer screening test.
Majority had low level of knowledge. This is not surprising as the majority had never heard about the disease. In a study of influences on uptake of reproductive health services in Nsanger Community in Uganda and their implications on uptake of cervical cancer screening by (6) they reported that �knowledge about cervical cancer among Ugandan women was very low�. Prominent in their finding was the fact that patients were not given adequate information on cervical cancer and screening. Also that some of the nurses had gaps in their knowledge of cervical cancer. A study of out-patients� attendants� knowledge and attitude towards cervical cancer in Nigeria revealed that among these women aged 20 to 65, only 15% had heard of the disease (17).  These reports are consistent with the present study which has shown that awareness and knowledge about cervical cancer is still very low.

Women�s uptake of cervical cancer screening services
Majority of the women were willing to uptake cervical cancer screening.  Despite their willingness they were unable to utilize the services mainly because the services were not available. The hindrances to the uptake of screening by women in this study were mainly, unavailability services, cost of obtaining service, and lack of information about screening. Others were lack of decision making ability, invasion of one�s privacy. (16)  Reported that all of the screening was done as an opportunistic screening exercise. Looking at Anderson health care utilization model, one can deduce that various factors could impede the utilization of cervical cancer screening despite willingness to utilize the services. 
 Reason for poor health seeking behaviour of the women according to (18) was fear of violation of privacy while potential reasons for uptake of cervical cancer screening include development of symptoms, adequate educative information, and physician's recommendation. (12) carried out a study to describe some of the factors that act as barriers to effective uptake of breast and cervical cancer screening services among black minority ethnic (BME) groups living in Brent and Harrow in the UK. The result showed poor knowledge, underlying health and cultural beliefs, attitudes, language and unhelpful attitudes of health professionals to be important barriers. According to (13) Barriers to screening include increased age, nonwhite race/ethnicity, low educational level, low income, decreased access, in sufficient funding, and unfavourable attitudes towards screening�. The barriers identified by (6) were �ignorance about cervical cancer, cultural constraint/beliefs about illness, economic factors, domestic gender power relations, alternative authoritative sources of reproductive health knowledge and unfriendly health care services. Healthcare workers, who come into contact with women, should inform them about cervical cancer screening (19). 
The Hypotheses tested on the association between various variables and willingness to utilize cervical cancer screening services. There was a significant association between level of awareness of cervical cancer and women�s willingness to utilize cervical cancer screening as well as between level of education and women�s willingness to utilize cervical cancer screening. The association between age of respondents and willingness to utilize cervical cancer screening was not significant. (16) reported a significant association between the educational status and the knowledge of the cervical smear Pap test�. Similarly, (18) stated that Level of knowledge of cervical cancer prevention, university education, and age had a significant impact on the uptake of cervical cancer screening. 

Implications for Further studies
There is need to carry out a larger study using other zones in the country to make the findings more general.
A comparative study can be carried out in centers where there are services compared with willingness and uptake where screening services are not available.
        
Recommendations
Information on cervical screening should be given regularly to women. There is an urgent need for an aggressive awareness campaign and the provision of a screening program nationally.
Cervical cancer screening services should be incorporated in family planning services 
Screening services should be available in all secondary facilities at subsidized rate. Developing countries should develop policy and framework on health screening. Reminder services should be in place to ensure compliance with appointments increase utilization. 

Summary and Conclusion
         Cervical cancer is one of the common cancers in women. It is responsible for the death of many women. It is preventable through screening to detect precancerous lesions and appropriate treatment before the lesions develop into cancer. Various cervical cancer screening, diagnostic, and treatment methods are currently being used in developed and developing countries. Each method of screening has its advantages and disadvantages. Treatment should be available for women who under go screening. The study sought to determine awareness and willingness utilize of CCS services among Antenatal Clinic (ANC) attendees in selected health facilities in Ibadan. 
Cross-sectional design was used for the study. Systematic random sampling was used to select 846 women attending ANC in the facilities. Data were collected from the women using validated structured questionnaire. Data were analysed using Chi square at Pd"0.05
Awareness of CC was quite low as majority had never heard of cervical cancer.  The women were willing to utilize CCS services but Uptake of CCS was low. Contributory factors to low uptake were non-availability of CCS services, lack of information on CCS and cost of services among others. There was a significant association between awareness and willingness to utilize CCS services as well as educational level and willingness to undergo screening. Age of respondents did not have significant association with willingness to utilize CCS services.
There was low awareness and poor utilization of CCS among the women despite their high level of willingness to utilize the CCS services. There is need to provide more information on cervical cancer screening as well as make the services available at reduced cost.


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&F	�f�]�f�a$gd��m$�u�u�u�uvvvvvvvvvvvvvvv#v*v+v-v/v0v4v5vwvxv�v�v�v�v�v�v�v�v�v�v�v�v�v�v�v�v�vwwww�w�w�w�w�w�w���������������������������������뷮���h��h��0J=h��h��0J<PJh��h��0J;h��h��0J:h��h��0J:6�h��h��PJh��0JmH	sH	h��h��6�jh��h��UhISh��h��	hIS\�h��h��\�7�w�w�w�w�w�x�x�x�y����/012������ !(+,-/34��Z[p����(M��������ûᴬ�ᚓ�������������wow�ᴬh|Q}h|Q}6�h|Q}h�!�6�jh|Q}h�!�6�Uh��h|Q}h��h�!�jh��h�!�Uh|Q}h|Q}h|Q}h�7(6�h��h�7(
h|Q}0JUh|Q}h�7(0JmH	sH	h|Q}0JmH	sH	h�#kh|Q}h|Q}h��h��h��h��0J]h��h��0J>PJ+ology clinics in a tertiary level medical care center in southeastern Nigeria. Journal of Reproductive Medicine. 56(11-12):491-6.

Ajayi, I.O and Adewole I.F. 1998 Knowledge and Attitude of General Outpatients� Attendants in Nigeria to Cervical Cancer. Central African Journal of Medicine 44 (2): 41:43.

HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Chigbu%20CO%5BAuthor%5D&cauthor=true&cauthor_uid=21946294"Chigbu C. O, and HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Aniebue%20U%5BAuthor%5D&cauthor=true&cauthor_uid=21946294"Aniebue, U. (2011)  Why southeastern Nigerian women who are aware of cervical cancer screening do not go for cervical cancer screening HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/21946294" \o "International journal of gynecological cancer : official journal of the International Gynecological Cancer Society."International Journal of Gynecological Cancer. 21(7):1282-6.

Anorlu, R. I. Ribiu, K. A. Abudu O. O. And Ola E. R. (2007) Cervical cancer screening practices among general practitioners in Lagos Nigeria. Journal of Obstetrics and Gynaecology; 27(2): 181 � 184









 PAGE   \* MERGEFORMAT 11



Personal health choices



Use of health services

Perceived Need for Health care

Predisposing characteristics- sociodemographic variables







Individual/ Provider related

Community

Health Care system




External environment

Enabling resources- income, services



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