AWARENESS AND UTILIZATION OF CANCER OF CERVIX FACILITIES AMONG WOMEN: A CASE STUDY OF LURAMBI KAKAMEGA COUNTY, KENYA.

Sally Jepkosgei Oronje 1 , Ameldah Barasa 1 , And Sharon Kosgey 2 . 1. County Health Office, Department of Health, Kakamega County, Kenya. 2. School of Nursing and Midwifery/ Masinde Muliro University of Science and Technology, Kenya. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 12 September 2018 Final Accepted: 14 October 2018 Published: November 2018

The study determined awareness of cancer of cervix and utilization of cancer of cervix facilities among women inKakamegaLurambi sub county. The study was a cross-section study. The target population were young women in reproductive age of 16-25 years. The sampling procedure used was a stratified random sampling and simple random sampling. A structured questionnaire and interview was used to collect data. Descriptive survey was used to present the findings of the research. The analysis showed that the major causes of late presentation of cervical cancer was significantly associated with lack of awareness on basic symptoms among women of reproductive age , lack of awareness on the predisposing factors to cervical cancer and also ignorance on importance of routine gynecological examination, therefore the study recommends provision of health education to people about the disease to include signs and symptoms and its presentation and also advise them to seek medical attention once they notice any sign or symptoms for early diagnosis and treatment. The study also recommends provision of screening facilities in every ward to enable early diagnosis and treatment.

…………………………………………………………………………………………………….... Introduction:-
Cervical Cancer remains the number one cancer death for women in developing countries. It was once among the leading causes of death in developed countries like America; however, incidences of invasive cervical cancer have declined steadily over the years in these countries. According to American cancer society, estimated 11,500 cases of invasive cervical cancer were diagnosed in United States in 2007, with approximately 3100 deaths from cervical cancer during the same period. However worldwide, the incidence of the mortality associated with cervical cancer are second only breast cancer and in parts of the developing world, cervical carcinoma is the major cause of death in the woman of reproductive age (Carol Mattson ports, 2009).Cervical cancer is the second most frequent cancer among women in Kenya and the leading cause of cancer deaths in women of reproductive age (WRA). Currently, the estimated annual number of cervical cancer cases is 2454 while the annual number of deaths due to cervical cancer is 1676 in Kenya (Cancer Incidence Report, 2006).It was projected that by the year 2025, the number of new cervical cancer cases annually in Kenya will reach 4261 (Kenya National Cancer Control Strategy, 2011).
Cervical Cancer is a deadly disease once it reaches its invasive stages but out of all the female genital tract cancers, it is the only preventable cancer if detected at its early stages. This is probably why a lot of work and researches ISSN: 2320-5407 Int. J. Adv. Res. 6(11), 990-996 991 have been carried out concerning this cancer since it can save thousands of lives which unnecessarily die each year. The common method of detecting cervical cancer is by screening. According to gynecological foundation (2008), worldwide, approximately 5,000 new cases of cancer of the cervix occur annually and about 200,000 women dies of disease each year. It is estimated that the cervical cancer accounts for 80%of all gynecological cancer conditions in several African countries. The Kenya Age-standardized rates are 17.3 with annual number of deaths being at 1676 (IARC, Globocan, 2008). Poor health imposes a heavy burden on society and slows down economic growth. Illness in the family is one of the major causes in the reduction of incomes and assets of poor Kenyans. Cancer, for instance, has had a demonstrated negative impact on households, their education, as well as in their workforce productivity.
While many University students underestimate their risk of contracting various sexually transmitted diseases, HPV has become a common sexually transmitted infection on college campuses. University students have a greater risk of acquiring STDs than the general population because of the high-risk sexual behaviour in which they engaged (Cancer Incidence Report, 2006). Risky behaviour, a lack of knowledge and preventive care; such as a regular Pap test, lead to a high incidence of HPV infection in University students that lead to cervical cancer later. In Kenya in a study conducted in 2008, 2454 cases of cervical carcinoma were diagnosed and 1676 deaths related to the cervical cancer were recorded. Comparing to this to USA statistics in the same year where 12,200 cases were diagnosed 4100 deaths noted and then in Kenya has a very high mortality rate than USA in provincial general hospital Kakamega cancer of the cervix is the commonest gynecological malignancy, accounting to 70 %of all cancer admission as evidence from the health records information office. In 2010, 800 admissions, 150 were due to cervical cancer and out of these cases were from municipality division and cases were presented in late stages.
Despite the magnitude of the problem in Kenya and the fact that it is easily preventable, the cervical cancer screening coverage in Kenya for all women 18 to 69 years of age is only 3.2% (NCCPSP, 2012). Despite the existence of a previous National Cervical Cancer Prevention Strategic Plan -NCCPSP- (2002 -2006), implementation of the national screening program is still low and haphazard.Cancer research in Kenya is not commensurate with the magnitude of the problem. This is due inadequate funding and training facilities in cancer research. There is also no comprehensive cancer surveillance system and no population based cancer registry (KNCCS, 2011).There is therefore a need to establish why more women are not receptive to cancer screening facilities thus assessment of their awareness and utilization of these facilities is vital.

Literature Review
Cancer begins when cells in a part of the body start to grow out of control. Most cervical cancers begin at the cells lining the cervix (the lower part of the uterus which connects the uterine body to the vagina). These cells begin as normal, and then gradually change to pre-cancerous cells which appear as lesion on cervical wall. The cells may eventually become cancerous; however in 50 percent of women with pre-cancerous lesions, the cells remain benign. Cancer cells intrude into adjacent cells and tissues (invasion) and ultimately spread to other parts of the body than the location at which they arose (metastasis) (National cancer institute 2009). Cervical cancer at its early stage exhibits no symptoms, which is why it is frequently not detected until it has progressed to an advanced stage (Kumer, 2007).
The leading cancers in women are breast, oesophagus and cervical cancers (KNCCS, 2011). Cervical cancer tends to occur in midlife. Most cases are found in women younger than 50 years. It rarely develops in women younger than 20 years. More than 20 percent of cases of cervical cancer are found in women over 65 years (American Cancer Society, 2011).Cancer begins when cells in a part of the body start to grow out of control. Most cervical cancers begin at the cells lining the cervix (the lower part of the uterus which connects the uterine body to the vagina). These cells begin as normal, and then gradually change to pre-cancerous cells which appear as lesion on cervical wall. The cells may eventually become cancerous; however in 50 percent of women with pre-cancerous lesions, the cells remain benign. Cancer cells intrude into adjacent cells and tissues (invasion) and ultimately spread to other parts of the body than the location at which they arose (metastasis) (National cancer institute 2009). Cervical cancer at its early stage exhibits no symptoms, which is why it is frequently not detected until it has progressed to an advanced stage (Kumer, 2007).
Globally, cervical cancer is one of the most common cancers in women, with an estimate of 500,000 new cases. Studies have shown that human papilloma virus (HPV) infection is responsible for more than 90 percent of the cases of invasive cervical cancer worldwide, and it is related to 80 percent of pre 992 cancerous changes in the cervix (Walboomers et al, 1999).In sub-Saharan Africa, cervical cancer is the most common cancer in women and second to breast cancer in Northern Africa. According to Magrend (2002) in the developing countries, initiation of substance of cervical screening program involves sexual active women annually or in every 2-5 years have resulted in large decline in cervical malignance incidence and mortality over the last 40-50 years Other factors associated with the cancer of the cervix are low education state, lack of knowledge about screening, high parity and presence of other STI.
In sub-Saharan Africa, it accounts for 22.2% of all cancers in women and it is also the most common cause of cancer death among women (Parkin, 2003). About 60-75percent of women in sub-Saharan Africa who develop cervical cancer live in rural areas and mortality rates are very high (Parkin, 2003). Many of the University female students who develop cervical cancer are untreated, mostly due to lack of access to health care. According to Mergerand et al. (2000) the developing countries accounted for 370,000 out of 466,000 cases of cancer of the cervix that were estimated to have occurred in the world in 2000. Most of the women in developing countries are diagnosed at an advanced stage compared to their counterparts in developing countries for example in a study in Nigeria about 81%of the cases were diagnosed in stage 3 and 4. Likewise studies conducted in Tanzania showed that most of CA patients (more than 90%) seek medical help in advanced stages of the disease. The also showed that this is due to lack of awareness of cervical and early symptoms. It is estimated that for each successive stage e.g. the disease at the time diagnosis, the overall risk of dying increases. In the study done by Thomas et al (2005) in Atlanta four years journal in clinical stage 1A was 94% 1B was 79% stage 2 was 39% and stage 4 was 0. Cervical cancer screening is included as part of routine care for HIV -positive women under the country national policy for HIV care. However screening levels remain low, according to the WHO just 2-3 %of Kenyan women aged 18-69 years of age are screened for cervical cancer every 3 years compared with 70%of women in developed countries. A study was conducted by WHO in 2005 revealed that cervical uterine cancer as one of the recommended malignant causes in Kenya. Due to lack of knowledge among women in the country and its ranks as the second most frequent cancer among woman in Kenya about 39% of the women in general population are estimated to harbor carrier HIV infections at any given time.

Methodology:-
This was a descriptive survey design study aimed to determine awareness and utilization of cancer of cervix facilities among women in Kakamega central. A total of 384 women of reproductive age from 16 to 45 years from Kakamega Central were selected to participate in this study using random sampling technique. Focused group discussion, interview and questionnaires were used to collect information. Questionnaires that assessed women awareness and utilization of cancer of cervix facilities was administered to women after ethical approval was given and verbal consent was gained from participants. Content validity of instrument was ensured by ensuring that items in the questionnaires were based on extensive review of literature. Reliability was affirmed by documenting all procedures carried out in the development and implementation of the study. Guidelines for the completion of the questionnaires were explained and participants were instructed to tick where appropriate. Completed questionnaires were collected and coded for analysis. Data was analyzed using descriptive statistics of tables and percentages, and inferential statistics of Chi-square to test the hypotheses at 0.05 level of significance. Statistical Package of Social Science (SPSS 16.0 version) was used.  From the above table, majority of responsibility of respondent i.e 120 respondents represented by (62.5%) were married and 72 respondents represented by (37.5%) were single. This implies that majority of the respondents were married.

Level of Knowledge on Cervical Cancer
Frequency Percent  Valid  True  278  72  False  75  20  don't know  31  8  Total  384 100.0 The results shows that majority of the women respondents (72%) are aware that is the major cause of cancer among women. From the tabulation, we observe that 31% of the respondents have ever had cervical cancer screening test; which shows low level of awareness on cervical cancer screening. On rating the extent of facilities on cervical cancer screening, we observe that most of the respondents 57% rated the facility to be fair.  They consider that there is no much they can do to prevent it. This makes most of them to be afraid and scared of the cancer. This misconceptions and disbelieves led most of them not to attend regular cervical screening tests; that's why most of the patients present themselves in the very advance stages.

Level of Knowledge on testing of Cervical Cancer
On the other hand, 67.2% of the female students consider cervical screening to be painful. This attitude makes them shy away from cervical cancer screening tests. This disbelieve makes them to be at a higher risk of developing cervical cancer as early detection and prevention is avoided.

Discussion:-
From the analysis, of cervical cancer 31% of the respondents said they are aware of cervical cancer and 69% had never heard of it. This implies that majority had no knowledge on cervical cancer. This is in agreement with a research which was done among Kenyan women in Kisumu by the university of North Carolina chapel which found that 89% of the study population were aware of cancer in general but only 15%had heard of cervical cancer. When asked about the symptoms of cancer cervix, majority of the respondents 106(55.2%) said that its lower abdominal pains, 56(29.1%) respondents said its vaginal discharge, 18(9.4%) respondents said its pelvic pain and 12(6.3%) respondents said its abnormal vaginal bleeding between, and after intercourse or after menopause. This implies that least respondents were aware of the signs and symptoms of cervical cancer i.e. 6.3%respondents.This goes hand in hand with the finding of Merger and et al (2000) WHO stated that majority of the women in developing countries 995 are diagnosed at an advanced stage compared to their counterparts in developed countries rise to lack of awareness of early signs and symptoms of cervical cancer.On the knowledge and awareness of predisposing factors to cervical cancer the least of the respondents 14(7.3%) had a clear knowledge which they said is caused or predisposed by human papilloma virus. This revealed that there is lack of knowledge on predisposing factors to cervical cancer.This is in agreement with the study conducted by world health organization (WHO) in 2005 in Kenya, about 39% of women in general population is estimated to labor a cervical human papilloma virus infection at any given times. It revealed that cervical cancer is one of the commonest malignant among women in Kenya due to lack of knowledge among women in the country.The majority of respondents have never had any routine gynecological examination 182(94.8%) respondents who had a routine gynecological examinations were 10(5.2%).this is agreement with Dr.lucymuchiri 12 th June 2012 WHO says that every year Kenya loses approximately 3,400 women, this is because a fewer than 5% of Kenyan are screened for cervical cancer annually, and this is because there is less knowledge about the disease since majority of respondents find it not necessary to have routine checkup 100(52.1%)respondents.On the data collected it revealed that s few number of respondents 12(6.2%) had ever done the pap's-smear and majority of respondents 180(93.8%) have never done pap'ssmear. Majority of those never done pap's smear was because they have never heard of it, 165(91.7%), 15(8.5%) respondents find it unnecessary. This is in agreement with the finding of WHO(2008) which revealed that just 3.2% of Kenyan women age 18-69 years are screened for cancer of cervix every year compared with 70%of women in developed countries.The majority of respondents 115(59.9%) were not sure whether cervical cancer can be treated, 67(34.9) respondents said cancer of cervix cannot be cured while 10(5.2%) respondents said had cancer of cervix can be cured.

Conclusion:-
From the data collected, the researcher concluded that the majority causes of late presentation of cervical cancer was significantly associated with lack of awareness on basic symptoms of cervical cancer among women in Kakamega central sub-county. From the data collected it showed that majority of respondents knew cancer of general but they had never heard of cervical cancer leading to a conclusion that lack of awareness about the cancer of cervix. The researcher also concluded that there is lack of awareness on and utilization of cervix cancer facilities in the subcounty.