TABLE OF CONTENTS
COVER PAGE………………………………………………………………………………………………… i
DECLARATION…………………………………………………………………………………………….. ii
DEDICATION……………………………………………………………………………………………….. iii
ACKNOWLEDGEMENT……………………………………………………………………………….. iv
TABLE OF CONTENTS………………………………………………………………………………….. v
LIST OF TABLES………………………………………………………………………………………….. ix
LIST OF FIGURES…………………………………………………………………………………………. x
ABBREVIATION AND ACRONYMS……………………………………………………………… xi
DEFINITION OF TERMS…………………………………………………………………………….. xiii
ABSTRACT………………………………………………………………………………………………….. xv
CHAPTER ONE: INTRODUCTION………………………………………………………………… 1
- Background of the Study…………………………………………………………………………….. 1
CHAPTER TWO: LITERATURE REVIEW……………………………………………………… 6
- Overview of Cervical Cancer………………………………………………………………………. 6
CHAPTER THREE: METHODS AND MATERIALS……………………………………….. 16
- Research Design……………………………………………………………………………………….. 16
CHAPTER FOUR: RESULTS………………………………………………………………………… 24
- Introduction……………………………………………………………………………………………… 24
- Proportion of study population utilizing visual cervical cancer screening service in Imenti South sub-county…………………………………………………………………………………………………….. 25
- Influence of respondents’ socio-demographic characteristics and RH factors on utilization of visual cervical cancer screening service…………………………………………………………………….. 25
- Association of Respondents’ demographic characteristics and utilization of cervical cancer visual screening service……………………………………………………………………………………………. 25
CHAPTER FIVE: DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS 33
5.1.2 Respondents’ demographic characteristics……………………………………………….. 33
- The influence of respondents’ socio-demographic factors on utilization of VCCS service 34
REFERENCES……………………………………………………………………………………………… 48
APPENDICES……………………………………………………………………………………………….. 52
APPENDIX I: CONSENT FORM…………………………………………………………………… 52
APPENDIX II: RESPONDENTS QUESTIONNAIRE……………………………………….. 53
APPENDIX III: FOCUSED GROUP DISCUSSION QUESTIONNAIRE…………….. 57
APPENDIX IV: A CHECK LIST FOR AVAILABLE RECOMMENDED RESOURCES FOR VISUAL CERVICAL CANCER SCREENING………………………………………………………………. 59
APPENDIX V: MAP OF IMENTI SOUTH SUB-COUNTY……………………………….. 60
APPENDIX VI: NATURAL HISTORY OF CERVICAL CANCER……………………. 61
APPENDIX VII: INTERPRETING VISUAL CERVICAL CANCER SCREENING RESULTS AS WHETHER POSITIVE OR NEGATIVE (RESULTS FOR VIA AND VILI)……….. 62
APPENDIX VIII: VILI RESULTS INTERPRETATION CHART……………………… 63
APPENDIX IX: RESEARCH AUTHORIZATION FORM………………………………… 66
APPENDIX X: KENYATTA UNIVERSITY ETHICAL REVIEW COMMITTEE PERMIT 67
APPENDIX XI: NATIONAL COMMISSION FOR SCIENCE TECHNOLOGY AND INNOVATION PERMIT………………………………………………………………………………………………………. 68
LIST OF TABLES
Table 3.1: Independent variables…………………………………………………………………….. 17
Table 3.2: Strata of health care facilities according to administrative divisions 19
Table 3.3: Sampled health facilities from each stratum, average number of clients attending reproductive health clinics per month and sample of respondents per facility………………………….. 20
Table 4.1: Socio-demographic characteristics of the study respondents……………….. 24
Table4.2: Respondents’ demographic characteristics and utilization of visual cervical cancer screening service………………………………………………………………………………………………………….. 26
Table 4.3: Significant Respondents’ reproductive health factors that influence utilization of visual cervical cancer screening service……………………………………………………………………… 28
Table 4.4 Respondents’ partner influence on visual cervical cancer screening service utilization 29
Table 4.5: influence of Reproductive health system factors on utilization of visual cervical cancer screening service……………………………………………………………………………………………. 30
Table 4.6: The extent to which VCCS service is integrated in RH clinics…………….. 31
LIST OF FIGURES
Figure 1.1: Conceptual framework……………………………………………………………………. 5
Figure 4.1: Proportion Study population utilizing visual cervical cancer screening service in Imenti South sub-county…………………………………………………………………………………………… 25
Figure 4.2: The influence of Respondents’ reproductive health factors on utilization of visual cervical cancer screening service…………………………………………………………………………………. 27
Figure 4.3: total number of health care providers verses Number of health care providers trained on visual cancer screening in the sampled RH clinics……………………………………………… 32
ABBREVIATION AND ACRONYMS
| ACCP | Alliance for Cervical Cancer Prevention |
| AVSC | Access to Voluntary and Safe Contraception |
| CECAP | Cervical Cancer Prevention |
| CIN | Cervical Intraepithelial Neoplasia |
| COPE | Client Oriented Provider Efficient |
| DNA | Deoxyribo – Nucleic Acid |
| DRH | Division of Reproductive Health |
| ECSA | East Central and South Africa |
| FIGO | International Federation of Gynaecology and Obstetrics |
| HIV | Human Immune Deficiency Virus |
| HPV | Humam Papilloma Virus |
| IARC | International Agency for Research on Cancer |
| KDHS | Kenya Demographic Health Survey |
| KII | Key Informant Interview |
| KNBS | Kenya National Bureau of Statistics |
| MCH/FP | Maternal Child Health and Family Planning |
| MOH | Ministry of Health |
| MOMS | Ministry of Medical Services |
| MOPHS | Ministry of Public Health and Sanitation |
| NCCPSP | National Cervical Cancer Prevention Strategic Plan |
| PAHO | The Pan American Health Organization |
| PATH | Program for Appropriate Technology in Health |
| RH | Reproductive Health |
| SD | Standard Deviation |
| SIL | Squamous Intraepithelial Lesions |
| SPSS | Statistical Package for the Social Studies |
| STI | Sexually Transmitted Illnesses. |
| VCCS | Visual Cervical Cancer Screening |
| VIA | Visual Inspection with Acetic Acid |
| VILI | Visual Inspection with Lugos Iodine |
| WHO | World Health Organization |
| WHS | World Health Survey |
| WKCCPP | Western Kenya Cervical Cancer Prevention Program |
| HIMS | Health Information Management System |
DEFINITION OF TERMS
Cervical cancer: This is a disease in which the cells of the cervix become abnormal and start to grow uncontrollably forming tumours (Invasive cancer).
Cervical cancer visual screening tests: These are screening test that are employed to identify abnormal changes on the cells of the cervix. They rely on use of naked eyes after application of certain reagents on the cervix to note colour change on the surface of the cervix that is suggestive of either pre cancer lesions or invasive cancer or no change depending on the colour change on the cervix.
Challenge: Factors that cause difficulty or trouble in achieving a positive result or tends to produce a negative result; an impendent. In this study, this has been used to mean those factors that impend full integration and utilization of cervical visual screening (VIA/VILI) in all primary health facilities.
Client: Means a person or group of persons that use professional advice or services. In this study, this will be used to mean women attending reproductive health clinics to seek services offered at the clinic.
Facility: Something designed or installed for a specific purpose. In this study, this will be used to mean primary health care facilities that operate with the government of Kenya guidelines and have a functional reproductive health department.
Integration: Means combining parts so that they work together as one. Also means bringing services under one roof to ensure they are provided together. In this study, this has been used to mean including VIA/VILI cervical cancer screening tests in the reproductive health clinics to ensure it is offered routinely to clients together with other services offered at the clinic.
Reproductive health (RH) clinic: This is a department within the health care system that offers a range of reproductive health services to include; family planning, antenatal care, child welfare, post natal care and other obstetric and gynaecologic services. In Kenya, until recently, it has been known as maternal child health and family planning department (MCH/FP).
Screening: A strategy used in a population to detect a disease in individuals without signs or symptoms of that disease. It identifies those who have the characteristic of interest from those without. It is usually a simple test performed on a large number of people to identify those who have or are likely to have the disease of interest.
For the purpose of this study, this will be used to refer to cervical cancer visual inspection screening test by use of VIA/VILI to identify clients with pre-cancerous cells for treatment before it advances to invasive cervical cancer disease.
Utilization: means the act of using. In this study, this will be used to mean using visual cervical cancer screening (VIA/VILI) test by women attending reproductive health clinics.
ABSTRACT
Cancer is among the leading causes of morbidity and mortality worldwide with approximately fourteen million new cases and eight million cancer related deaths annually with an approximated 60 per cent of these new cases and 70 percent of these deaths occurring in Africa and other developing countries. Cervical cancer in particular has contributed a fair share of this burden. In Kenya, cervical cancer incidence and prevalence is second to breast cancer and leading cause of cancer related deaths among Kenyan women with most cases being diagnosed when it is too late for any interventions. The solution lies in early screening of women, with visual cervical cancer screening approach being the most feasible for low resource settings in developing countries. Kenya, in recognition of this piloted and adopted this screening approach in the year 2002 in efforts to integrate the screening approach in all the reproductive health clinics through formation of national cervical cancer prevention strategic plan with an aim of raising screening coverage to over 70 per cent. Despite this effort, the population of women screened remains alarmingly low with an estimated screening prevalence of only 3.2 per cent nationally. This cross- sectional study sought to identify challenges to visual cervical cancer screening service integration and utilization in Imenti South Sub-County, Kenya with the specific objectives of determining the proportion of respondents utilizing visual cervical cancer screening service, how respondents socio-demographic and reproductive health factors, facility based and system based factors influence integration and utilization of visual cervical cancer screening service. Six reproductive clinics were sampled for the study out of the nineteen in the Sub-County and a total of 354 respondents visiting the sampled reproductive health clinics. Questionnaires, checklist and key informant interviews were used to collect data. Chi- square and Fisher exact test were used to test significant associations with a P ≤ 0.05 being considered significant while qualitative data was analyzed and discussed in key thematic areas. The sampled reproductive health clinics had the required screening resources, however only 20 per cent of the respondents had ever been screened for cervical cancer at the time of this study. The opportunistic screening approach, Low level of awareness, inexistence of a functional referral system, poor reporting, monitoring and supervision on visual screening were key screening challenges among others. The study concluded that, establishing clinical services alone will not achieve the desired screening target unless critical components are put in place to address the observed challenges in this study.
CHAPTER ONE: INTRODUCTION
Background of the Study
Cancer is among the leading cause of death worldwide with an estimated 14 million new cases and 8 million cancer related deaths annually. More than 4 in 10 cancer cases occurring worldwide are in low and middle income countries (Ferlay et al, 2012). The number of new cases is expected to rise by 70 per cent over the next two decades (Mathers et al, 2011). In Kenya, cancer is ranks third cause of death after infectious and cardiovascular diseases with 7 per cent of total annual mortality (KEMRI, 2006).
Cervical cancer is second commonest cancer among women after breast cancer with prevalence ratio of 34:100,000 for breast cancer and Cervical 25:100,000 for cervical cancer. Over 90 per cent of cervical cancer burden occurs in developing countries (Bruni et al, 2015). Cervical cancer is leading in case mortality rate among cancer in women in developing countries.
Kenya has an incidence of 4,802 and 2451 deaths from cervical cancer annually. It is projected that by the year 2025, the annual incidence and mortality will have doubled if no measures are put in place to reverse the current trend (Bruni et al, 2015). Secondary prevention and early diagnosis remains the only feasible approach to reverse the incidence and mortality trends. The challenge has been late diagnosis when the disease had already advanced and possibly spread to other parts of the body. Screening programmes have proved effective in developed countries resulting to a significant fall in cervical cancer incidence and mortality. While developed countries have employed cytology based screening approach, developing countries lack the capacity to implement and sustain cytology based screening approach that is resource
demanding (Sankaranarayanan et al, 2001). A new screening initiative through the visual approach that is less resource demanding has given a breakthrough in cervical cancer screening in developing countries. The visual cervical cancer screening approach has a high sensitivity decreasing the chances for false negative results. The approach has been recommended for implementation in low resource settings where health care cannot sustain cytology based screening approach (Sankaranarayanan et al, 2001). Kenya piloted and adopted the visual cervical cancer screening (VCCS) approach in the year 2004 with an aim of integrating the screening approach in all the reproductive health (RH) clinics to raise the screening prevalence to over 70 percent through setting up a national cervical cancer prevention programme. The integration of screening in RH clinics implies that, as women seek other services in the clinic, they also get the opportunity to be screened for cervical cancer within the same clinic (PATH, 2002). The current estimated Kenya national cervical cancer screening prevalence is at 3.2 per cent (MOH, 2012).
Problem Statement
Despite the existence of Kenya National Cervical Cancer Prevention Strategic Plan – NCCPSP for over ten years, implementation of the national screening program is still low and haphazard. The screening prevalence is still very low with an estimated population of eligible women screened by 2012 at only 3.2 per cent. The reason why the screening program has failed to raise the screening to the expected target of 70 per cent has not been established and lack substantial scientific explanation.
Justification of the Study
There is insignificant achievement in integrating visual screening in all RH clinics and raising screening coverage of screened women despite having a running cervical cancer prevention program for over 10 years. The 2012- 2015 national cervical cancer prevention strategic plan was rolled out without any effort to establish the challenges experienced by previous strategic plans between 2002- 2012.
This study sought to establish the existing challenges within the reproductive health care system that impede screening of women at risk of cervical cancer with an aim of laying basis for an approach to address the challenges thus raising the screening coverage to the intended over 70 percent.
: Research Questions
- What proportion of the Women is utilizing visual cervical cancer screening service in Imenti south sub-county?
- What influence do the client’s demographic and reproductive health factors have on utilization of visual cervical cancer screening service?
- What facility based challenges influence utilization of visual cervical cancer screening service in Imenti south sub-county?
- What RH care system challenges influence integration of visual cervical cancer screening service into the existing RH care system in Imenti south sub-county?
: Null Hypothesis
There are no existing challenges to facility integration and client utilization of cervical cancer visual inspection screening test in Imenti south sub-county.
: Study Objectives
: Broad Objective
To establish the existing challenges within the reproductive health care system and among clients utilizing reproductive health services in Imenti south sub-county that influence integration and utilization of visual cervical cancer screening service.
: Specific Objectives
- To determine the proportion of the women utilizing visual cervical cancer screening service in Imenti South Sub-County.
- To determine the influence of client’s demographic and reproductive health factors on utilization of visual cervical cancer screening service.
- To determine the facility based challenges that influence utilization of visual cervical cancer screening service in Imenti south sub-county.
- To examine the RH care system challenges that influence integration of visual cervical cancer screening service into the existing RH care system in Imenti south sub-county.
Scope of the Study
The scope of this study was to be limited to integration and utilization of only visual cervical cancer of screening.
Study Limitations
Lack of centralised data of women attending reproductive health clinics by age; the available data at the sub-county health information management system (HIMS) office was cumulative as per service hence impossible to categorize service users by age.
Since the study involved the entire sub-county, a lot of money was spent to meet the expenses incurred and a lot of time was required to ensure that, the study completed without compromising its reliability.
