University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES PERCEPTION AND PRACTICES OF CERVICAL CANCER SCREENING AND PREVENTION AMONG FEMALE HEALTH WORKERS IN THE KORLE BU TEACHING HOSPITAL BY PRECIOUS OWOO (10703116) A DISSERTATION SUBMITTED TO THE SCHOOL OF PUBLIC HEALTH IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF A MASTER OF PUBLIC HEALTH DEGREE JULY, 2019 1 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Precious Owoo, declare that this dissertation is entirely my own work. References to, quotations from, and discussions of the work of any other person has been duly acknowledged within the work in accordance with University guidelines. I further declare that this dissertation has not been submitted for any degree program in this university or other university elsewhere. …………………………………… …………………………… PRECIOUS OWOO (Student) DATE …………………………………… ……………………………… PROF. RICHMOND ARYEETEY (Supervisor) DATE i University of Ghana http://ugspace.ug.edu.gh DEDICATION I humbly dedicate this work to my lovely family – the two pillars of love and strength – Chris Snr and Chris Jnr. Their love, faith and support have been my motivation during this very challenging past year. And to my family and friends for their prayers and generosity. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS I am grateful to my academic supervisors Prof. Richmond Aryeetey for his guidance and directions during this study. I also thank all my lecturers both in the University of Ghana School of Public Health and the Department of Population, Family and Reproductive Health (PFRH) for their contributions to my public health knowledge and practice. And also to my KBTH Group discussion members for supporting each other and me especially and being such a lovely family – it was great getting to know and study with you guys. My thanks to my Husband, Dr Chris Owoo, Morris (SBAH) and Kofi Agyabeng (Dept of Biostatistics, SPH) for their help during the pretesting, data collection and analysis of this work. I am grateful for the role played by all health professionals who patiently participated in this study – they have helped broaden knowledge that will go a long way to improve cervical cancer screening in KBTH and Ghana. My very special and deep gratitude goes to Agneta, you have been a fantastic friend and a true sister. To my family, friends and Hagar (my nanny), may the Good Lord bless all of you for your prayers, support and understanding through this stressful but immensely rewarding time. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Cervical cancer is the most common cancer among women in Ghana and the leading cause of cancer mortality among women in Ghana. Health care professionals are important predictors of the use of cervical cancer screening, however, there is no evidence of how health workers use cervical cancer screening services. General Objective: To assess the knowledge, perception and practices of cervical cancer screening and prevention among female doctors and nurses in Korle Bu Teaching Hospital (KBTH). Methods: The study employed a quantitative cross-sectional design in studying female doctors and nurses in the KBTH. Data was collected over a four week period from 387 female health workers in seven clinical departments through systematic sampling technique using a structured self-administered questionnaire. Descriptive statistics of categorical variables were presented in frequencies and proportions while that of continuous variables were presented with means and standard deviations. Chi-square and Fishers’ exact tests were used to test for association between the categorical independent variables and various outcome variables. T-test and One-way ANOVA tests were also used to compare the average age of the respondents across the various levels of the outcome variables. Binary logistic as well as linear regression models were used to assess the strength of association between independent variables and dependent variables. Level of statistical significance was pegged at 5%. Results: The knowledge level of majority (72%) of female doctors and nurses in Korle Bu Teaching Hospital on cervical cancer and its screening and preventive methods was moderate. significantly higher proportion of doctors had high knowledge level than nurses iv University of Ghana http://ugspace.ug.edu.gh (35.4% vs 5.1%, p< 0.001). The proportion of health workers with perception that cervical cancer screening is important for reducing risk of the disease was high (94%). The multiple binary logistic regression models identified marital status, work profession, and department as the only statistically significant predictors of Preparedness to Educate Women on Cervical Cancer Screening(p<0.05). It also revealed department, and awareness of cervical cancer screening (ever heard about cervical cancer screening) as the only statistically significant predictors of Cervical Cancer Screening Practice (p<0.05). Not being aware of cervical cancer screening (ever heard about cervical cancer screening) was associated 83% reduced odds of having Cervical Cancer Screening compared to those who were aware (AOR: 0.17, 95% CI: 0.03 - 0.93). Conclusions: The overall level of knowledge of female doctors and nurses in KBTH on cervical cancer, its screening and prevention is inadequate. There was almost universal positive perception of the importance of cervical cancer screening in reducing the disease. The practice of being screened for cervical cancer among female doctors and nurses in KBTH was poor (32%) and this is coupled with inadequate preparedness to talk to or educate other women. The factors significantly associated with positive cervical cancer screening practice among female health workers in KBTH were respondent’s department and awareness of cervical cancer screening. Key words: cervical cancer, screening, preventive practices, pap smear, knowledge, perception, health workers. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION....................................................................................................................... i DEDICATION………………………………………………………………………………. .ii ACKNOWLEDGEMENT……………………………………………………………………iii ABSTRACT ........................................................................................................................... ivv TABLE OF CONTENT .......................................................................................................... vi LIST OF TABLES .................................................................................................................. ix LIST OF FIGURES ................................................................................................................. x LIST OF ABBREVIATION................................................................................................... xi CHAPTER ONE ...................................................................................................................... 1 INTRODUCTION.................................................................................................................... 1 1.1 Background of the study .................................................................................................. 1 1.2 Statement of the problem ................................................................................................. 3 1.3 Conceptual Framework…………………………………………………………………4 1.4 Justification……………………………………………………………………………..7 1.5 General objective ............................................................................................................. 8 1.5.1 Specific objectives ................................................................................................... 8 1.6 Research Questions……………………………………………………………………..8 CHAPTER TWO ..................................................................................................................... 9 LITERATURE REVIEW ....................................................................................................... 9 2.1 General overview of cervical cancer ................................................................................ 9 2.2 Epidemiology of cervical cancer ................................................................................... 10 2.3 Methods of screening for cervical cancer ...................................................................... 13 2.3.1 Cytology or Papinicolaou ....................................................................................... 13 2.3.2 Human Papilloma Virus - Deoxyribonucleic Acid (HPV- DNA) and care HPV ... 14 2.3.3 Visual Inspection with Acetic Acid (VIA) ............................................................. 14 2.4 Vaccination - Cervical Cancer Prevention Method ........................................................... 15 2.5 Knowledge and perceptions about cervical cancer and screening and association with cervical cancer screening practices ...................................................................................... 16 2.6 Practices and behaviours about cervical cancer screening and factors associated with screening practices ............................................................................................................... 17 CHAPTER THREE ............................................................................................................... 19 METHODS ............................................................................................................................. 19 vi University of Ghana http://ugspace.ug.edu.gh 3.1 Study site ........................................................................................................................ 19 3.2 Study design ................................................................................................................... 20 3.3 Study population ............................................................................................................ 20 3.3.1 Inclusion criteria ..................................................................................................... 20 3.3.2 Exclusion criteria .................................................................................................... 20 3.4 Sample size determination ............................................................................................. 21 3.5 Study variables ............................................................................................................... 21 3.6 Sampling Procedure ....................................................................................................... 24 3.7 Pretesting........................................................................................................................ 25 3.8 Data collection technique and tools ............................................................................... 25 3.9 Quality control ............................................................................................................... 25 3.10 Data Processing and Analysis ...................................................................................... 26 3.11 Ethical Consideration ................................................................................................... 26 CHAPTER FOUR…………………………………………………………………………....28 REESULTS…………………………………………………………………………………..28 4.1 Characteristics of Health Workers ……………………………………….28 4,2 Health Workers' Knowledge on Etiology and Epidemiology of Cervical Cancer……30 4,3 Health Workers' Knowledge on the Risk factors, signs and symptoms of Cervical Cancer……………………………………………………………………………………..30 4.4 Health Workers' Knowledge on Cervical Cancer Screening………………………….31 4.5 Health Workers' Knowledge on Cervical Cancer Screening Guidelines……………...32 4.6 Health Workers' Knowledge on Vaccination and Prevention of Cervical Cancer……33 4.7 Respondents' Combined Overall Knowledge Distribution……………………………33 4.8 Association between Health Worker Characteristics and Combined Overall Knowledge Levels……………………………………………………………………………………...34 4.9 Effects of Respondents Characteristics on Combined Overall Knowledge Levels…...36 4.10 Health Workers Perception on Cervical Cancer Screening; Respondents Preparedness to Educate Women and Perceived Barriers to Screening…………………………………38 4.11 Health Worker Practices on Cervical Cancer Screening and Sources of Information39 4.12 Association between Respondents' Characteristics and Cervical Cancer Screening Practices…………………………………………………………………………………...42 4.13 Association between Respondents' Knowledge Level and Perceptions and Cervical Cancer Screening Practices………………………………………………………………..44 4.14 Association between Respondents' Characteristics; Knowledge Levels and Perception on Cervical Cancer Screening Practices…………………………………………………...45 vii University of Ghana http://ugspace.ug.edu.gh 4.15 Association between Health Worker Characteristics and Preparedness to Educate Women on Cervical Cancer Screening……………………………………………………49 4.16 Association between Respondent Knowledge Levels and Preparedness to Educate Women on Cervical Cancer Screening……………………………………………………51 4.17 Association between Respondents' Characteristics, Knowledge Levels and Perception on Preparedness to Educate Women on Cervical Cancer Screening……………………..53 CHAPTER FIVE…………………………………………………………………………….56 DISCUSSIONS………………………………………………………………………………56 5.1 Characteristics of Female Health Worker Respondents………………………………56 5.2 The Knowledge of Female Health Workers on Cervical Cancer, its Screening and Prevention…………………………………………………………………………………57 5.3 Association between Health Workers' Characteristics and Overall Knowledge Levels60 5.4 Health Workers' Perception on Cervical Cancer Screening; Respondents' Preparedness to Educate Women and Perceived Barriers to Screening…………………………………62 5.5 Health Workers' Practices on Cervical Cancer Screening and Their Sources of Information on Cervical Cancer Screening and Prevention………………………………64 5.6 Association between Knowledge Levels of Health Workers and Cervical Cancer Screening Practices………………………………………………………………………..66 5.7 Limitations of the Study………………………………………………………………67 CHAPTER SIX………………………………………………………………………………68 CONCLUSIONS AND RECOMMENDATIONS…………………………………………..68 6,1 Conclusions……………………………………………………………………………68 6.2 Recommendations……………………………………………………………………..68 REFERENCES ........................................................................................................................ 70 APPENDICES ......................................................................................................................... 74 Appendix A: Participant’s Consent form ............................................................................. 74 Appendix B: Research questionnaire ................................................................................... 78 Appendix C: Budget ............................................................................................................ 85 Appendix D: Timelines ........................................................................................................ 86 Appendix E: Ethical Clearance Letters ................................................................................ 87 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 3.1 Dependent and independent variables definition ..................................................... 23 Table 4.1 Characteristics of Health Worker Respondents……..…………………………….29 Table 4.2 Respondents' Knowledge on Etiology and Epidemiology of Cervical Cancer……30 Table 4.3 Knowledge on the Risk factors, signs and symptoms of Cervical Cancer……….. 31 Table 4.4 Respondents' Health Workers' Knowledge on Cervical Cancer Screening……… 32 Table 4.5 Respondents' Knowledge on Cervical Cancer Screening Guidelines……………..32 Table 4.6 Respondents' Knowledge on Vaccination and Prevention of Cervical Cancer……33 Table 4.7 Association between Respondents' Characteristics and Combined Overall Knowledge Levels……………………………………………………………........................35 Table 4.8 Effects of Respondents Characteristics on Combined Overall Knowledge Levels.37 Table4.9 Respondents' Perception on Cervical Cancer Screening; Respondents Preparedness to Educate Women and Perceived Barriers to Screening……………………………………39 Table 4.10Respondents' Practices on Cervical Cancer Screening and Sources of Info……..41 Table 4.11a Association between Respondents' Characteristics and Cervical Cancer Screening Practices…………………………………………………………………………..43 Table 4.11b Association between Respondents' Characteristics and Cervical Cancer Screening Practices…………………………………………………………………………..44 Table 4.12 Association between Respondents' Knowledge Level and Perceptions and Cervical Cancer Screening Practices………………………………………………………..45 Table 4.13a Association between Respondents' Characteristics; Knowledge Levels and Perception on Cervical Cancer Screening Practices………………………………………...47 Table 4.13bEffects of Respondents' Characteristics; Knowledge Levels and Perception on Cervical Cancer Screening Practices …….…………………………………………………48 Table 4.14a Association between Health Worker Characteristics and Preparedness to Educate Women on Cervical Cancer Screening……………………………………………………..50 Table 4.14b Association between Health Worker Characteristics and Preparedness to Educate Women on Cervical Cancer Screening……………………………………………………..51 Table 4.15 Association between Respondent Knowledge Levels, Perception and Preparedness to Educate Women on Cervical Cancer Screening…………………………………………52. Table 4.16a Association between Respondents' Characteristics, Knowledge Levels and Perception on Preparedness to Educate Women on Cervical Cancer Screening………54 Table 4,16b Association between Respondents' Characteristics, Knowledge Level and Perception onPreparedness to Educate Women on Cervical Cancer Screening….…..55 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1.1 Conceptual framework showing KAP of cervical cancer prevention among female health workers .................................................................................................................... 7 Figure 4.1Distribution of Respondents' Combined Overall Knowledge Levels ..................... 34 x University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ACCP - Alliance for Cervical Cancer Prevention AIDS - Acquired Immune Deficiency Syndrome AOR - Adjusted Odds Ratio ANOVA - Analysis of Variance A & E - Accident and Emergency β - Beta CI - Confidence Interval DNA - Deoxyribonucleic acid DDNS - Deputy Director of Nursing Services GLOBOCAN - Global Cancer Incidence, Mortality and Prevalence HAC - Health Assistant Clinical HIV - Human Immunodeficiency Virus HO - House Officer HPV - Human Papilloma Virus HPV- DNA - Human Papilloma Virus - Deoxyribonucleic Acid ICUs - Intensive Care Units IRB - Institutional Review Board Jnr - Junior KAP - Knowledge, Attitude and Practices KBTH - Korle Bu Teaching Hospital MIDO - Midwifery Officer MO - Medical Officer MPH - Masters in Public Health NO - Nursing Officer OCP - Oral Contraceptive Pill O & G - Obstetrics and Gynaecology xi University of Ghana http://ugspace.ug.edu.gh PFRH - Population, Family and Reproductive Health PHAC - Principal Health Assistant Clinical PMIDO - Principal Midwifery Officer PNO - Principal Nursing Officer RES - Resident SBAH - School of Biomedical and Allied Health SHAC - Senior Health Assistant Clinical SHO - Senior House Officer SMID - Staff Midwife SMIDO - Senior Midwifery Officer SMO - Senior Medical Officer SN - Staff Nurse SNO - Senior Nursing Officer Snr - Senior SPEC - Specialist SPH - School of Public Health SPSS - Statistical Package for Social Sciences SSA - Sub-Saharan Africa SSN - Senior Staff Nurse STATA - Statistics and Data VIA - Visual Inspection with Acetic Acid WHO - World Health Organization xii University of Ghana http://ugspace.ug.edu.gh xiii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background of the study Cervical cancer is an uncontrolled proliferation of the cells of the cervical region of the uterus; this abnormality in cell growth being initially clinically silent and usually progressing over an appreciable period of time before the appearance of suggestive clinical features. The cervix is the lower narrow part of the uterus which protrudes into the upper part of the vagina (National Cancer Institute, 2015). The aetiology of cervical cancer is usually sexually transmitted and is often caused by genotypes 16 and 18 of the Human Papilloma Virus (HPV).It occurs as a result of early initiation or exposure to sexual activities in girls or young women. There are in excess of over forty HPV genotypes that have been implicated in the development of malignant legions of the cervix, however majority of the cancers are as a result of genotypes 16 and 18. Women or younger girls (of age six to 14 years) with multiple sex partners and recurrence of sexually transmitted infections tend to be at higher risk of cervical cancer. Other risk factors for cancer of the cervix are multiple births, early marriage and cigarette smoking (WHO, 2006). Men can be considered as the main reservoir of sexually-transmitted HPV that infects women and may result in cervical cancer. Studies have reported a much higher prevalence of HPV infection of the glans/ corona among uncircumcised men and boys (46%) compared to their circumcised counterparts (29.0%) (Hernandez et al., 2008). This underlines the importance of cultural and religious in the sustenance of this disease and the difficulties that may be encountered in trying to reduce the incidence of the cancer in communities where the practice of circumcision among boys and men are. Other modalities for preventing the infection or protecting women from the impact of the disease are therefore crucial if the association mortality is to be reduced, 1 University of Ghana http://ugspace.ug.edu.gh Studies by WHO and other investigators have suggested that cervical cancer is the second highest cause of cancer mortality in women and the fourth highest prevalence of female cancer worldwide. They suggest that these statistics are much worse in underdeveloped and developing countries (WHO, 2015; Wong, Wong, Low, Khoo & Shuid, 2009). In these developing and underdeveloped countries, cervical cancer has been reported to be commonest or one of the most common cancers with an annual incidence of about 440,000 new cases, (Wong et al., 2009). The annual mortality associated with cervical cancer is as high as 270,000; with over 85% of these deaths recorded in developing countries (WHO, 2015). This is as a result of limited access to effective screening, thus the disease is often identified in the advanced stage. Also, treatment for the late-stage of the disease is usually inadequate or unavailable with the consequence of a higher mortality rate in developing countries (Adu- Amankwa, 2016). Malignancy of the cervix can be reduced by looking out for the early lesions before the development of malignancy. This can be done using Pap smear or visually inspecting the cervical mucosa and applying acetic acid and this should be repeated timeously and prompt treatment before progression to cancer (Wong et al., 2009). At the national level, Ghana records an incidence of 35.4% with an 18.9% mortality rate from cervical cancer (WHO, 2014). A study conducted at the Korle Bu Teaching Hospital concluded that cervical cancer is not receiving adequate attention both at national and institutional level in comparison to other public health diseases of similar interest (Nkyerkyer, 2000). The investigator opined that there is the need for the prioritization of cancer of the cervix, with adequate and sustained investment of resources if the impact of the disease and cancer death were to be reduced (Nkyerkyer, 200). The author further noted that it is fortunate that cervical is largely a preventable disease that is amenable to appropriate and well organized interventions (Nkyekyer, 2000). However, in Ghana there is no routine national cervical cancer screening. Most screening is opportunistic, where doctors request 2 University of Ghana http://ugspace.ug.edu.gh pap smears or visual inspection with acetic acid (VIA) for patients during their visits to the clinics for either general medical examinations or for consultations unrelated to cervical cancer (Adanu et al., 2010). It is necessary, therefore, to have a better organized national program that incorporates all the different aspects such as provision of accessible facilities for screening, training of human resources for the program, availability and affordability of screening modalities and preventive vaccine as well as outreaching to more remote or rural communities. At the KorleBu Teaching Hospital for example, cervical cancer is reported to be the commonest gynaecological malignancy making up 64% of gynaecological malignancies seen at the hospital (Adanu, Seffah, Duda, Hill &Anarfi, 2010). Even though this dire statistic and the related hospital specific death continue to persist after a decade since the study, it is still not receiving the level of attention given to other public health disease such as malaria and HIV. 1.2 Statement of the problem Globally, every year, cervical cancer claims the lives of 270,000 women with over 85% of them found in developing countries (Tripathi, Yugantara, Randhir&Alkal. 2014). 34.8 per 1,000 new cases of cervical cancer are diagnosed among women annually, and 22.5 per 1,000 women die from the disease in sub Saharan Africa, (Muthali, Ngwira&Taulo, 2015). A study in Nigeria showed only 3.1% of 162 female health workers had had a cervical cancer screening (Akhigbe et al., 2009). In Ghana, a number of studies suggest that cervical cancer is the second most common cancer among women aged 15 to 44 years and the studies estimate that annually, 3,038 women are diagnosed with cervical cancer and 2,006 die from it in Ghana (Nkyekyer, 2000; WHO, 2010; Edwin, 2010; WHO, 2012). It is very worrying that 3 University of Ghana http://ugspace.ug.edu.gh the level of screening for cancer of the cervix is this low across the West African Sub-region despite the staggering statistics on the incidence and related death that have been demonstrated by several investigators in the sub-region. The low screening level has been suggested in other similar settings that affect women of different background both urban and rural, with no discrimination on health workers (Mutyaba et al, 2007). Health care professionals are important predictors of the use of cervical cancer screening, and it seems that even the health workers themselves in large numbers do not uptake the cervical cancer screening (Mensah, 2016). Health workers, especially females are expected to provide information on cervical cancer and act as advocates to effective preventive practices. However, there is little documentation in KBTH on the awareness and prevention practice of female health workers. It was therefore important to assess the knowledge and practices of female health workers on cervical cancer and its preventive methods in the KBTH. 1.3 Conceptual framework The conceptual framework in Figure 1.1 presents the knowledge, attitude and practices (KAP) and prevention of cervical cancer. It is believed that the knowledge and attitude of female health workers such as access to free screening for cervical cancer, fear of the results after testing, number of sexual partners and fear of the pain to some extent influence the KAP and prevention practices of cervical cancer. The passive attitude of female health workers towards seeking regular check-ups on cervical cancer influences the prevention of cervical cancer (Wong et al. 2013; Gattoc, Nair & Ault, 2015). Adequate or accurate knowledge has been reported by most of the investigator earlier cited as resulting in improvement in screening practices; while absence of awareness of the importance of screening and the its guidelines would be expected to have an adverse effect on the woman’s decision making regarding screening and consequently result in higher number 4 University of Ghana http://ugspace.ug.edu.gh of new cases and related cancer death. However, Riain (2001) argued that adequate knowledge on itself alone or positive perception alone may not achieve the desired attitude to screening for cancer of the cervix and practice of the women may not necessarily improve. Knowledge and positive perception need to complement other equally important factors such as availability and accessibility of screening facility; encouraging attitude of well trained health provider and improvement in socio-economic and cultural factors. It is imperative for women, especially health workers to seek early screening for prompt prevention of cervical cancer. Preventive measures include practices such as screening with Pap smear, visual inspection with acetic acid (VIA), liquid based cytology, Evalyn brush and human papilloma virus (HPV). Subsequently, seeking early treatment with any of the preventive measures is crucial to preventing cervical cancer among female health workers (Idowu, Olowookere, Fabgbemi & Ogunlaja, 2016; Sudenga, Rositch et al, 2013). A number of factors influence the use of cervical cancer methods. Determinants such as the cost of seeking cervical cancer screening, pressure from family matters (especially married female health workers with children), cultural and religious beliefs are crucial to seeking early and regular screening for the effective prevention of cervical cancer. In effect, some cultural beliefs cause fear and cause myth around seeking early and regular treatment for the prevention of cervical cancer (Modibbo et al. 2016; Prempeh, 2015) From the conceptual framework in fig. 1.1, it is shown that the knowledge, attitude of female health workers and women in general on cervical cancer would be expected to impact on the level of use of cervical cancer screening and preventive measures and ultimately on the incidence of the disease and associated mortality. Higher level of knowledge and positive perception and screening practices would be expected to result in higher screening uptake and 5 University of Ghana http://ugspace.ug.edu.gh lover disease incidence whiles poor level of knowledge and attitude may result in lower use of screening methods and possibly increase in disease incidence. The knowledge, attitude and practice of women, however, exert their influences through related intermediary groups of factors which interact both simply and complexly to determine their impact on the use of cervical cancer screening methods and incidence of the disease. These factors have been grouped in this framework as knowledge-related factors, accessibility of effective screening method and other determinants (such as cost, family influence, cultural and religious beliefs). It would be expected that awareness of the need for cervical cancer screening and understanding of the issues on the aetiology, guidelines and available management coupled with accessibility of effective screening methods as well as positive cost-related and socio-cultural determinants will be expected to improve the use of screening methods among women. Whereas women who are less knowledgeable with limited access to effective screening facilities and hampered by negative socio-cultural and economic determinants may have lower usage of cervical cancer screening measures. So it will stand to expect that knowledge and perception alone may be inadequate in predicting the usage of cervical cancer screening and preventive measures and will require other important factors such as accessibility of effective methods, economic and socio- cultural determinants to align positively in order to improve impact on the screening practices and disease incidence, morbidity and mortality. In summary, knowledge, perception and practices of cervical cancer prevention interact to influence the uptake of cervical cancer screening. The interactions can be at different levels in differnt settings and may vary in the direction of the impact – positively or negatively – among women from different background or even from the same community or make up dependent on the relative strength of the differnt competing variables and the characteristics of the women individually or as a set. 6 University of Ghana http://ugspace.ug.edu.gh Knowledge, attitude and practices (KAP) of cervical cancer prevention Knowledge related Preventive/ screening Determinates of use of factors measures cervical cancer screening methods a. Access to free a. Pap smear screening b. VIA a. Cost of cervical cancer b. Fear of results c. Liquid based cytology screening c. Sexual behaviour d. Evalyn brush b. Family pressure d. Fear of painful e. HPV testing c. Cultural and religious procedure f. vaccination belief g. Abstenance/delayed sexual activities Cervical cancer prevention measures Figure 1.1 Conceptual framework showing KAP of cervical cancer prevention among female health workers (Source: Researcher’s own construct) 1.4 Justification The findings of the study will help in making recommendations towards the structuring and implementation of training programs aimed at adequately equipping female health workers as agents of change in the community in bridging the awareness gap and as practice role models for other women in reproductive age. Also, the information derived from this study will inform health authorities (Ministry of Health) to encourage health workers (nurses) to access the numerous screening opportunities to know their status for prompt medical attention. Further the results can facilitate the evaluation of current cervical cancer screening programs particularly for female health workers. 7 University of Ghana http://ugspace.ug.edu.gh 1.5 General objective To assess the knowledge, perception and practices of cervical cancer screen and prevention among female doctors and nurses in Korle Bu Teaching Hospital (KBTH). 1.5.1 Specific objectives 1. To determine the knowledge and attitude of female doctors and nurses in KBTH on cervical cancer and its prevention 2. To assess practices of female doctors and nurses in KBTH on cervical cancer screening and prevention 3. To determine the factors associated with the use of cervical cancer screening among female doctors and nurses in KBTH 4. To determine the association between knowledge level and cervical cancer screening among female doctors and nurses in KBTH 1.6 Research questions The following questions will be posed; 1. What is the level of knowledge and attitude on cervical cancer and its prevention practices among female doctors and nurses in KBTH? 2. What are the cervical cancer prevention practices of female doctors and nurses in KBTH? 3. What are the determinants of the use of cervical cancer screening methods among female doctors and nurses in KBTH? 4. What is the association between knowledge level and cervical cancer screening among female doctors and nurses in KBTH? 8 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 General overview of cervical cancer Cervical cancer is usually asymptomatic with the absence of suggestive signs in its early stages (Lim et al, 2014; Petignat & Roy, 2007). However, the pre-cancerous lesions can be easily detected at this stage by routine cervical cancer screening of at-risk women (Nkerkyer, 2000; Mishra et al, 2011). The pre-cancerous lesion phase of the disease can be very long, affording a higher effectiveness of screening methods for its detection before the symptomatic cancer phase of the disease (Mishra et al, 2011). Symptoms and clinical features suggestive of cervical cancer start to appear as the disease progresses into advanced stages. The suggestive signs and symptoms of cancer progression include: dysparunia, pelvic pain, vaginal discharge and abnormal vaginal bleeding. Many patients especially in developing countries present with late stage advanced cervical cancer disease due to this absence of signs and symptoms in the early stages of the disease coupled with the low uptake of cervical cancer screening in these setting(Nkerkyer, 2000; Mishra et al, 2011). By the time the non- specific clinical features which are suggestive of cervical cancer appear, it may already be too late and results in a higher mortality rate (Gillet et al, 2012). The clinical features of cervical cancer are quite non-specific and mimic many other pelvic and gynaecological non-malignant or benign conditions such as vaginitis and pelvic inflammatory disease. Patients experiencing these clinical feature would therefore, be commonly seen and managed by general medical practitioners with multiple hospital visits and treated empirically for more benign differential diagnoses and only referred to the gynaecologist when the complaints persists or patient condition deteriorates(Nkerkyer, 2000; Mishra et al, 2011; Gillet et al, 2012). A high proportion of them will therefore, report to the gynaecologists with advanced disease which has been minimally investigated. Some of them 9 University of Ghana http://ugspace.ug.edu.gh may even seek help from alternative health care practitioners or purchase over the counter medications on the advice of friends and family who had experienced similar complaints or for managing “menstrual problems”, without seeking proper professional consultation (Gillet et al., 2012). All these factors coupled with poverty, lack of awareness and paucity of accessible health service and availability of affordable cervical cancer screening programs impact adversely on cervical cancer prevention and management. 2.2 Epidemiology of cervical cancer Malignancy was estimated by GLOBOCAN in 2012 to be the leading cause of mortality worldwide with 8.2 million deaths in 2012. Low- and middle-income countries carry the heaviest of cancer burden worldwide with 56.8% of all cancer prevalence and 64.9% of all cancer mortality estimated to occur in these countries (GLOBOCAN, 2012). With projected global population increase expected, an increase of the incidence of malignancy worldwide to 19.3 million new cases of malignancy per year by 2025 was predicted by the GLOBOCAN (WHO 2013). The World Health Organization has projected that in excess of 30% of morbidity and mortality associated or attributed to cancer can be removed from the burden associated with cancer if there are sufficient investments in the preventive and control measures targeted at malignant diseases (WHO fact sheet, 2011). These gains will not only be limited to the preservation of life and health of individuals afflicted by cancer but would also extend to economic gains from preservation of productivity and reduction in cost incurred in the chronic management of cancer related complications. Cervical cancer is the second most common female malignant disease worldwide and the commonest cause of cancer mortality in developing countries with an estimated 529,409 new 10 University of Ghana http://ugspace.ug.edu.gh cancer cases occurring globally, with 52% of them dying in 2008(GLOBOCAN, 2008). About 86% of the total new cases each year occur in developing countries, where unfortunately 80-90% of cervical cancer related deaths occur (GLOBOCAN, 2008). Cervical cancer morbidity and mortality afflicts women at the peak age of 35-35 year of age when they are most productive in both their families and community; thereby, denying families their maternal contribution in raising children and caring for the family as well as the loss of social and economic contributions from these women to their community. In developing countries where the role of the woman is central in crucial in the upkeep of the immediate and extended family, the impact on the family system and the socio-economic wellbeing and development of the community may be impacted. Cervical cancer is fortunately easy to detect and curable in its early stages, this gives the opportunity to reduce the adverse impact of the disease on morbidity and mortality if women at-risks are frequently screened. Unfortunately, only 5% of women in developing countries undergo screening for cervical cancer in contrast to more than 40% of their counterparts in developed countries, and at least 70% in countries that have shown marked reduction in incidence and prevalence of cervical cancer. Most women in Africa frequently present with late stages of the disease unsurprisingly, because of the low uptake of cervical cancer screening and preventive practices among these women. The magnitude of the problem related with cervical cancer in Sub-Saharan Africa is under- reported, under-appreciated and not adequately appreciated compared with other competing public health issues such as malaria, tuberculosis and HIV/AIDS even though 34.8 new cases of cervical cancer are diagnosed per 100,000 women annually and 22.5% per 100,000 women die from the disease (WHO 2013). Denny et al (2006) and Parkin et al (2008) noted that the reason for not recognizing the true weight of the problem that malignancy of the cervix poses can be partly traced to the paucity of epidemiological data and limited awareness as well as 11 University of Ghana http://ugspace.ug.edu.gh other contributing limitations including human resource constraints, lack of guiding policies on cancer and fleeting political will to tackle the issue. The stressed that the problem is multi- factorial and therefore, requires efforts on all fronts to deal with it sustainably. Cervical cancer in Ghana is responsible for up to about 57.8% of all gynaecological cancers; making it the commonest gynaecological malignancy in Ghana (WHO, 2010). Several investigators have shown that it is the second most common female malignancy with an estimated incidence of 26.4 per 100,000 as well as the second most common cancer in women in the reproductive age group aged 15 to 44 years in Ghana. These investigators estimate that every year, 3,038 women are diagnosed with cervical cancer and 2,006 die from it in Ghana (Edwin, 2010; Nkyerkyer, 2000; WHO, 2010). The World Health Organization predicted in 2007 that five thousand new cases of cervical cancer and estimated 3,361 cervical cancer-related deaths are expected yearly, by the year 2025 in Ghana. This is obvious alarming, considering its potential impact on social and economic wellbeing of the community and the development agenda of the country. For a malignancy that is easily detectable and highly preventable, it is imperative therefore the employ all effort at improving the early detection of the pre-cancerous lesion with effective cervical cancer screening modalities as well as preventive measures at minimizing the infection (Nkyekyer, 2000). If detected early, cervical cancer can be easily treated and cured in contrast to the advance stages of the disease when the management becomes challenging and more expensive. Despite the overwhelmingly unacceptable statistics both from investigators in the sub-region and reliable global estimates, the promotion of cervical cancer awareness, prevention and screening in Ghana are still very low in comparison to other public health diseases of interest. 12 University of Ghana http://ugspace.ug.edu.gh 2.3 Methods of screening for cervical cancer There are several modalities for screening for cancer of the cervix which effective in detecting the early and benign stages of the disease and will therefore, help in reducing the proportion of lesions moving on to advanced malignant disease (Nkerkyer, 2000; Mishra et al, 2011; Gillet et al, 2012). These methods include Pap smear, VIA and HPV DNA testing. It is important that the choice of screening method for a program needs to take into consideration all the advantages and disadvantages associated with each method in order to maximize the effect of the program. Cost, reliability of result, ease of performance and how soon an accurate screening result can be obtained are very valuable when making the choice of screening modality to employ for a program(Maine et al., 2011). Methods that are reliable, rapid, simple, inexpensive and associated with minimal requirement for a formal laboratory setup of sophisticated technology would be preferable when setting up a national, institutional or facility-based screening program(Maine et al., 2011). 2.3.1 Cytology or Papanicolaou Cytology or “Pap” smear is the most effective and common screening method for the detection of early stages of cervical cancer in its pre-cancerous lesion phase. It consists of spreading and staining a smear of collected cervical cells and analysing them under the microscope to detect lesions(Maine et al., 2011). The procedure of obtaining the sample can be as short as less than five minutes and a highly accurate test result can be ready in less than 30 minutes. This screening method enables professionals to accurately detect and stage high grade lesions as well as allow early detection, thereby decreasing the incidence of advanced cervical cancer and associated mortality. This simple method allows women to be quickly 13 University of Ghana http://ugspace.ug.edu.gh screened even in more rural communities where laboratory facilities and other amenities are scarce and with minimal interruption to their daily activities. They can just walk in and be out in less than half an hour with the knowledge of their status. 2.3.2 Human Papilloma Virus - Deoxyribonucleic Acid (HPV- DNA) and careTM HPV test Human Papilloma Virus (HPV) is implicated as the cause of sexually-transmitted cervical cancer among women. The demonstration of DNA of HPV is a newer modality for cervical cancer screening among women. The HPV-DNA testing consists of screening for high-risk strains of HPV and has been shown to reduce mortality in high grade lesions in advanced invasive cervical cancer and even in women with human immunodeficiency virus (HIV) (Louie et al., 2009). The problems with this test method are the requirement for formal laboratory facility, its prohibitive especially for rural communities; and the duration of at least seven (7) hours needed for the processing of the test result. These limitations have restricted the uses of HPV-DNA testing as a screening tool in settings where access and affordability are important Another way of testing for cervical cancer is HPV test. The test is simple and rapid; with the availability of the result in less than three hours and not requiring the sophistication that comes with the formal DNA test. 2.3.3 Visual Inspection with Acetic Acid (VIA) VIA is the simplest method among the three for screening for cancer of the cervix and is associated with the least cost and is the easiest screening method. The non-requirement for sophisticated technology and its affordability especially in rural communities has been shown to reduce morbidity and cancer death among rural women in resource-limited communities 14 University of Ghana http://ugspace.ug.edu.gh (Wright & Kuhn, 2012). The procedure involves the application of 5% acetic acid or vinegar to the cervical mucosa; normal tissue will remain unaffected by the vinegar wash, but abnormal cells including dysplastic and cancerous cells will turn white. The immediate availability of the result of the screening test from VIA affords the practitioner the ability to promptly diagnose and commence treatment of treatment of abnormal cell, usually by the application of cryotherapy to the dysplastic area (Shi et al., 2012). 2.4 Vaccination - Cervical Cancer Prevention Method Interventions and practices that either reduce the exposure of girls and women who are at risk of sexually-transmitted cancer of the cervix; or take them out of the risk group such as vaccination are gradually becoming common tackling the disease especially with persisting low level of screening among women. HPV Infection of most women with usually occurs soon after they become sexually active. Although more than 40 genotypes of HPV are implicated in malignancy of the cervix, over 70% of the cancer is caused genotypes 16 and 18 (Maine et al., 2011). Prophylactic vaccination of young girls as young as nine years of age before the development of high risk behaviours and child birth have shown to be preventive against HPV infection (Louie et al., 2009). The HPV vaccine has been available since 2006 and can prevent 70% of HPV-caused cervical cancers if the 3 dose vaccine series is completed. There are several vaccines that have been used in different settings for the prevention of transmission of HPV infection. Although vaccination against HPV adds more weapons to the quest at primary prevention of malignancy of the cervix, it does not replace or reduce the role of screening but rather augments the different measures for reducing cervical (Louie et al., 2009). 15 University of Ghana http://ugspace.ug.edu.gh 2.5 Knowledge and perceptions about cervical cancer and screening and the association with cervical cancer screening practice Lack of knowledge or absence of awareness of the role of screening in the reduction of cancer of the cervix among women of various backgrounds have been shown by many studies to adversely impact the use of screening methods (Merchant, 2007; Nakalevu, 2009). Perception and knowledge interact to influence the decision of many women when seeking for healthcare and cervical cancer is not different in this regard. Lack of understanding of the implication of screening results among many women in the community results in anxiety and fear of what the result means for them and their families in terms of outcome and many them may wrongly but fearfully think a positive screen equates to having cancer. This very common anxiety prevents a lot of women in the community from seeking to participate in screening activities (Nakalevu, 2009). Other important contributing factors for the low uptake of cervical cancer screening among women in the community include, cultural norms of secrecy that do not allow discussion of reproductive health issues by women outside the home and sometime even in their homes, leading to worsening of the inadequacies in awareness of cervical cancer screening options. Other contributing knowledge barriers to poor screening practices among women include absence of suggestive clinical features, poor knowledge of screening guidelines and regimen (Nakalevu, 2009). Riain (2001) demonstrated in a study that availability of knowledge alone without the compliment of other determinants does not necessarily result in increasing the voluntary use of screening methods in women and suggested that this is because of other social and economic problems that prevent them from utilizing the screening. Apart from lack of knowledge, Mutyaba (2007) concluded in a study in Uganda that the role of men as resource providers in the family and community impacts of the screening habit of the women and their 16 University of Ghana http://ugspace.ug.edu.gh lack of participation in reproductive health issues adversely affects the quest at reducing cancer death through screening. Mutyaba’s study was very informative about the role of different stakeholders in the fight against cervical cancer because the mix of the study participant which included men, women and health workers. 2.6 Practices and behaviours about cervical cancer screening and the factors associated with screening practices Practices of women in the community regarding screening and prevention are influenced by many different factors – personal, community-related and institutional- resulting in either positive or negative effects. In two separate studies, the investigator demonstrated positive correlation between the provision of sustained, well-structured screening programs found in some developed countries and radical reduction in cancer death in these countries (Hakama et al., 2008; Mutyabaet al. 2007). These programs had as their common thread the provision of appropriate infrastructure, well-trained manpower, efficient follow up and surveillance systems. The findings and recommendations of these two studies were in agreement with an earlier review of five different studies by investigators in Mexico, Peru and Ecuador (ACCP, 2004). This emphasizes the need for a well structured and sustainable cervical cancer screening and health promotion program spearheaded from national level but decentralized enough to be efficient and accessible to women in the community. It is not debateable that a properly organized and well-resourced screening program is very important in improving the practice among women of participating in cervical cancer screening; however, other authors have insisted that this in itself is not enough and the role played by other equally – if not more – important factors are crucial if there is to be a sustained improvement in the use of screening methods and reduction in the magnitude of death related to cervical cancer. Among these other important factors are adequate 17 University of Ghana http://ugspace.ug.edu.gh knowledge, appropriate attitude of health seekers and health worker, cultural beliefs and norms, socio-economic and institutional factors. They argued that these other factors may actually supersede the role of just provision of an organized screening program (Engender Health, 2002; Nakalevu; 2009). It is important to indicate that, although the same factors have been investigated by many studies on cancer of the cervix, the findings are not always in agreement concerning the practices of women on cervical cancer screening participation. For example, ACCP (2004) and Bradly et al. (2004) showed different effects of socio-economic factors among women from India in comparison to South African women. Mutyabaet al. (2006; 2007) on the other hand, demonstrated combined effects of the found the earlier mentioned factors in determining what a women decides to do regarding participation in screening programs; and that these factors interact at several levels to determine their practice in Uganda. Nakalevu (2009) observed that the role of culture in determining practice among Fijian women was not a major player in their decision to participate in cervical cancer screening programs as long as adequate knowledge and positive perception. 18 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODS 3.1 Study site Korle Bu Teaching Hospital is a tertiary referral hospital in Greater Accra Region, Ghana. It is located in the Ablekuma Sub-Metro of Ghana and covers an area of about 44 acres. The hospital has staff strength of about 4500 in various clinical and administrative disciplines. Currently, the hospital has 17 clinical and diagnostic departments and units, with different categories of personnel. It has an average daily out patients’ attendance of 1,200 with an admission rate of about 150 patients per day. It has a bed capacity of 2000 in its 48 functioning wards with 430 doctors and 1050 nurses. The clinical and diagnostic departments are; Medicine, Surgery, Child health, Obstetrics and Gynecology, Allied Surgery, Pathology, Hematology, Laboratories, Radiology, Anesthesia, and Polyclinics. Others are Accident and Emergency Centre, Pharmacy, Central Sterilization and Supply Department and Physiotherapy. The study was concurrently conducted in seven (7) clinical departments, Internal Medicine, Surgery, Obstetrics and Gynaecology, Anaesthesia and ICUs, Orthopaedics and A&E, Child Health and Polyclinic. These clinical settings were chosen because of the large numbers of doctors and nurses in these departments to give a representative perspective while allowing for comparison between different departments and between doctors and nurses on the knowledge, perception and practices of the different female doctors and nurses on the preventive measures of cervical cancer. Although it would have been desirable to add female other health professionals such as pharmacists and physiotherapists, their much smaller numbers and non-permanent attachment to specific department would have made comparison between departments and professions difficult. 19 University of Ghana http://ugspace.ug.edu.gh 3.2 Study design This was a facility-based cross-sectional study using a quantitative method (structured questionnaire) to assess the knowledge, practices, attitude and prevention of cervical cancer among female health workers in Korle Bu Teaching Hospital, Accra. 3.3 Study population The study population was made up of female doctors, and nurses at theKBTH. The participants in the study were recruited from seven (7) clinical departments of the hospital – Internal Medicine, Surgery, Child Health, Obstetrics and Gynaecology, Anaesthesia and Intensive Care Units, Orthopaedics and Accident and Emergency and Polyclinic. These departments were used because of the large numbers of doctors and nurses to afford ease of comparison. 3.3.1 Inclusion criteria • Female doctors and nurses who are currently practicing in the hospital in the selected clinical departments. 3.3.2 Exclusion criteria • Female health doctors and nurses on rotation or attachment from other health facilities • Female doctors and nurses on leave or external rotation at the time of the study 20 University of Ghana http://ugspace.ug.edu.gh 3.4 Sample size determination The sample size for the study was calculated using the Cochran’s (1967) formula; (𝑍𝜕)²𝑝(1 − 𝑝) 𝑛 = 2 𝑑2 Where: n= minimum required sample size, Z= z-score value for 95% confidence level = 1.96, P= prevalence of cervical cancer screening methods awareness among women set at 0.52 (Ezem, 2007). d= margin of error = 0.05. n= 1.96×1.96 × (0.52) (0.48) 0.05 ×0.05 Using the formula above, a total sample size of 369 participants was used. A 5% error margin was allowed for non-responses bringing the total sample size to 387 participants. 3.5 Study variables The study variables were categorized into two groups as dependents and independents variables. Dependents Variables: Regarding this study the dependents variables were Knowledge Level of Cervical Cancer and the practice of cervical cancer screening among female doctors and nurses in KBTH. Knowledge of Cervical Cancer among female doctors and nurses in KBTH: This study assessed the knowledge level of the study participants on cervical cancer on the following areas: the etiology and epidemiology ofcervical cancer, risk factors, signs and symptoms, screening of cervical cancer, knowledge on vaccination and prevention of cervical 21 University of Ghana http://ugspace.ug.edu.gh cancer and cervical cancer screening guidelines for which respondents were supposed to provide correct answers. Each correct answer attracted 1 mark while wrong answer attracted no mark (Zero). The numbers of questions asked under each category are as follows: Etiology and Epidemiology of Cervical cancer 5 question Risk factors, signs and symptoms 18 questions in the form of two multiple response questions For Cervical cancer screening guidelines 3 questions Cervical cancer screening guidelines 5 questions Knowledge on Vaccination and Prevention of 3 questions Cervical Cancer Overall knowledge 34 questions The total points scored under each category were computed and later categorized as follows Etiology and Epidemiology of Cervical cancer – Low (0-2 points), Moderate (3 points) and High (4-5 points) Risk factors, signs and symptoms – Low (0-7 points), Moderate (8-12 points) and High (13- 18 points), Cervical cancer screening guidelines - Low (0-1 point), Moderate (2 points) and High (3 points), Cervical cancer screening guidelines – Low (0-2 points), Moderate (3 points) and High (4-5 points), Knowledge on Vaccination and Prevention of Cervical Cancer – Low (0-1 point), Moderate (2 points) and High (3 points) and Overall knowledge – Low (0 - 16), Moderate (17-27) and High (28-34). 22 University of Ghana http://ugspace.ug.edu.gh Practices of female doctors and nurses in KBTH on cervical cancer screening and prevention To assess practices of female doctors and nurses in KBTH on cervical cancer screening and prevention, they were asked these two questions “Ever had cervical cancer screening before (Options: Yes or No)” and “How prepared do you consider yourself to talk to women about cervical cancer (Options: Very Prepared, Somewhat prepared, Not prepared)” Independents variables: The independent variables studied and how they were measured is presented in Table 3.1. Table 3.1 Dependent and independent variables definition Variables Operational definition Type of variable Levels Age Age in complete years Continuous ……..in years Marital status Current marital status Nominal Single Married Cohabiting Divorced Separated Widowed Current Religious Nominal Religion Christian affiliation Islam Traditionalist Other Current Professional Nominal Doctor Worker Profession category Nurse Department of Nominal Participant Department Internal medicine affiliation Surgery Obstetrics&Gyaenecology Orthopaedics/ A&E Anaesthesia and ICUs Polyclinic Child Health Experience Years of work Ordinal 1-3yrs 4-5yrs 6-10yrs 11-20yrs >20yrs Family members’ Nominal Family history of any experience of any Yes cancer cancer No Don't know 23 University of Ghana http://ugspace.ug.edu.gh Family members’ Nominal Family history of experience of cervical Yes cervical cancer cancer No Don't know cervical cancer Is cervical cancer Nominal Yes screening important screening important No Don't Know Effectiveness of Pap How effective is of Pap Nominal Very effective smear screening for smear screening for precancerous cervical precancerous cervical cancer detection cancer detection Somewhat effective Unknown effectiveness Don't know Table 3.1 Dependent and independent variables definition 3.6 Sampling Procedure The list of female doctors and nurses were obtained from the human resource department of the hospital. Eligible participants were selected from the entire staff data and arranged in an alphabetical order to ensure that each participant had an equal chance of being selected for the study. Systematic sampling method was used for participant selection. The estimated female doctors and nurses populations were divided by the allocated number of participants for each category to determine a sampling interval (k=N/n) for each department. A simple random sampling method was used to select the first participants for each department and the skip interval of 2 was applied for consecutive selection of subsequent participants to be included in the study. The study recruited a total of 113 doctors and 274 nurses in keeping with the doctor nurse ratio of the hospital (1:2.4). This procedure was repeated for all the selected departments and units using different sampling intervals and with doctors sampled separately from nurses. 24 University of Ghana http://ugspace.ug.edu.gh 3.7 Pretesting The participant questionnaire for collecting data in this study was pre-tested at the Korle Bu Fevers Unit with 20 female health workers made up of doctors and nurses in similar make up as the study population. The similarity between the pretest populations allowed for fine- tuning and auditing of the content of the data collection tool. 3.8 Data collection technique and tools A structured questionnaire was used for assessing level of knowledge/awareness of preventive measures of cervical cancer among female health workers in the hospital. The questionnaire was structured to seek relevant information for collecting data on knowledge and practices of cervical cancer and its prevention for participating female health workers. The questionnaire was used to collect information from female health workers on individual characteristics2 [Demographic characteristics (Age, Sex, length of service); health workers awareness [knowledge of cervical cancer etiology, epidemiology, screening and preventive vaccination]; attitude toward cervical cancer and its screening [health workers’ perception of cervical cancer screening] and practice of cervical cancer screening [cervical cancer screening methods ever used by participants]. Self-administered structured questionnaire was employed upon receipt of informed consent. 3.9 Quality control The researcher selected three research assistants who had public health background and adequate training was given to them over a one week period. The content of the training included; data collection techniques, hospital entry ethics and data collection ethical guidelines. The principal researcher was part of the team during the entire data collection period to ensure that relevant information in line with the objectives of the study was 25 University of Ghana http://ugspace.ug.edu.gh captured. The questionnaires were checked for errors and completeness before final entry into SPSS version 22. 3.10 Data Processing and Analysis Data in SPSS version 22 was imported into STATA Version 15 for cleaning, merging and analysis. Simple proportions and means were used to describe categorical and numerical data, respectively. Descriptive statistics of categorical variables were presented in frequencies and proportions while that of continuous variables were presented with means and standard deviations. Chi- square and Fishers’ exact tests were used to test for association between the categorical independent variables and various outcome variables. T-test and One-way ANOVA tests were also used to compare the average age of the respondents across the various levels of the outcome variables. Binary logistic as well as linear regression models were used to assess the strength of association between independent variables and dependent variables. Level of statistical significance was pegged at 5%. 3.11 Ethical Consideration Ethical issues involved in the study were addressed by obtaining ethical clearance from the Korle Bu Teaching Hospital Institutional Review Board.Appropriate permissions wereobtained at departmental and wards unit levels. Participants were assured of confidentiality and privacy of the information provided by not asking them to state their names and telephone numbers. Informed consent was obtained from all participants after the purpose of the study had been explained to them (Appendix A – consent form) . Participants were assured that participation in this research is entirely voluntary; they were free to 26 University of Ghana http://ugspace.ug.edu.gh withdraw consent and discontinue participation in this study at any time without prejudice from the study team. Respondents were not provided any reward/compensation to respond to the questionnaire. There was no conflict of interest from KBTH or the researcher. It was purposely for academic work and the entire study was funded by the principal investigator 27 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.1 Characteristics of Health Workers A total of 387 female health workers were recruited into the study made up of 113 (29.2%) doctors and 274 (70.8%) nurses. The mean age of all respondents was 31.1 ± 6.6 years; about half of them (49.6%) were either married or cohabiting; and majority (94.6%) were Christians. Child Health (16.5%) and Internal Medicine departments contributed the most respondents (16.0%); the Polyclinic (9.6%) contributed the least number of respondents. More than half (52.2%) of the female doctors were junior residents or senior medical officers while half of the nurses, who indicated their ranks, were Health Assistant Clinical (HAC)/Staff Nurse (SN)/Staff Midwife (SMID). About 4 in every 10 respondents had between one and three years of clinical practice experience. The details of the characteristics of health workers are contained in Table 4.1. 28 University of Ghana http://ugspace.ug.edu.gh Table 4.1 Characteristics of Health worker respondents Frequency Percentage Age, years (Mean ± SD) Marital Status (31.10 ± 6.63) Married/cohabiting 192 49.6 Single 195 50.4 Religion Christian 366 94.6 Non-Christian 21 5.4 Worker Profession Doctor 113 29.2 Nurse 274 70.8 Participant Department Internal medicine 62 16.0 Surgery 58 15.0 Obstetrics &Gynaecology 60 15.5 Orthopaedics, Accident & Emergency 52 13.4 Anaesthesia and Intensive Care Units 54 14.0 Polyclinic 37 9.6 Child Health 64 16.5 Rank of doctors House Officer (HO)/Senior HO 21 18.6 Medical Officer (MO) 29 25.7 Junior Resident /Senior MO 59 52.2 Specialist (Spec)/Senior Spec/Consultant 4 3.5 Rank of nurses HAC/SN/SMID 137 50.0 Senior HAC/Principal HAC/ Senior SN/Senior SMID 42 15.3 Nursing Officer (NO)/ Midwifery Officer (MIDO) 48 17.5 Senior NO/Senior MIDO 28 10.2 Principal NO/Principal MIDO/ Deputy Director of Nurs Serv (DDNS) 19 6.9 Participant duration of practice 1-3years 172 44.4 4-5years 50 12.9 6-10yrs 106 27.4 11-20yrs 37 9.6 >20yrs 22 5.7 Keys: HO – House Officer MO – Medical Officer Spec – Specialist SN – Staff Nurse NO – Nursing Officer HAC – Health Assistant Clinical SHAC – Senior HAC PHAC – Principal HAC SMID – Staff Midwife MIDO – Midwifery Officer DDNS – Deputy Director of Nursing Services SMIDO – Senior MIDO PNO – Principal NO PMIDO – Principal MIDO SSN – Senior SN SSMID – Senior SMID SNO – Senior NO 29 University of Ghana http://ugspace.ug.edu.gh 4.2 Health Workers Knowledge on Etiology and Epidemiology of Cervical Cancer Majority (86.3% and 84.0%) of respondents correctly answered the cause of cervical cancer and its relative prevalence in comparison it is relative to all female cancers respectively. There was poor knowledge of who was at risk and the duration of the pre-cancerous stage of cervical cancer with less than half of the respondents answering correctly. Overall, about 73% of all respondents demonstrated moderate or high knowledge level on the etiology and epidemiology as shown in Table 4.2 Table 4.2 Respondents Knowledge on the Etiology and Epidemiology of Cervical Cancer Correct Answers To: Frequency Percentage Cause of cervical cancer 334 86.3 How common is cervical cancer relative to all cancers among women in Ghana? 325 84.0 How common is cervical cancer relative to gynaecological cancers in Ghana? 275 71.1 Who is at risk of cervical cancer? 80 20.7 How long is the precancerous lesion period of cervical cancer? 168 43.4 Overall knowledge level Poor 103 26.6 Moderate 145 37.5 High 139 35.9 4.3 Health Workers Knowledge on the Risk Factors, Signs and Symptoms of Cervical Cancer Health workers’ knowledge of the risk factors for cervical cancer revealed that over 75% of respondents were aware of high risk associated with early initiation of sexual activity during teenage period (78.8%), multiple sexual partners (92.3%) and HPV infection (78.3%); but less than 35% were aware of linkages to cigarette smoking (32.8%) and long duration of reproductive period (14.7%) with cervical cancer. Only half of the respondents were aware of the absence of symptoms in the early stage of cervical cancer. Less than 50% of the respondents had correct knowledge of the common signs and symptoms except for post-coital 30 University of Ghana http://ugspace.ug.edu.gh bleeding (65.1%). Health workers who had moderate overall knowledge level on the risk factors, signs and symptoms of cervical cancer constituted just over half (54.0%) of respondents with only 1.3% of respondents having poor knowledge level. The details are captured in Table 4.3. Table 4.3 Knowledge on Risk Factors, Signs and Symptoms of Cervical Cancer Correct Answers To: Frequency Percent Risk Factors Early commencement of sexual activity 305 78.81 Long duration of reproductive period 57 14.73 Multiple sexual partners 357 92.25 Prostitution 261 67.44 Cigarette smoking 127 32.82 HPV infection 303 78.29 Late commencement of sexual activities 377 97.42 Short duration of reproductive period 370 95.61 Excessive alcohol intake 327 84.5 Poor personal hygiene 300 77.52 Long-term OCP use 329 85.01 Multiple pregnancies 363 93.8 Signs and Symptoms No symptoms in early stage 197 50.9 Post-coital bleeding 252 65.12 Post-menopausal bleeding 138 35.66 Dyspareunia 151 39.02 Increased vaginal discharge 178 45.99 Overall knowledge level Poor 5 1.29 Moderate 209 54.01 High 173 44.7 4.4 Health Workers’ Knowledge on Cervical Cancer Screening Majority (94.6%) of respondents were aware of cervical cancer screening and nine out of ten respondents indicated Pap smear (PS) as the method of screening they are aware of; over 80% were aware that PS is effective. Few of the respondents were aware of other cervical cancer screening methods such as Visual inspection with acetic acid (VIA) screening (11.6%) 31 University of Ghana http://ugspace.ug.edu.gh and Human Papilloma Virus (HPV) DNA testing (7.0%). Respondents’ knowledge on cervical cancer screening is in Table 4.4. Table 4.4 Respondents’ Knowledge on Cervical Cancer Screening Frequency Percent Heard about cervical cancer screening Yes 366 94.6 No 21 5.4 Screening methods Pap Smear (PS) 349 90.2 Visual Inspection with Acetic Acid (VIA) 45 11.6 Human Papilloma Virus (HPV) DNA Testing 27 7.0 Effectiveness of Pap smear screening Very effective 318 83.9 Somewhat effective 30 7.9 Unknown effectiveness 3 0.8 Don’t know 28 7.4 4.5 Health Workers’ Knowledge on Cervical Cancer Screening Guidelines Although 76.0% of respondents were aware of the correct age to begin screening for cervical cancer, only 21.7% of respondents were aware of the interval for repeating the screening. Most of the respondents had either poor (40.1%) or moderate (45.5%) level of knowledge on cervical cancer screening guidelines as shown in Table 4.5. Table 4.5 Respondents’ Knowledge on Cervical Cancer Screening Guidelines Correct Answer To: Frequency Percent What age do you begin screening of asymptomatic average risk women for cervical cancer? 294 76.0 How often do you screen asymptomatic average-risk women for cervical cancer? 84 21.7 How long does the Pap smear screening test for cervical cancer take to do? 257 66.4 Overall knowledge level Poor 155 40.1 Moderate 176 45.5 High 56 14.5 32 University of Ghana http://ugspace.ug.edu.gh 4.6 Health Workers’ Knowledge on Vaccination and Prevention of Cervical Cancer The proportion of respondents who had knowledge of the availability of cervical cancer vaccine was 75.7% but only a few of them (28.9%) were aware of the age for vaccination or if vaccinated women required cervical cancer screening (15.5%). Majority (63.3%) of the respondents had poor overall knowledge level on cervical cancer prevention and vaccination. The details are contained in Table 4.6. Table 4.6 Respondents’ Knowledge on Vaccination and Prevention of Cervical Cancer Correct Answer To: Frequency Percent Vaccine available against cervical cancer? 293 75.7 Age should girls/women be vaccinated 112 28.9 Do women who have received vaccination against cervical cancer require screening? 60 15.5 Overall knowledge level Poor 245 63.3 Moderate 126 32.6 High 16 4.1 4.7 Respondents’ Combined Overall Knowledge Distribution A combined overall knowledge level for each respondent was computed by combining all the scores from the five knowledge sub-sections and categorizing the total score into low, moderate and high combined total knowledge level. The average knowledge score was 21.1 with minimum and maximum scores of 10 and 31 respectively. Majority (72%) of the female health workers demonstrated moderate knowledge level. The distribution of respondents’ combined overall knowledge level is presented in Fig 4.1. 33 University of Ghana http://ugspace.ug.edu.gh 14% 14% 72% low Moderate High Fig 4.1 Distribution of Respondents Combined Overall Knowledge Levels. 4.8 Association between Health Workers Characteristics and Combined Overall Knowledge Levels Table 4.7 presents the association between respondents’ characteristics and the combined overall knowledge levels. From the chi-square tests, Worker Profession , Rank of nurses, and religion were identified to be significantly associated, with combined overall knowledge level on cervical cancer (p<0.05). Level of knowledge was significantly higher among the non- Christians compared to the Christians as they had lesser proportion of workers with low knowledge. Doctors were identified to be significantly knowledgeable than to nurses. For nurses’ rank, higher rank was identified to be associated with better knowledge level. The one way ANOVA test showed that older health workers were more knowledgeable than the younger ones. These differences in the average ages were statistically significant. The associations between combined overall knowledge level and respondents’ department and years of clinical practice were not found to be statistically significant. 34 University of Ghana http://ugspace.ug.edu.gh Table 4.7Association between Respondents’ Characteristics and Combined Overall Knowledge Combined Overall Knowledge Low N (%) Moderate N (%) High N (%) chi-square P-value Age (Mean ± SD) 28.51 ± 5.60 31.29 ± 6.72 32.70 ± 6.54 0.003¥ Marital status 4.25 0.119 Married/cohabiting 21(10.94) 140(72.92) 31(16.15) Single 34(17.44) 138(70.77) 23(11.79) Religion 11.34 0.003 Christian 54(14.75) 266(72.68) 46(12.57) Non-Christian 1(4.76) 12(57.14) 8(38.1) Worker Profession 74.01 <0.001 Doctor 1(0.88) 72(63.72) 40(35.40) Nurse 54(19.71) 206(75.18) 14(5.11) Participant Dept 0.116§ Internal medicine 12(19.35) 37(59.68) 13(20.97) Surgery 7(12.07) 42(72.41) 9(15.52) Obs&Gynaecology 6(10) 42(70) 12(20) Orthopaedics, A&E 9(17.31) 39(75) 4(7.69) Anaesth and ICUs 5(9.26) 42(77.78) 7(12.96) Polyclinic 4(10.81) 26(70.27) 7(18.92) Child Health 12(18.75) 50(78.13) 2(3.13) Rank of doctors 0.517§ HO/SHO 1(4.76) 12(57.14) 8(38.1) MO 0(0) 20(68.97) 9(31.03) Jnr Res/Snr MO 0(0) 38(64.41) 21(35.59) Spec/SnrSpec/Cons 0(0) 2(50) 2(50) Rank of nurses 17.07 0.029 HAC/SN/SMID 35(25.55) 96(70.07) 6(4.38) SHAC/PHAC/SSN/S SMID 11(26.19) 30(71.43) 1(2.38) NO/MIDO 4(8.33) 42(87.5) 2(4.17) SNO/SMIDO 3(10.71) 21(75) 4(14.29) PNO/PMIDO/ DDNS 1(5.26) 17(89.47) 1(5.26) Participant 14.28 0.075 1-3yrs 35(20.35) 118(68.6) 19(11.05) 4-5yrs 6(12) 36(72) 8(16) 6-10yrs 10(9.43) 77(72.64) 19(17.92) 11-20yrs 2(5.41) 28(75.68) 7(18.92) >20yrs 2(9.09) 19(86.36) 1(4.55) Family history of any cancer 7.46 0.114 Yes 4(7.41) 37(68.52) 13(24.07) No 47(15.16) 226(72.9) 37(11.94) Don't know 4(17.39) 15(65.22) 4(17.39) Family history of cervical cancer 0.054§ Yes 0(0) 4(100) 0(0) No 46(12.99) 256(72.32) 52(14.69) Don't know 9(31.03) 18(62.07) 2(6.9) N: Frequency, %: Row Percentage ¥: P-value obtained from One-way ANOVA test. §: P-values from Fishers’ Exact test Keys:HO – House Officer MO – Medical Officer Spec – Specialist SN – Staff Nurse NO – Nursing Officer HAC – Health Assistant Clinical SHAC – Senior HAC PHAC – Principal HAC SMID – Staff Midwife MIDO – Midwifery Officer DDNS – Deputy Director of Nursing Services SMIDO – Senior MIDO PNO – Principal NO PMIDO – Principal MIDO SSN – Senior SN SSMID – Senior SMID SNO – Senior NO 35 University of Ghana http://ugspace.ug.edu.gh 4.9 Effects of Respondents’ Characteristics on Combined Overall Knowledge Levels In assessing the effects of the Respondents’ Characteristics on Combined Overall Knowledge Levels on cervical cancer, the raw knowledge score was used. From the multiple linear regression model, profession, department and family history were identified as the only significant predictors of respondents’ Overall Knowledge Levels on cervical cancer (p<0.05). Regarding profession, nurses scored 4.7 points lower than doctors (β: -4.17, 95% CI: -5.52, - 3.9). For history of cervical cancer in family, respondents with no such history and do not know of such history in their families scored averagely 0.71 and 2.95 points lesser than those who had such history in their families. Table 4.8 presents the effects of Respondents’ Characteristics on Combined Overall Knowledge Levels on cervical cancer. From the multiple linear regression model, profession, department and family history 36 University of Ghana http://ugspace.ug.edu.gh Table 4.8 Association of Combined Knowledge of Cervical Cancer and Respondents’ Background Characteristics Unadjusted Adjusted Β 95% CI P-value Β 95% CI P-value Age 0.10 0.04, 0.16 0.001 0.04 -0.03, 0.12 0.244 Marital status 0.029 0.967 Married/cohabiting Ref Ref Single -0.92 -1.75, -0.09 -0.02 -0.81, 0.78 Religion 0.037 0.15 Christian Ref Ref Non-Christian 1.94 0.12, 3.77 1.12 -0.41, 2.65 Worker Profession <0.001 <0.001 Doctor Ref Ref Nurse -5.05 -5.82, -4.29 -4.71 -5.52, -3.9 Participant Dept 0.099 0.011 Internal medicine Ref Ref Surgery -0.27 -1.75, 1.22 -0.19 -1.44, 1.07 Obs&Gynaecology 0.72 -0.75, 2.19 1.55 0.31, 2.79 Ortho, A&E -0.61 -2.13, 0.92 0.05 -1.22, 1.33 Anaesthesia and ICUs 0.78 -0.73, 2.29 0.70 -0.58, 1.99 Polyclinic 0.26 -1.43, 1.95 0.76 -0.66, 2.17 Child Health -1.22 -2.67, 0.22 -0.73 -1.93, 0.47 Participant 0.0208 0.588 1-3yrs Ref Ref 4-5yrs 1.50 0.2, 2.79 0.27 -0.86, 1.39 6-10yrs 1.32 0.32, 2.32 0.45 -0.52, 1.41 11-20yrs 1.22 -0.24, 2.69 0.76 -0.78, 2.29 >20yrs -0.52 -2.35, 1.32 -0.56 -2.38, 1.26 Family history of any cancer 0.0017 0.284 Yes Ref Ref No -2.15 -3.33, -0.96 -0.60 -1.67, 0.47 Don't know -2.36 -4.37, -0.36 0.58 -1.4, 2.56 Family history of cervical cancer 0.0109 0.0244 Yes Ref Ref No -2.04 -6.1, 2.03 -0.71 -4.18, 2.75 Don't know -4.28 -8.6, 0.03 -2.95 -6.71, 0.82 β: Linear regression coefficient, CI: Confidence Interval 37 University of Ghana http://ugspace.ug.edu.gh 4.10 Health Workers Perceptions on Cervical Cancer Screening; Respondents’ Preparedness to Educate Other Women and Perceived Barriers to Screening Majority of the respondents making up 93.8% perceived cervical cancer screening important in reducing the disease incidence and also indicated that all women of child bearing age should be screened. However, only 39.8% of the health workers considered themselves prepared or capable of talking to other women about cervical cancer and its screening. The most commonly perceived barriers to cervical cancer screening were lack of knowledge/awareness (88.9%), cost of screening (70.5%), fear of vaginal examination (62.3%), absence of symptoms (61.5%), fear of test result (59.7%) and embarrassment (50.9%). Religious reasons (21.7%) and the gender of the screening provider (28.4%) were not perceived by most respondents to be common barriers to cervical cancer screening. The details of the perceptions and self-reported preparedness of respondents are captured in Table 4.9. 38 University of Ghana http://ugspace.ug.edu.gh Table 4.9 Respondents’ Perceptions on Cervical Cancer Screening; Self-ReportedPreparedness to Educate Other Women and Barriers to Screening Frequency Percentage In your opinion, who should be screened All women of child bearing age 363 93.8 Only women with symptoms suggestive of 3 0.8 Only women with promiscuous life style 2 0.5 Don’t know 2 0.5 Missing 17 4.4 How prepared do you consider yourself to talk to women about cervical cancer Very Prepared 154 39.8 Somewhat prepared 134 34.6 Not prepared 82 21.2 Missing 17 4.4 Is Cervical Cancer Screening important in reducing the disease Yes 363 93.8 No 5 1.3 Don't Know 19 4.9 common barriers to participation of women in cervical cancer screening and prevention Lack of awareness 344 88.9 Absence of symptoms 238 61.5 Difficult access to health facility with screening 200 51.7 Fear of vaginal examination 241 62.3 Cost of the screening 273 70.5 Fear of test results 231 59.7 Fear of pain of procedure 191 49.4 Too busy 176 45.5 Not recommended by health workers 75 19.4 Religious reasons 84 21.7 Sex (Gender) of the screening provider 110 28.4 Age limit 47 12.1 Embarrassment 197 50.9 4.11 Health Workers’ Practices on Cervical Cancer Screening and Sources of Information Most of the respondents indicated that their profession training (81.7%) and the Media (53.0%) were their source of information. Only 31.5% of the respondents have ever had cervical cancer screening before and most (56.5%) of them were done in a health facility mainly within the last one year. The most common reason for doing the screening was to 39 University of Ghana http://ugspace.ug.edu.gh know respondent status (39.1%) and the reasons for those who had not done it yet was because they were too busy (26.4%) and cost of screening (19.6%). 36.0% of all respondents intend to have cervical cancer screening done within the nest one year but almost half (49.1%) of all the respondents were still undecided on when to do their cervical cancer screening. Details of the practices and sources of information on cervical cancer screening are shown in Table 4.10. 40 University of Ghana http://ugspace.ug.edu.gh Table 4.10 Respondents Practices on Cervical Cancer Screening and Sources of Information F requency P ercentage Media 205 53.0 professional formal education 316 81.7 cervical cancer training or workshop 83 21.5 health professionals 178 46.0 never heard of it 4 1 .0 Ever had cervical cancer screening before Yes 122 31.5 No 265 68.5 Done screening within the last one year? Yes 63 16.3 No 324 83.7 Where did you have your cervical cancer screening done? Home by myself 1 0.5 Health facility 118 56.5 Others, specify 90 4 3.0 Reason for doing the screening Doctors recommendation 19 8.8 Previous test result 1 0.5 Just to know status 84 39.1 The services were free 6 2.8 Awareness that if detected early, it is 23 10.7 Others 8 2 3 8.1 When was your last cervical cancer screening test done? Within the last one year 45 13.9 1-2 years ago 23 7.1 2-3years ago 23 7.1 3-4 years ago 18 5.6 More than 4 years ago 15 4.6 Never had a screening test 1 99 6 1.6 When do you intend to re-screen for cervical cancer? Within the next year 116 36.0 In the next 2 years 24 7.5 In the next 3 years 13 4.0 Have not decided 158 49.1 Do not ever intend to 1 1 3 .4 Reason for not doing it Cost of the screening 76 19.6 Fear of test results 29 7.5 Fear of pain 49 12.7 Too busy 102 26.4 Religious reasons 3 0.8 Sex (Gender) of the provider 10 2.6 Not necessary 10 2.6 Age limit 11 2.8 Embarrassment 20 5.2 41 University of Ghana http://ugspace.ug.edu.gh 4.12 Association between Respondents’ Background Characteristics and Cervical Cancer Screening Practice With the exception of religion, Family history of any cancer and Family history of Cervix cancer, all background characteristics were of respondents were identified to be significantly associated with screen practice of health workers (p<0.05). Years of professional practice, higher years of practice was identified to be associated with higher proportion of cervical cancer screening. Similarly, higher proportion of health workers who have conducted cervical cancer screening before was identified to be associated with higher ranks of both rank doctors and nurses. Doctors in general were identified to have significantly conducted more cervical cancer screening before compared to the nurses (43.4% vs 26.6%, p=0.001). Respondents from O&G, Polyclinic and Anaesthesia& ICU departments were significantly more likely to have conducted cervical cancer screening before than respondents from the other departments (p< 0.05). Married/ Cohabiting women (40.6%) were more likely to have conducted cervical cancer screening before than Single women (40.6% vs 22.6%, p< 0.001). The details of association between cervical cancer screening and respondent’s characteristics are shown in Table 4.11a and 4.11b 42 University of Ghana http://ugspace.ug.edu.gh Table 4.11a Association between Background Characteristics and Cervical Cancer Screening Practice. Ever Had Cervical Cancer Screening Yes N (%) No N (%) chi-square P-value Age: Mean ± SD 33.51 ± 7.84 29.98 ± 5.68 <0.001¥ Marital status 14.62 <0.001 Married/cohabiting 78(40.63) 114(59.38) Single 44(22.56) 151(77.44) Religion 0.44 0.505 Christian 114(31.15) 252(68.85) Non-Christian 8(38.10) 13(61.90) Worker Profession 10.36 0.001 Doctor 49(43.36) 64(56.64) Nurse 73(26.64) 201(73.36) Participant Department 17.95 0.006 Internal medicine 17(27.42) 45(72.58) Surgery 17(29.31) 41(70.69) Obs&Gynaecology 27(45.00) 33(55.00) Ortho, A&E 10(19.23) 42(80.77) Anaesthesia& ICUs 21(38.89) 33(61.11) Polyclinic 17(45.95) 20(54.05) Child Health 13(20.31) 51(79.69) Rank of doctors 16.23 0.001 HO/SHO 3(14.29) 18(85.71) MO 10(34.48) 19(65.52) RES/SMO/SPEC 32(54.24) 27(45.76) SNRSPEC/CONS 4(100) 0(0) Rank of nurses 10.61 0.031 HAC/SN/SMID 31(22.63) 106(77.37) SHAC/PHAC/SSN/SS MID 6(14.29) 36(85.71) NO/MIDO 18(37.5) 30(62.5) SNO/SMIDO 11(39.29) 17(60.71) PNO/PMIDO/DDNS 7(36.84) 12(63.16) N: Frequency, %: Row Percentage ¥: P-value obtained from t-test. Keys: # HO – House Officer MO – Medical Officer Spec – Specialist SN – Staff Nurse NO – Nursing Officer HAC – Health Assistant Clinical SHAC – Senior HAC PHAC – Principal HAC SMID – Staff Midwife MIDO – Midwifery Officer DDNS – Deputy Director of Nursing Services SMIDO – Senior MIDO PNO – Principal NO PMIDO – Principal MIDO SSN – Senior SN SSMID – Senior SMID SNO – Senior NO 43 University of Ghana http://ugspace.ug.edu.gh Table 4.11b Association between Background Characteristics and Cervical Cancer Screening Practice. Ever Had Cervical Cancer Screening Yes N (%) No N (%) chi-square P-value Participant Duration of Practice 19.55 0.001 1-3yrs 36(20.93) 136(79.07) 4-5yrs 19(38) 31(62) 6-10yrs 38(35.85) 68(64.15) 11-20yrs 19(51.35) 18(48.65) >20yrs 10(45.45) 12(54.55) Family history of any cancer 1.88 0.39 Yes 15(27.78) 39(72.22) No 97(31.29) 213(68.71) Don't know 10(43.48) 13(56.52) Family history of Cervix cancer 0.31 0.855 Yes 1(25) 3(75) No 113(31.92) 241(68.08) Don't know 8(27.59) 21(72.41) N: Frequency, %: Row Percentage ¥: P-value obtained from t-test. Keys: # HO – House Officer MO – Medical Officer Spec – Specialist SN – Staff Nurse NO – Nursing Officer HAC – Health Assistant Clinical SHAC – Senior HAC PHAC – Principal HAC SMID – Staff Midwife MIDO – Midwifery Officer DDNS – Deputy Director of Nursing Services SMIDO – Senior MIDO PNO – Principal NO PMIDO – Principal MIDO SSN – Senior SN SSMID – Senior SMID SNO – Senior NO 4.13 Association between Respondents’ Knowledge Levels and Perception; and Cervical Cancer Screening Practice Female health workers with moderate and high level of knowledge in all the knowledge sub- sections except knowledge of the risk factors, signs and symptoms were found to have significantly higher proportion of them screened for cervical cancer than those with low level of knowledge, (p< 0.05). Although a higher proportion of women who perceive cervical cancer screening to be important in reducing the incidence of the disease had had screening done than those do not perceive its importance, the association was not statistically significant. This is presented in Table 4.12. 44 University of Ghana http://ugspace.ug.edu.gh Table 4.12 Association between Respondents’ Knowledge and Perception; and Cervical Cancer Screening Practice Ever Had Cervical Cancer Screening Before Yes N (%) No N (%) chi-square P-value Knowledge on Etiology and Epidemiology of Cervical cancer 10.15 0.006 Poor 20(19.42) 83(80.58) Moderate 49(33.79) 96(66.21) High 53(38.13) 86(61.87) Have you ever heard about cervical cancer screening 3.06 0.08 Yes 119(32.51) 247(67.49) No 3(14.29) 18(85.71) How effective is Pap smear screening for precancerous cervical cancer detection 11.45 0.01 Very effective 110(34.59) 208(65.41) Somewhat effective 9(30) 21(70) Unknown effectiveness 1(33.33) 2(66.67) Don't know 1(3.57) 27(96.43) Knowledge on Risk factors, signs and symptoms 4.56 0.102 Poor 0(0) 5(100) Moderate 60(28.71) 149(71.29) High 62(35.84) 111(64.16) Knowledge on screening of Cervical cancer 16.36 <0.001 Poor 31(20) 124(80) Moderate 67(38.07) 109(61.93) High 24(42.86) 32(57.14) Knowledge on Cervical cancer screening guidelines 21.60 <0.001 Poor 58(23.67) 187(76.33) Moderate 54(42.86) 72(57.14) High 10(62.5) 6(37.5) Cervical cancer screening important 4.45 0.108 Yes 119 (32.78) 244 (67.22) No 1 (20.00) 4 (80.00) Don't Know 2 (10.53) 17(89.47) N: Frequency, %: Row Percentage ¥: P-value obtained from t-test. 4.14 Association between Background Characteristics, Knowledge Levels and Perception on Cervical Cancer Screening Practice Tables 13a and 13b show the effects of Respondents’ Respondents’ Characteristics, Knowledge Levels and Perception on Cervical Cancer Screening Practice. The multiple 45 University of Ghana http://ugspace.ug.edu.gh binary logistic regression model revealed department, and awareness of cervical cancer screening (ever heard about cervical cancer screening) as the only statistically significant predictors of Cervical Cancer Screening Practice (p<0.05). Not being aware of cervical cancer screening (ever heard about cervical cancer screening) was associated 83% reduced odds ofhaving Cervical Cancer Screening compared to those who were aware (AOR: 0.17, 95% CI: 0.03 - 0.93). With the exception of health workers from Surgery, Ortho, A&E, and Child Health, the odds of having cervical cancer screening relatively higher in all other departments compared to workers from internal medicine department. 46 University of Ghana http://ugspace.ug.edu.gh Table 4.13a Association between Background Characteristics, Knowledge Levels and Perception on Cervical Cancer Screening Practice Unadjusted Adjusted UOR 95% CI P-value AOR 95% CI P-value Age 1.08 1.05 - 1.12 <0.001 1.05 0.99 - 1.11 0.082 Marital status <0.001 0.192 Married/cohabiting Ref Ref Single 0.43 0.27 - 0.66 0.67 0.37 - 1.22 Religion 0.507 0.765 Christian Ref Ref Non-Christian 1.36 0.55 - 3.37 1.18 0.4 - 3.49 Worker Profession 0.001 0.054 Doctor Ref Ref Nurse 0.47 0.3 - 0.75 0.51 0.26 - 1.01 Participant Dept 0.008 0.004 Internal medicine Ref Ref Surgery 1.10 0.5 - 2.43 0.69 0.26 - 1.82 Obs&Gynaecology 2.17 1.02 - 4.61 2.67 1.08 - 6.58 Ortho, A&E 0.63 0.26 - 1.53 0.67 0.25 - 1.85 Anaesthesia and ICUs 1.68 0.77 - 3.68 1.97 0.78 - 4.97 Polyclinic 2.25 0.96 - 5.29 3.52 1.23 - 10.12 Child Health 0.67 0.3 - 1.54 0.78 0.3 - 2.03 Participant 0.001 0.374 1-3yrs Ref Ref 4-5yrs 2.32 1.17 - 4.57 1.48 0.64 - 3.39 6-10yrs 2.11 1.23 - 3.63 1.18 0.57 - 2.44 11-20yrs 3.99 1.9 - 8.37 2.82 0.93 - 8.57 >20yrs 3.15 1.26 - 7.87 2.43 0.63 - 9.34 Family history of any cancer 0.397 0.179 Yes Ref Ref No 1.18 0.62 - 2.25 2.04 0.87 - 4.74 Don't know 2.00 0.72 - 5.53 3.22 0.68 - 15.35 Family history of cervical cancer 0.856 0.648 Yes Ref Ref No 1.41 0.14 - 13.67 3.52 0.25 - 49.96 Don't know 1.14 0.1 - 12.66 3.63 0.19 - 70.51 Knowledge on Etiology and Epidemiology of Cervical cancer 0.007 0.276 Poor Ref Ref Moderate 2.12 1.17 - 3.85 1.78 0.86 - 3.66 High 2.56 1.41 - 4.64 1.65 0.8 - 3.4 Keys HO – House Officer MO – Medical Officer Spec – Specialist SN – Staff Nurse NO – Nursing Officer HAC – Health Assistant Clinical SHAC – Senior HAC PHAC – Principal HAC SMID – Staff Midwife MIDO – Midwifery Officer DDNS – Deputy Director of Nursing Services SMIDO – Senior MIDO PNO – Principal NO PMIDO – Principal MIDO SSN – Senior SN SSMID – Senior SMID SNO – Senior NO 47 University of Ghana http://ugspace.ug.edu.gh Table 4.13b Effects of Respondents’ Characteristics, Knowledge Levels and Perception on Cervical Cancer Screening Practice Unadjusted Adjusted UOR 95% CI P-value AOR 95% CI P-value Ever heard about cervical cancer screening 0.094 0.041 Yes Ref Ref No 0.35 0.1 - 1.2 0.17 0.03 - 0.93 How effective is PS for precancerous cervical cancer detection 0.075 0.295 Very effective Ref Ref Somewhat effective 0.81 0.36 - 1.83 0.61 0.24 - 1.58 Unknown effectiveness 0.95 0.08 - 10.54 2.96 0.21 - 41.64 Don't know 0.07 0.01 - 0.52 0.23 0.03 - 1.81 Knowledge on risk factors, signs&symptoms Poor 1.00 1.00 Moderate 0.72 0.47 - 1.11 0.137 1.59 0.87 - 2.92 0.135 High 1.00 1.00 Knowledge on screening of Cervical cancer <0.001 0.333 Poor Ref Ref Moderate 2.46 1.5 - 4.04 1.58 0.86 - 2.89 High 3.00 1.55 - 5.8 1.41 0.61 - 3.3 Knowledge on Ca Cervix screening guidelines <0.001 0.055 Poor Ref Ref Moderate 2.42 1.53 - 3.83 1.82 1 - 3.32 High 5.37 1.87 - 15.42 3.26 0.91 - 11.63 Perceive cervical cancer screening as important 0.145 0.187 Yes Ref Ref No 0.51 0.06 - 4.64 0.17 0.01 - 2.23 Don't Know 0.24 0.05 - 1.06 0.26 0.04 - 1.95 Keys HO – House Officer MO – Medical Officer Spec – Specialist SN – Staff Nurse NO – Nursing Officer HAC – Health Assistant Clinical SHAC – Senior HAC PHAC – Principal HAC SMID – Staff Midwife MIDO – Midwifery Officer DDNS – Deputy Director of Nursing Services SMIDO – Senior MIDO PNO – Principal NO PMIDO – Principal MIDO SSN – Senior SN SSMID – Senior SMID SNO – Senior NO 48 University of Ghana http://ugspace.ug.edu.gh 4.15 Association between Health Workers Characteristics and Preparedness to Educate Women on Cervical Cancer Screening Preparedness to Educate Women on Cervical Cancer Screening was identified to be significantly associated with Worker Profession, and Department. Female nurses (46.7%) and female health workers from departments of O&G (61.4%) and Polyclinic (60.0%) were significantly better prepared to educate or talk to other women about cervical cancer screening compared to female doctors and health workers from other departments. Proportionally more nurses were very prepared to educate women on cervical cancer compare to doctors. There was no enough statistical evidence to show that the other background characteristics were significantly associated with preparedness to educate women on cervical cancer. The details on Association between Health Workers Characteristics and Preparedness to Educate Women on Cervical Cancer Screening are shown in Table 4.14. 49 University of Ghana http://ugspace.ug.edu.gh Table 4.14a Association between Health workers Characteristics and Preparedness to Educate Women on Cervical Cancer Screening Preparedness To Educate Women on Cervical Cancer Screening Somewhat prepared Not prepared chi- Very Prepared N (%) N (%) N (%) square P-value Age: Mean ± SD 32.00 ± 8.04 30.99 ± 5.13 30.11 0.107 Marital status 5.37 0.068 Married/cohabiting 88(47.31) 63(33.87) 35(18.82) Single 66(35.87) 71(38.59) 47(25.54) Religion 0.84 0.658 Christian 144(41.26) 126(36.1) 79(22.64) Non-Christian 10(47.62) 8(38.1) 3(14.29) Worker Profession 26.57 <0.001 Doctor 33(29.73) 62(55.86) 16(14.41) Nurse 121(46.72) 72(27.8) 66(25.48) Participant Dept 32.85 0.001 Internal medicine 24(38.71) 26(41.94) 12(19.35) Surgery 17(31.48) 24(44.44) 13(24.07) Obs&Gynaecology 35(61.4) 13(22.81) 9(15.79) Ortho, A&E 24(48.98) 12(24.49) 13(26.53) Anaesthesia and ICUs 17(31.48) 20(37.04) 17(31.48) Polyclinic 21(60) 13(37.14) 1(2.86) Child Health 16(27.12) 26(44.07) 17(28.81) Rank of doctors 6.66 0.354 HO/SHO 2(10.53) 12(63.16) 5(26.32) MO 10(34.48) 17(58.62) 2(6.9) RES/SMO/SPEC 20(33.9) 31(52.54) 8(13.56) SNRSPEC/CONS 1(25) 2(50) 1(25) Rank of nurses 7.81 0.453 HAC/SN/SMID 64(50.39) 29(22.83) 34(26.77) SHAC/PHAC/SSN/SSMID 14(35) 14(35) 12(30) NO/MIDO 21(43.75) 16(33.33) 11(22.92) SNO/SMIDO 10(40) 8(32) 7(28) PNO/PMIDO/DDNS 12(63.16) 5(26.32) 2(10.53) N: Frequency, %: Row Percentage ¥: P-value obtained from On-way ANOVA test. §: P- values from Fishers’ Exact test, Keys: # HO – House Officer MO – Medical Officer Spec – Specialist SN – Staff Nurse NO – Nursing Officer HAC – Health Assistant Clinical SHAC – Senior HAC PHAC – Principal HAC SMID – Staff Midwife MIDO – Midwifery Officer DDNS – Deputy Director of Nursing Services SMIDO – Senior MIDO PNO – Principal NO PMIDO – Principal MIDO SSN – Senior SN SSMID – Senior SMID SNO – Senior NO 50 University of Ghana http://ugspace.ug.edu.gh Table 4.14b Association between Health workers Characteristics and Preparedness to Educate Women on Cervical Cancer Screening Preparedness To Educate Women on Cervical Cancer Screening Somewhat prepared Not prepared chi- Very Prepared N (%) N (%) N (%) square P-value Participant 13.45 0.097 1-3yrs 66(40.99) 54(33.54) 41(25.47) 4-5yrs 17(34) 26(52) 7(14) 6-10yrs 43(41.35) 39(37.5) 22(21.15) 11-20yrs 15(42.86) 13(37.14) 7(20) >20yrs 13(65) 2(10) 5(25) Family history of any cancer 5.18 0.269 Yes 18(33.33) 24(44.44) 12(22.22) No 126(43) 105(35.84) 62(21.16) Don't know 10(43.48) 5(21.74) 8(34.78) Family history of cervical cancer 1.14 0.888 Yes 1(25) 2(50) 1(25) No 141(41.84) 123(36.5) 73(21.66) Don't know 12(41.38) 9(31.03) 8(27.59) N: Frequency, %: Row Percentage ¥: P-value obtained from On-way ANOVA test. §: P- values from Fishers’ Exact test, Keys: # HO – House Officer MO – Medical Officer Spec – Specialist SN – Staff Nurse NO – Nursing Officer HAC – Health Assistant Clinical SHAC – Senior HAC PHAC – Principal HAC SMID – Staff Midwife MIDO – Midwifery Officer DDNS – Deputy Director of Nursing Services SMIDO – Senior MIDO PNO – Principal NO PMIDO – Principal MIDO SSN – Senior SN SSMID – Senior SMID SNO – Senior NO 4.16 Association between Respondents’ Knowledge Levels and Preparedness to Educate Women on Cervical Cancer Screening There was significant positive association (p< 0.005) between respondents’ knowledge levels for all the different knowledge sub-sections and the preparedness of respondents to educate other women about cervical cancer screening. Health workers who perceived cervical cancer screening to be important in reducing the disease also significantly self-reported better preparedness to educate other women (p= 0.005). The associations between preparedness to educate women and knowledge levels and perception are presented in Table 4.15. 51 University of Ghana http://ugspace.ug.edu.gh Table 4.15 Association between Respondents’ knowledge levels, Perception and Preparedness to Educate Women on Cervical Cancer Screening Preparedness To Educate Women on Cervical Cancer Screening Somewhat Not prepared Very Prep N (%) N (%) N (%) c hi-square P-value Knowledge on Etiology and Epidemiology of Cervical cancer 14.48 0.006 Poor 36(38.3) 28(29.79) 30(31.91) Moderate 57(40.14) 49(34.51) 36(25.35) High 61(45.52) 57(42.54) 16(11.94) Ever heard about cervical cancer screening 0.29 0.867 Yes 147(41.64) 127(35.98) 79(22.38) No 7(41.18) 7(41.18) 3(17.65) How effective is PS for precancerous cervical cancer detection 25.60 <0.001 Very effective 138(45.1) 110(35.95) 58(18.95) Somewhat effective 8(26.67) 13(43.33) 9(30) Unknown effectiveness 1(33.33) 2(66.67) 0(0) Don't know 5(19.23) 6(23.08) 15(57.69) Knowledge on risk factors, signs&symptoms 19.47 0.001 Poor 1(20) 0(0) 4(80) Moderate 90(45.92) 58(29.59) 48(24.49) High 63(37.28) 76(44.97) 30(17.75) Knowledge on screening of Cervical cancer 16.56 0.002 Poor 57(39.86) 40(27.97) 46(32.17) Moderate 71(41.28) 75(43.6) 26(15.12) High 26(47.27) 19(34.55) 10(18.18) Knowledge on Ca Cervix screening guidelines 12.96 0.011 Poor 90(38.96) 77(33.33) 64(27.71) Moderate 57(45.97) 49(39.52) 18(14.52) High 7(46.67) 8(53.33) 0(0) Perceive cervical cancer screening as important 9.48 0.05 Yes 149(41.74) 133(37.25) 75(21.01) No 2(50) 0(0) 2(50) Don't Know 3(33.33) 1(11.11) 5(55.56) 52 University of Ghana http://ugspace.ug.edu.gh 4.17 Association between Respondents’ Characteristics, Knowledge Levels and Perception on Preparedness to Educate Women on Cervical Cancer Screening In assessing the effects of Respondents’ Characteristics, Knowledge Levels and Perception on their Preparedness to Educate Women on Cervical Cancer Screening, the three levels (Very prepared, somewhat prepared and not prepared) were collapsed into two groups (Very prepared =1 and somewhat prepared/ not prepared = 0) since the variable did not satisfied the proportional odds assumption. The multiple binary logistics regression model identified marital status, work profession, and department as the only statistically significant predictors of Preparedness to Educate Women on Cervical Cancer Screening(p<0.05). Single health workers were identified to have 45% reduced odds of being prepared to educate women on cervical cancer (AOR: 0.17, 95% CI: 0.03 - 0.93). With the exception of health workers from Surgery, Ortho, A&E, and Child Health, the odds of having cervical cancer screening is relatively higher in all other departments compared to workers from internal medicine department. Tables 4.16a and 4.16b show the effects of Respondents’ Respondents’ Characteristics, Knowledge Levels and Perception on Cervical Cancer Screening Practice. 53 University of Ghana http://ugspace.ug.edu.gh Table 4.16a Association between Respondents’ Characteristics, Knowledge Levels and Perception on Preparedness to Educate Women on Cervical Cancer Screening Unadjusted Adjusted UOR 95% CI P-value AOR 95% CI P-value Age 1.03 0.99 - 1.06 0.061 1.05 1 - 1.11 0.055 Marital status 0.026 0.035 Married/cohabiting Ref Ref Single 0.62 0.41 - 0.94 0.55 0.31 - 0.96 Religion 0.567 0.523 Christian Ref Ref Non-Christian 1.29 0.54 - 3.13 1.38 0.51 - 3.75 Worker Profession 0.003 0.004 Doctor Ref Ref Nurse 2.07 1.29 - 3.33 2.69 1.37 - 5.27 Participant Dept <0.001 0.001 Internal medicine Ref Ref Surgery 0.73 0.34 - 1.57 0.54 0.22 - 1.33 Obs&Gynaecology 2.52 1.2 - 5.27 2.25 0.98 - 5.16 Ortho, A&E 1.52 0.71 - 3.24 1.51 0.65 - 3.51 Anaesthesia and ICUs 0.73 0.34 - 1.57 0.51 0.21 - 1.23 Polyclinic 2.38 1.02 - 5.54 2.68 1.02 - 7.03 Child Health 0.59 0.27 - 1.27 0.64 0.28 - 1.5 Participant 0.248 0.124 1-3yrs Ref Ref 4-5yrs 0.74 0.38 - 1.44 0.43 0.19 - 0.95 6-10yrs 1.01 0.61 - 1.67 0.57 0.29 - 1.13 11-20yrs 1.08 0.52 - 2.26 0.40 0.14 - 1.18 >20yrs 2.67 1.01 - 7.06 1.18 0.31 - 4.45 Family history of any cancer 0.412 0.613 Yes Ref Ref No 1.51 0.82 - 2.78 0.86 0.41 - 1.84 Don't know 1.54 0.57 - 4.18 0.51 0.13 - 1.96 Family history of cervical cancer 0.802 0.458 Yes Ref Ref No 2.16 0.22 - 20.96 3.93 0.27 - 16.62 Don't know 2.12 0.2 - 22.9 0.499 6.06 0.34 - 19.44 Knowledge on Etiology and Epidemiology of Cervical cancer 0.429 Poor Ref Ref Moderate 1.08 0.63 - 1.84 1.50 0.8 - 2.83 High 1.35 0.79 - 2.3 1.42 0.74 - 2.71 # HO – House Officer MO – Medical Officer Spec – Specialist SN – Staff Nurse NO – Nursing Officer HAC – Health Assistant Clinical SHAC – Senior HAC PHAC – Principal HAC SMID – Staff Midwife MIDO – Midwifery Officer DDNS – Deputy Director of Nursing Services SMIDO – Senior MIDO PNO – Principal NO PMIDO – Principal MIDO SSN – Senior SN SSMID – Senior SMID SNO – Senior NO 54 University of Ghana http://ugspace.ug.edu.gh Table 4.16b Association between Respondents’ Characteristics, Knowledge Levels and Perception on Preparedness to Educate Women on Cervical Cancer Screening Unadjusted Adjusted UOR 95% CI P-value AOR 95% CI P-value Ever heard about cervical cancer screening 0.97 0.726 Yes Ref Ref No 0.98 0.36 - 2.64 0.80 0.23 - 2.76 How effective is PS for precancerous cervical cancer detection 0.028 0.064 Very effective Ref Ref Somewhat effective 0.44 0.19 - 1.03 0.39 0.15 – 1 Unknown effectiveness 0.61 0.05 - 6.78 0.91 0.06 - 13.58 Don't know 0.29 0.11 - 0.79 0.32 0.1 - 0.99 Knowledge on risk factors, signs&symptoms 0.1596 0.671 Poor Ref Ref Moderate 3.40 0.37 - 30.93 0.90 0.08 - 10.55 High 2.38 0.26 - 21.74 0.70 0.06 - 8.49 Knowledge on screening of Cervical cancer 0.634 0.692 Poor Ref Ref Moderate 1.06 0.68 - 1.67 1.16 0.67 - 1.99 High 1.35 0.72 - 2.53 1.40 0.64 - 3.04 Knowledge on Ca Cervix screening guidelines 0.409 0.089 Poor Ref Ref Moderate 1.33 0.86 - 2.07 1.91 1.06 - 3.42 High 1.37 0.48 - 3.91 1.12 0.32 - 3.92 Perceive cervical cancer screening as important 0.832 0.888 Yes Ref Ref No 1.40 0.19 - 10.02 0.56 0.05 - 5.8 Don't Know 0.70 0.17 - 2.84 1.02 0.21 - 5.03 55 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.1 Characteristics of Female Health Worker Respondents This study assessed the knowledge, perception and self-reported practices of female doctors and nurses in a tertiary hospital, KBTH, on their knowledge, perception of importance of cervical cancer screening and their self-reported practice of being ever screened for cervical cancer as against other studies that focused on community-based non health professional respondents (Liu et al, 2017; Elamurugan et al, 2019; Sothy et al, 2018) or on a heterogeneous group of participants made up of a mixture of men, women and health workers (Mutyaba, 2007). It was however similar to a study among health worker respondents in China but which included men and women (Di et al, 2016). The focus on female doctors and nurses was because these are the frontline professionals who are expected as per their gender and profession to appreciate the impact and challenges of cervical cancer screening and prevention more than other groups. They therefore, posses a huge potentials as health educators, advocates and role models to influence both their clients and their communities in promoting cervical cancer screening and prevention to reduce the associated morbidity and mortality. Assessing the knowledge of female doctors and nurses would therefore, assist in structuring appropriate training programs to equip them as agents of change both through their regular professional contacts with patients and clients as well as prepare them as sources of information and education in their communities. The choice of seven clinical departments in Korle Bu Teaching, Internal Medicine, Surgery, Anaesthesia& ICUs, Orthopaedics and A & E, Obstetrics &Gynaecology, Child Health and Polyclinic made it easy to both have a holistic picture of the hospital’s status as well as allow for direct comparison of the knowledge and preparedness of the health workers to educate 56 University of Ghana http://ugspace.ug.edu.gh their clients even in non-gynaecological clinical setting. Also this will assist the hospital in planning for interventions for its own female workers in forms of both health promotion and instituting screening programs aimed at the female staff. Although six of the clinical departments aside Obstetrics and Gynaecology do not usually participate in formal education and screening of at risk women in their clinic, they probably could play a role in augmenting the efforts of the formal clinics if they are well equip to do so. The mean age of the respondents was 31.10 years ± 6.63 with about 85% of them still in their initial ten (10) years of professional practice which allowed the study to look at a population which is both at risk of cervical cancer as well as have to potential of benefiting most from screening intervention and with appreciable length of time to impact the fight against cervical cancer. 5.2 The knowledge of Female Health Workers on Cervical Cancer, Its Screening and Prevention In this study, the knowledge of the participants was assessed with collection of questions that addressed awareness of the etiology and epidemiology of cervical cancer; the risk factors, signs and symptoms of cervical cancer; availability and effectiveness of cervical cancer screening method; guideline for screening for cervical cancer; and awareness of preventive methods (vaccination) against cervical cancer. This was similar to other studies (Di et al, 2016) that assessed similar range of knowledge of participants but more extensive in its range than a study conducted in India which looked at only a narrow range of knowledge limited to awareness of screening methods excluding the assessment of knowledge on the etiology, epidemiology, risk factors, signs, symptoms and preventive methods (Elamurugan et al, 2019). 57 University of Ghana http://ugspace.ug.edu.gh In the later study the limited probe may have been advised by the focus and the population being a rural community-based women population. It was necessary to widen the range of knowledge assessment of this study which is among frontline clinical health care provider who would be expected to have much higher knowledge level and with the added responsibility of educating other women. In analyzing the information obtained from the knowledge section of the questionnaire of this study, the overall knowledge score and levels were computed to allow both intra and inter- group comparisons as was done by other studies (Di et al, 2016) and in contrast to studies that considered every single question individually (Liu et al, 2017; Mutyaba, 2007; Sothy et al, 2018). However, unlike all the other studies, this study in addition sub-divided the analysis of the knowledge section into sub-sections (which were groups of questions with different emphasis) in order to obtain more in-depth information on where knowledge strengths and gaps in knowledge of the study population resides. This is expected to help in identifying critical elements that needs to be addressed when planning educational interventions to bridge the gaps. The overall knowledge level of female doctors and nurses in Korle Bu Teaching Hospital on cervical cancer, its screening and prevention was found to be mostly moderate (72% of respondents) with only 14% of participants each exhibiting either high or poor knowledge level. Although this compares slightly favourably to other studies that were conducted among community-based women (Liu et al, 2017; Sothy et al, 2018) or in other non health worker study populations among teachers and housewives (Elamurugan et al, 2019) where teachers showed similar or even better knowledge than we found among the health workers but housewives demonstrated poorer knowledge level; the expectation would have been that a much higher proportion of female health worker would exhibit much higher knowledge level. 58 University of Ghana http://ugspace.ug.edu.gh The knowledge limitation among these health workers is probably due to lack of extensive and sustained well structure targeted training programs aimed at the health worker with the assumption that they have adequate knowledge whilst this may not be necessarily accurate as demonstrated by this study. Most educational interventions on cervical cancer screening and prevention are either community-based, general public targeted or conducted at the Gynaecology or Reproductive Health units without much effort at tailored education for health workers. This may also explain the difficulties in increasing the coverage of education on cervical cancer and limitations in translating education to practice without tapping into this potential group of educators and advocates. There were more revelations when the knowledge level of the female doctors and nurses in KBTH was subjected to more scrutiny in the five sub-sections; etiology and epidemiology; risk factors, signs and symptoms; cervical cancer screening; screening guidelines; and prevention (vaccination). This sub-division as indicated earlier was unique to this study except for another study in China, among health workers providing services in different socio-economic regions(Di et al, 2016) that also sub-sectioned their knowledge level to three sub-sections among health workers involved in education and screening; and was aimed at determining where the knowledge gaps were. Although there was almost all (95%) of the respondents had heard about cervical cancer screening and more than 90% aware of pap smear as a screening method which is similar to findings among teachers in India (Elamurugan et al, 2019) and higher than housewives in India and patients attending clinic in Nepal (Shrestha et al, 2013); there was a better knowledge among the participants on the etiology and epidemiology of cervical cancer and the knowledge of the risk factors, signs and symptoms of cervical cancer, with 73% and 99% of the respondents possessing moderate and high knowledge level respectively. 59 University of Ghana http://ugspace.ug.edu.gh Their knowledge level on cervical cancer screening guidelines and prevention and vaccination knowledge were inadequate with 40% and 63% of the participants demonstrating poor knowledge level respectively. Poor knowledge on screening guidelines and preventive measures was also similarly reported in a study among teacher and housewives (Elamurugan et al, 2019). It was also informative that only 12% and 7% of the female health workers studied were aware of visual inspection with acetic acid (VIA) and HPV DNA testing respectively; these being other cervical cancer screening methods aside pap smear testing. This finding was similar to another study on health workers involved in education and screening women from six provinces in China (Di et al, 2016). The poor knowledge in the screening guidelines and preventive methods would have contributed to the lowering of the overall knowledge level of the female doctors and nurses in KBTH and is worrying because this may be negatively impacting on their ability to talk to or educate other women as well as their own practice of getting screened, as there are several studies that have demonstrated that lack of awareness or poor knowledge level impacts negatively on the screening practices of participants (Nakalevu, 2009, Di et al, 2016, Merchant, 2007, Liu et al, 2018). 5.3 Association between Health Worker Characteristics and Overall Knowledge on Cervical Cancer There were significant associations between the age, religion, profession and rank of nurses and the overall knowledge level in this study. The older female health workers exhibited higher the knowledge level. This is similar to finding from another study (Di et al, 2016) and is probably due to the greater exposure to both clinical educational experience and the need for accessing more health information for their own use and for other. Most of the younger 60 University of Ghana http://ugspace.ug.edu.gh health workers may be minimally exposed to information obtained during their formal training in medical school or nursing school and usually professional continuing education in the hospitals may favour the older staff in the facility. Doctor are exposed to longer period of formal training which is also more detailed especially in the areas of Obstetric and Gynaecology, Internal Medicine, General Surgery and Child health during medical school and internship. It is therefore, not surprising that they demonstrated significantly higher overall knowledge level than female nurses, with less than 1% of the female doctors as against 20% of the female nurses exhibiting poor overall knowledge level and then 35% of the doctors in contrast to 5% of the nurses being in the high overall knowledge level bracket. As probably expected, nurses of higher ranks were found to be significantly more knowledgeable than those of lower ranks on cervical cancer, its screening and prevention. This may be re-emphasizing the impression that there is inadequate educational exposure on cervical cancer and other gynaecological and reproductive health issues in the formal nursing education. The limitation in the level of knowledge of the nurses is worrying because, ironically, majority of the health education activities to clients and patients in KBTH and other hospitals are done by nurses and should therefore, be better equipped with adequate knowledge to promote good health. It is therefore, informative from this study that a lot of effort in properly planned and frequently implemented targeted post-qualification professional education program on cervical cancer, its screening and prevention is needed to bridge the obvious gap in knowledge from the formal nursing education. This may include frequent workshops and health promotion programs on cervical cancer that is not only organized and restricted to staff of the department Obstetrics and Gynaecology but extended to all other departments, both and non clinical. 61 University of Ghana http://ugspace.ug.edu.gh Incidentally, there was a finding of significant association between religion and overall knowledge level on cervical cancer, its screening and prevention, where non-Christians were shown to be significantly more knowledgeable than Christian respondents in the study. This may be because of the lack of balance in the two groups been compared with non-Christians constituting less than ten percent of the study population, whilst the vast majority of respondents were Christians. Although this study did not show a statistically significant association between respondents’ family history of any cancer or family history of cervical cancer and overall knowledge level, those with a family history of any cancer or cervical cancer exhibited better knowledge levels than those who did not have a family history or did not know of their family history. Actually, not a single one of respondents with family history of cervical cancer had poor knowledge level. This finding is most probably due to the urge to seek more knowledge on the disease driven by having a loved one or family member suffer from it. 5.4 Health Workers Perceptions on Cervical Cancer Screening; Respondents’ Preparedness to Educate Other Women and Perceived Barriers to Screening There was almost universal positive perception of the importance of cervical cancer screening in reducing the disease among the health worker in KBTH with 94% of them positively perceiving its important and same percentage also indicating that women of child-bearing age should be the group to be screened. This is in agreement with the findings of several other studies even among community-based participants (Liu et al, 2017; Elamurugan et al, 2019; Sothy et al, 2018). This is a good foundation to work on to improve screening practice and education to other women although as was shown in this study that positive perception does not always translate to significant appropriate practice especially when the knowledge level is poor as have been seen in other studies (Di et al, 2016; Liu et al, 2017; Mutyaba, 2009). 62 University of Ghana http://ugspace.ug.edu.gh In spite of the very high positive perception among the respondents in this study, their self- reported preparedness or capability to talk to or educate other women was found to be rather poor, with only 40% of female doctors and nurses in KBTH considering themselves very prepared to talk to other women about cervical cancer screening and as much as 21% saying that they do not consider themselves prepared at all to educate other women on it. This is obviously pointing to untapped potential resources for reducing the menace of cervical cancer that need to be better equipped and utilized. Interestingly, there was statistically significant association between health worker profession and self-reported preparedness to talk to other women. This is probably because in the health sector in Ghana and Sub-Saharan Africa, nurses are usually given the role of patient and community health education and are therefore, more confident of delivering this service than doctors who usually limit themselves to clinical diagnostic and disease management. Although it is important to have more nurses indicate readiness to participate in health education on cervical cancer screening and prevention; it is equally important to ensure that their knowledge level is very high and accurate make sure the correct information is being delivered especially after the finding from this study that the nurses knowledge level was significantly lower than the doctors. Also more effort is required to train and assist doctors to participate actively in health education and promotion even on one-on-one interactions with clients in the clinics and community. As expected, female health workers from department of Obstetrics and Gynaecology and Korle Bu Polyclinic were found to be significantly better prepared to talk to other women about cervical cancer screening and prevention than other departments involved in the study. This is not surprising because these are the two departments most involved in educational programs for increasing awareness of both hospital clients and the community on cervical cancer screening. 63 University of Ghana http://ugspace.ug.edu.gh This study also revealed that there is significant positive association between combined overall knowledge of respondents and self-reported prepared to educate other women on cervical cancer screening and prevention. The positive association was also found with all the knowledge level sub-sections. As already mentioned in this discussion, high knowledge level would be expected to significantly increase health worker preparedness and confidence to participate in educating other women and increase the impact of reducing the disease incidence. This study also sorts to find out the perception of female doctors and nurses in KBTH on the barriers to cervical cancer screening for women. Lack of awareness (89%), cost of screening (71%), fear of vaginal examination (62%), absence of symptoms (62%), fearful of test results (60%), difficult access (52%) and embarrassment (51%) were the most perceived barriers reported by the respondents. Theses have been reported in other studies (Liu et al, 2017; Elamurugan et al, 2019; Sothy et al, 2018) where women have volunteered their reasons for not getting screened. Religion, cultural issues and the gender of the provider not highly thought of to pose as barriers by the respondents in this study unlike other studies (Sothy et al, 2018; Mutyaba, 2009) conducted among community-based women and in rural settings. 5.5 Health Workers’ Practices on Cervical Cancer Screening and Their Sources of Information on Cervical Cancer Screening and Prevention There was rather a low uptake of cervical cancer screening in this study among female doctors and nurses in KBTH with only 32% of respondents self-reporting to have ever been screened. This is in keeping with a study done in India (Elamurugan et al, 2019) among teachers and housewives which found cervical cancer screening rate of 38% among the teachers and 12% among the housewives. This was in contrast to a study among rural women in Eastern China (Liu et al, 2017), where a free screening program was provided which 64 University of Ghana http://ugspace.ug.edu.gh showed a 63% uptake of cervical cancer screening uptake. The low uptake of cervical cancer screening among the female health workers in KBTH in spite of very positive perception may be partly due to inadequate knowledge about the screening guideline found among the respondents and the lack of any sustained program targeting them. This would be expected to impact negatively on efforts to improve uptake of screening among other women and clients of the hospital. In this study, age, marital status, worker profession, respondent department, ranks of both doctors and nurses, duration of clinical practice were all significantly associated with respondents’ practice of getting screened. Significantly more doctors has been screened for cervical cancer than nurses which is thought to be partly due to higher knowledge level among the doctors than the nurses. This is similar to a study (Elamurugan et al, 2019) where teachers with better knowledge levels were found to have higher uptake of screening than housewives with lower knowledge levels. Older and married respondents from departments of Obstetric and Gynaecology and the Polyclinic with higher professional rank (both for doctors and nurses) and with longer duration of clinical practice were found to be significantly more screened for cervical cancer than their other colleagues. This is in keeping with the association found between respondents’ characteristics and knowledge level which exhibited a similar picture. This suggests the need for more rigorous educational programs and health promotion among health worker much earlier during their formal training and early practice in all hospital settings on cervical cancer screening. Implementation of institutional programs to promote early and sustained screening of female health workers would probably assist in increasing the uptake of health workers of screening and hopefully translate in improving their ability to educate other women in both the hospital and the community. 65 University of Ghana http://ugspace.ug.edu.gh Interesting, although health workers with positive perception about cervical cancer screening were found to have better screening uptake, the association was not statistically significant indication the need for other factors such as better knowledge and sustained institutional programs at screening staff. Also respondents with family history of any cancer and specifically cervical cancer were again better screened but not significantly more than the colleagues with no family history. Majority of the women in this study obtained their information on cervical cancer from their professional formal education unlike other studies in which most of the respondents obtained their information from health professional, the media and friends or relatives (Liu et al, 2017; Elamurugan et al, 2019; Sothy et al, 2018). Only 21% of the female health workers in KBTH had attended any cervical cancer training program or workshop. This may further explain both the inadequate knowledge level and poor screening uptake. More worrying was the finding that about half of all respondents were still undecided on when to do their next screening especially with the reason for not yet getting screened being because they are too busy. 5.6 Association between Knowledge Levels of Health Workers and Cervical Cancer Screening Practice Several studies (Merchant, 2007; Nakalevu, 2009; Liu et al, 2017; Elamurugan et al, 2019; Sothy et al, 2018; Di et al, 2016) have demonstrated that lack of knowledge or awareness on cervical cancer, its screening and preventive practice hugely contributes the low uptake of cervical cancer screening in the community, both rural and urban. Most of these studies have suggested that improving the knowledge of women and providing easy access to affordable or free screening programs would significantly increase cervical cancer screening uptake 66 University of Ghana http://ugspace.ug.edu.gh among at-risk women. This study conducted among female doctors and nurses in Korle Bu Teaching Hospital was found to be in agreement with these other studies. There were significantly higher proportions of screened women among those with moderate and high knowledge level than those with low knowledge levels for all knowledge sub-sections except for the knowledge of risk factors, signs and symptoms. Improving knowledge through a properly planned and sustained institutional and national programs as well as increasing accessibility to cervical cancer screening would seem to be a step in the right direction in increasing the uptake of cervical cancer screening uptake both among women working in the hospital and those in the community. These interventions in turn would be expected to contribute to the reduction of the incidence of cervical cancer and its related morbidity and mortality. 5.7 Limitations of the Study This study had some limitations. Firstly, it is focused on female doctors and nurses in a teaching hospital setting. Consequently, it may be difficult to generalize its findings to others female doctors and nurses in lower levels of the health delivery system. Secondly, it did not cover other health professionals, such as, pharmacists, laboratory technician and therefore, will also affect generalization of the study findings to all female health workers in the hospital. 67 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSIONS AND RECOMMENDATIONS 6.1 Conclusions The overall level of knowledge of female doctors and nurses in KBTH on cervical cancer, its screening and prevention is inadequate with 72% of them demonstrating only moderate overall knowledge level. There was almost universal positive perception of the importance of cervical cancer screening in reducing the disease. The practice of being screened for cervical cancer among female doctors and nurses in KBTH was poor at 32% and this is coupled with an inadequate preparedness to talk to or educate other women. The factors significantly associated with positive cervical cancer screening practice among female health workers in KBTH were respondent’s department of work and awareness of cervical cancer screening. 6.2 Recommendations Korle Bu Teaching Hospital (KBTH): • To develop a sustainable health education program through its Health Promotion Unit of the Public Health Department specifically targeting health workers in the hospital on cervical cancer screening and prevention. • To establish a free institutional cervical cancer screening and prevention program for female health workers in the hospital to improve access and uptake. 68 University of Ghana http://ugspace.ug.edu.gh • To extend education on cervical cancer screening to female clients attending other clinics aside Gynaecology and Reproductive Health clinics; and to involve health workers in those units for the health education with the assistance of the staff of the Health Promotion Unit Ministry of Health and Ghana Health Service: • To consider revisions in the formal training curricula in nursing school to improve education on cervical cancer screening and prevention. • To establish a national free cervical cancer screening and prevention programs and ensure it is widely accessible and sustained in all health facilities. • To strongly support community-based health education activities on cervical cancer screening and prevention by staff of health facilities in the communities to increase uptake of screening in the community. 69 University of Ghana http://ugspace.ug.edu.gh REFERENCES Adanu, M., K., Seffah, J., D., Duda, R., Darko, R., Hill, A., &Anarfi, J. (2010). Clinic Visits and Cervical Cancer Screening in Accra. Ghana Medical Journal. 44(2):59-63. Affriyie, K. (2004). Ghana Health Sector Annual Programme of Work: Ghana Ministry of Health. Maternal and Reproductive Health Services, 12. Alliance for Cervical Cancer Prevention (ACCP). (2004). Improving Screening Coverage Rates of Cervical Cancer Prevention Programs: A Focus on Communities. Seattle, USA. Cervical Cancer Prevention Issues in Depth, (4). Blumenthal, P., Gaffikin, L., Deganus, S., Lewis, R., Emerson, M.,& Adadevoh, S. (2008). Cervical cancer prevention: Safety, acceptability, and feasibility of a single-visit approach in Accra, Ghana. American Journal of Obstetrics and Gynecology. 196: 407 Denny L, Quinn M &Sankaranarayanan, R. (2006). Screening for cervical cancer in developing countries. Vaccine 24, Chapter 8(Suppl 3): 71–77. Ebu, N.I., Mupepi, S.C., Siakwa, M.P., &Sampselle, C.M. (2015). Knowledge, practice, and barriers toward cervical cancer screening in Elmina, Southern Ghana. International Journal of Women's Health, 7: 31-39. Edwin, A. K. (2010). Is routine human papillomavirus vaccination an option for Ghana? Ghana medical journal, 44(2). Engender Health (2002). Women’s Perspectives on Cervical Cancer Screening and Treatment: Participatory Research in Khayelitsha, South Africa. New York: Engender Health. Ezem, B.U. (2007). Awareness and uptake of cervical cancer screening in Owerri, South- Eastern Nigeria, Ann Afr Med. 6(3): 94-98. Doi: 10.4103/1596-3519.55727. Gattoc, L., Nair, N., & Ault K. (2013). Human Papillomavirus Vaccination: Current indication and Future Direction. Obstetrics and Gynecology Clinic of North America: 40 (2),177- 197 Gillet E, Meys JFA, Verstraelen H, Verhelst R, De Sutter P, et al. (2012) Association between Bacterial Vaginosis and Cervical Intraepithelial Neoplasia: Systematic Review and Meta-Analysis. PLoS ONE, 2012 7(10) Globocan(2008).Global Burden of Cancer (2008). International Agency for Research on Cancer (IARC), GLOBOCAN 2008: 4-15. Accessed on 23/12/2018 from http://globocan.iarc.fr/ Hakama, M., Coleman, M.P., Alexe, D.M. &Auvinen, A. (2008). Cancer Screening: Evidence and Practice in Europe. European Journal of Cancer, 44: 1404-13. 70 University of Ghana http://ugspace.ug.edu.gh Hernandez, B.Y., Wilkens, L.R., Zhu, X., McDuffie, K., Thompson, P., Shvetsov, Y.B., et al (2008) Circumcision and human papillomavirus infection in men: a sitespecific comparison. J. Infect Dis, 19 (7), 787–794 Idowu, A., Olowookere, S.A., Fagbemi, A.T., &Ogunlaja, O.A. (2016). Determinants of Cervical Cancer Screening Uptake among Women in Ilorin, North Central Nigeria: A Community-Based Study. Journal of Cancer Epidemiology 4 (1), 34-56 International Agency for Research on Cancer Organization (IARCO) (2003). Cancer in Africa. Epidemiology and Prevention. Uganda: IARCO Scientific Publications. Lim, A.W., Ramirez, A.J., Hamilton, W., Sasieni, P., Patnick, J., Forbes, L.J.L.(2014). Delays in diagnosis of young females with symptomatic cervical cancer in England: an interview-based study. BJGP, 64(627): e602-e610. Louie, S. K., de Sanjose, S. &Mayaud, P. (2009). Epidemiology and prevention of human papillomavirus and cervical cancer in Sub-Saharan Africa: A comprehensive review. Tropical Medicine and International Health, 14 (10), 1287-1302. Maine, D., Hurlburt, S. &Greeson, D. (2011). Cervical cancer prevention in the 21st century: Cost is not the only issue. American Journal of Public Health, 101 (9), 1549 -1555. Merchant, R.C., Gee, E.M., Bock, B.C., Becker, B.M. and Clark, A. (2007). Correlates of Women’s Cancer Screening and Contraceptive Knowledge among Female Emergency Department Patients. BMC Women’s Health, 7: 16. Mishra, G.A., Pimple, S.A,, Shastri, S.S. (2011). An overview of prevention and early detection of cervical cancers. Indian J Med Paediatr Oncol, 32(3): 125-132. Modibbo, F.,I., Dareng, E., Bamisaye, P., Jedy-Agba, E., Adewole, A., Oyeneyin, L., Olaniyan, O., &Adebamowo, C. (2016). Qualitative study of barriers to cervical cancer screening among Nigerian women. BMJ Open 20 (6); 6-21 Munthali A.C, Ngwira B.M, &Taulo F. (2015). Exploring barriers to the delivery of cervical cancer screening and early treatment services in Malawi: Some views from service providers. Patient Preference and Adherence, 9: 501-508. Murthy, P., Li, E., Azzam, H., Narasimhadevara, A., and Yezzo, M. (2010). Cervical Cancer Mortality: A Preventable Tragedy. In: Murthy PaS, C., editor. Women's Global Health and Human Rights. Sudbury: Jones and Bartlett Publishers. Mutyaba, T., Faxelid, E., Mirembe, F. &Weiderpass, E. (2007). Influences on Uptake of Reproductive Health Services on Nsangi Community of Uganda and their Implications for Cervical Cancer Screening. Reprod Health, 4: 4 Nakalevu, S.M. (2009). The Knowledge, Attitude, Practice and Behavior of Women towards Cervical Cancer and Pap Smear Screening. Fiji School of Medicine. 71 University of Ghana http://ugspace.ug.edu.gh Nkyekyer K. (2000). Pattern of Gynaecological Cancers in Ghana. East African Medical Journal 77 (10): 534-538. Parkin, D., & Bray, F. (2006). Chapter 2: The Burden of HPV-Related Cancers. Vaccine, 24 (3), 11-25. Petignat, P., & Roy, M. (2007). Diagnosis and management of cervical cancer. BMJ, 335(7623): 765-768. Prempeh, E.A.K. (2015). Thesis submitted to the department of health policy management and economics, school of public health, KNUST in partial fulfillment of the requirements for the degree of Master of Science in public health in health service planning and management. Riain, A., Stewart, M., Phelan, D., Bury, G. &Mulcahy, F. (2001). Cervical Smears: Comparison of Knowledge and Practice of a General Practice Sample with a High Risk Group. International Journal of STD &AIDS, 12:171-175. Shi, J., Chen, J., Canfell, K., Feng, X., Ma, J., Yong, Z.,Qiao, Y. (2012). Estimation of the costs of cervical cancer screening, diagnosis, and treatment in rural Shanxi, Province, China: A micro-costing study. BMC Health Services Research 12 (7), 12-25 Sudenga, S.L., Rositch, A.F., Otieno, W.,A., &Smith, J.,S. (2013). Knowledge, attitudes, practices, and perceived risk of cervical cancer among Kenyan women: brief report. International Journal of Gynaecology Cancer, 23(5): 895-9. Tripathi, N., Yugantara, R., K., Randhir, V., D., &Alka, D., G. (2014). Barriers for early detection of cancer amongst Indian rural women. South Asian Journal of Cancer, 3(2): 122–127. World Health Organization (WHO) (2006).Comprehensive Cervical Cancer Control: a guide to essential practice. Second Edition, 4:129-159. WHO (2007). Information Centre on HPV and Cerival Cancer (HPV Information Centre). Summary report on HPV and cervical cancer statistics in Ghana. WHO, (2010).International Agency for Research on Cancer (IARC) Handbook of Cancer Prevention, Volume 10: Cervix Cancer Screening. Geneva: IARC WHO (2011).International Agency for Research on Cancer (IARC) Fact Sheet on Cancer prevalence and preventionGeneva: IARC WHO (2014).2014 Africa Cervical Cancer Multi Indicator Incidence & Mortality Scorecard. Accessed on 25/12/2018 from http://www.who.int/pmnch/media/events/2014/africa_cancer_mortality.pdf. WHO (2015).Human papillomavirus (HPV) and cervical cancer. Fact Sheet: 380Accessed on 25/12/2018 from http://www.who.int/mediacentre/factsheets/fs380/en/. 72 University of Ghana http://ugspace.ug.edu.gh Wiredu E, &Armah, H. (2006). Cancer mortality patterns in Ghana: A 10-year review of autopsies and hospital mortality. BMC Public Health. 6 (159). Wong, L., P., Wong, Y., L., Low, W., L., Khoo, E., M., &Shuib, R. (2009). Knowledge and awareness of cervical cancer and screening among Malaysian women who have never had a Pap smear: a qualitative study. Singapore Medical Journal. 50(1), 49-53. Wright, T., & Kuhn, L. (2011). Alternative approaches to cervical cancer screening for Developing countries. Best Practice & Research Clinical Obstetrics and Gynecology, 26, 197- 208. 73 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix A: Participant’s Consent form Title of study:Perception and practices of cervical cancer screening and prevention among female health workers in Korle Bu Teaching Hospital Researcher:PreciousOwoo Department:Population Family and Reproductive Health (PFRH) Phone:+233546209725 Email address:preciouskofi86@gmail.com/ precious_kofi@yahoo.com Dear participant, my name is Precious Owoo, a student of the School of Public Health, University of Ghana, Legon. I am undertaking a study on knowledge, attitude and practices of cervical cancer prevention among female health workers in Korle Bu Teaching Hospital. Background of the study Cervical cancer, a largely preventable cancer, is the commonest cancer among women in Ghana and the leading cause of cancer mortalities. This studyseek to assess the knowledge, attitude and practices of cervical cancer prevention among female health workers in Korle Bu Teaching Hospital. Nature of study The study seeks to assess the knowledge, attitude and practices of cervical cancer prevention among female health workers in Korle Bu Teaching Hospital. A structured questionnaire with mostly closed ended questions covering all aspects of the objective of the study will be used for data collection. The study will involve answering questions about yourself, knowledge and attitude and practices on cervical cancer, preventive measures of cervical cancer anddeterminants of use of cervical cancer methods. 74 University of Ghana http://ugspace.ug.edu.gh Duration This should take about 15 minutes of your time. Potential risks/benefits The study will not cause any discomfort to participants. It is hoped that results obtained for this study will be used by policy makers and the community in particular to either improve upon existing measures of seeking regular check-ups for early detection and cure/prevention or to enforce existing ones with the objective of better improving the incidence of cervical cancer among health workers. Privacy/Confidentiality I would like to assure you that whatever information provided will be handled with strict confidentiality and will be used purely for the research purposes. Your data will not be shared with anybody who is not part of the research team. Data analysis will be done at the aggregate level to ensure anonymity. Your identity will not be disclosed in the material that will be published. Voluntary withdrawal and compensation Participation in this study is voluntary and participants can choose not to answer any particular question or all questions. You are at liberty to withdraw from the study at any time without prejudice from the study team. However, it is encouraged that you participate since your opinion is important in determining the outcome of the study. You will not be provided any reward/compensation to respond to the questionnaire. 75 University of Ghana http://ugspace.ug.edu.gh Provision of information and consent form A copy of the information sheet will be given to you after it has been signed or thumb-printed to take home. Ethical Approval The study will be reviewed and approved by the Korle-BuTeaching Hospital Institutional Review Board (KBTH-IRS). This committee is there to ensure that participants in researches are protected from harm and their rights are respected and protected. Before taking Consent Do you have any questions you wish to ask about the study? Yes |____| No |____| If yes, please, indicate the questions below ………………………………………………………………………………. ………………………………………………………………………………………… In case you have any questions on the study later please, do not hesitate to contact Precious Owoo, Department of PFRH, School of Public Health, University of Ghana. (Tel: +233546209725) Email: preciouskofi86@gmail.com/ precious_kofi@yahoo.com Also, if you need further clarifications on ethical issues, kindly contact the Administrator, KBTH IRB. 76 University of Ghana http://ugspace.ug.edu.gh Consent Form I……………………………………., declare that the purpose of the study has been thoroughly explained to me in English language/Ga/Twi and I have understood. I hereby agree to answer the questions. I understand that it is voluntary and can opt out at any time. Signature…………………………. Date……………………………… Witness Statement I declare that I was present while the benefits and procedures were read to the participants and all questions were answered and the participant has agreed to take part in the study Witnesss signature………………………… Date ……………………. Interviewer’s Statement I, the undersigned, have explained this consent form to the subject in the English language/Ga/Twi that he/she understands the purpose of the study, procedures to be followed as well as risks and benefits involved. The subject has freely agreed to participate in the study. Interviewer’s signature………………………… Date…………………………….. Address…………………………… 77 University of Ghana http://ugspace.ug.edu.gh Appendix B: Research questionnaire SECTION A: SOCIO-DEMOGRAPHIC PROFILE OF HEALTH WORKERS 1. Age of participant health worker……………………………………….. 2. Profession of participant health worker A. Doctor B. Nurse 3. Department/ specialty of participant A. Internal medicine B. Surgery C. Obstetrics and Gynaecology D. Orthopedics, Accident and Emergency E. Anaesthesia and ICUs F. Child Health G. Polyclinic 4. Rank of participant …………………………………… 5. Years of clinical practice of participant A. 1 – 3 years B. 4 – 5 years C. 6 – 10 years D. 11 – 20 years E. More than 20 years 6. Marital status A. Married B. Single C. Co-habitting D. Divorced E. Widowed 78 University of Ghana http://ugspace.ug.edu.gh 7. Religion A. Christianity B. Islam C. Traditional D. None E. Others, specify 8. Family history of any cancer? A. Yes B. No C. Don’t know 9. Family history of cervical cancer? A. Yes B. No C. Don’t know SECTION B: KNOWLEDGE OF PARTICIPANTS ON CERVICAL CANCER 10. What is the cause of cervical cancer? A. It is a genetic disease B. It is caused by HIV C. It is caused by HPV D. It is caused by Hepatitis B virus E. It is a bacterial infection 11. What are the risk factors for cervical cancer? (choose as many as apply) A. Early commencement of sexual activity B. Late commencement of sexual activities C. Short duration of reproductive period D. Long duration of reproductive period E. Multiple sexual partners F. Prostitution G. Excessive alcohol intake H. Cigarette smoking I. Poor personal hygiene J. Long-term OCP use K. HPV infection L. Multiple pregnancies 79 University of Ghana http://ugspace.ug.edu.gh 12. How common is cervical cancer relative to all cancers among women in Ghana? A. It is the commonest cancer among women B. It is the second commonest cancer among women C. It is the third commonest cancer among women D. It is a rare cancer among women E. Don’t know 13. How common is cervical cancer relative to gynaecological cancers in Ghana? A. It is the commonest gynaecological cancer B. It is the second commonest gynaecological cancer C. It is the third commonest gynaecological cancer D. It is a rare gynaecological cancer E. Don’t know 14. Who is at risk of cervical cancer A. All women B. Both men and women C. Only women involved in sexual activities D. Only postmenopausal women E. Don’t know 15. What are the signs and symptoms of cervical cancer? (choose as many as are correct) A. No symptoms in early stage B. Post-coital bleeding C. Post-menopausal bleeding D. Dyspareunia E. Increased vaginal discharge F. Don’t know 16. How long is the precancerous lesion period of cervical cancer A. Very short B. Short C. Long D. Very long E. Don’t know 17. Have you ever heard about cervical cancer screening? A. Yes B. No 80 University of Ghana http://ugspace.ug.edu.gh 18. Which cervical cancer screening methods are you aware of? A. ................................................... B. .................................................... C. .................................................... 19. How effective is Pap smear screening for precancerous cervical cancer detection? A. Very effective B. Somewhat effective C. Not effective D. Unknown effectiveness E. Don’t know 20. At what age do you begin screening of asymptomatic average risk women for cervical cancer? A. Before age 25 years B. 25 -29 years C. 30 – 34 years D. 35 years or above E. Don’t know 21. How often do you screen asymptomatic average-risk women for cervical cancer? A. Every 6 months B. Every year C. Every 2 years D. Every 3 years E. Every 5 years F. Don’t know 22. How long does the Pap smear screening test for cervical cancer take to do? A. Less than 30 minutes B. 1 hour C. 2 hours D. 3 or more hours E. Don’t know 23. Is there a vaccine available against cervical cancer? A. Yes B. No C. Don’t know 81 University of Ghana http://ugspace.ug.edu.gh 24. If a vaccine is available, at what age should girls or women be vaccinated? A. 9-10 years B. 11-12 years C. 13-18 years D. 19-25 years E. More than 25 years F. Don’t know 25. Do women who have received vaccination against cervical cancer require screening? A. Yes B. No C. Don’t know SECTION C: PERCEPTION AND PRACTICES OF PARTICIPANTS ON CERVICAL CANCER 26. Where did you hear about cervical cancer and Pap smear test from (choose as many as apply) A. The Media B. From my professional education C. From a cervical cancer training or workshop D. From other health professionals E. I have never heard of it F. Others, specify.................................................... 27. In your opinion, who should be screened? A. All women of child bearing age B. Only women with symptoms suggestive of cancerous cervix C. Only women with promiscuous life style D. Don’t know 28. How prepared do you consider yourself to talk to women about cervical cancer? A. Very prepared B. Somewhat prepared C. Not prepared 29. Have you done cervical cancer screening before? A. Yes B. No 82 University of Ghana http://ugspace.ug.edu.gh 30. Have you done screening within the last one year? A. Yes B. No 31. What kind of screening did you do? Please state,.............................................................. 32. Where did you do your cervical cancer screening? A. Home by myself B. Health facility C. Others, specify………………………………….. 33. Reason for doing the screening A. Doctors recommendation B. Previous test result C. Just to know status D. The services were free E. Awareness that if detected early, it is treatable F. Others, specify,…………………………………………. 34. When was your last cervical cancer screening test done? A. Within the last one year B. 1-2 years ago C. 2-3years ago D. 3-4 years ago E. More than 4 years ago F. Never had a screening test 35. When do you intend to screen again? A. Within the next year B. In the next 2 years C. In the next 3 years D. Have not decided E. Do not ever intend to 36. What is the reason for not doing it? (if you have never screened) A. Cost of the screening B. Fear of test results C. Fear of pain D. Too busy E. Religious reasons F. Sex (Gender) of the provider G. Not necessary H. Age limit 83 University of Ghana http://ugspace.ug.edu.gh I. Embarrassment J. Others, specify ………………………….. 37. In your opinion, is cervical cancer screening important in reducing the disease? A. Yes B. No C. No response 38. In your opinion, what are the common barriers to participation of women in cervical cancer screening and prevention? (choose as many as apply) A. Lack of awareness B. No symptoms C. Difficult access to health facility with screening D. Fear of vaginal examination E. Cost of the screening F. Fear of test results G. Fear of pain H. Too busy I. Not recommended by health workers J. Religious reasons K. Sex (Gender) of the screening provider L. Age limit M. Embarrassment N. Others, specify ………………………….. 84 University of Ghana http://ugspace.ug.edu.gh Appendix C: Budget Table Appendix C: Budget for the study Item Unit Cost Frequency Total (GHC) Proposal development Internet Data (Surfline) GHC 50 4 200 Ethical Review Committee (KBTH IRB) GHC 450 1 450 Training of research assistants Research Assistants GHC 100 3 300 Transportation GHC 50 3 150 Field Work Transport for field work GHC100 4 400 Stationary GHC 200 1 200 Meals GHC 40 3(2) 240 Finishing Final work Stationary /Print out /Hard Cover GHC100 7 700 Miscellaneous GHC 200 1 200 TOTAL GHC 2840 85 University of Ghana http://ugspace.ug.edu.gh Appendix D: Timelines Table Appendix D:Timelines for the study 2018 2019 ACTIVITY Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Proposal Development Proposal submission to KBTH IRB Training research assistants Pilot study Collection of data Data Editing and Proof Reading Data Entry Data Analysis Results and discussion Finalize Dissertation Submitting dissertation 86 University of Ghana http://ugspace.ug.edu.gh Appendix E: Ethical Clearance Letters 87