Extracto
TABLE OF CONTENTS
LIST OF TABLES
LIST OF FIGURES
LIST OF ABBREVIATIONS/ACRONYMS
ABSTRACT
CHAPTER ONE: INTRODUCTION
CHAPTER TWO: LITERATURE REVIEW
CHAPTER THREE: RESEARCH METHODS
CHAPTER FOUR: CERVICAL CANCER INTERVENTIONS IN NIGERIA
CHAPTER FIVE: DISCUSSION OF FINDINGS
CHAPTER SIX: RECOMMENDATIONS AND CONCLUSION
REFERENCES
LIST OF TABLES
Table 1.1: Global prevalence of cervical cancer per country in age-standardized rate
Table 1.2: Cervical cancer indicators in Nigeria compared to West Africa and the World
Table 1.3: Table showing availability of radiotherapy machines in West Africa including Nigeria
Table 2.1: Selected databases for literature search
Table 2.2: PICO criteria for literature data analysis
Table 3.1: International interventions on cervical cancer in Nigeria
Table 3.2: National interventions on cervical cancer in Nigeria
Table 3.3: Local interventions on cervical cancer in Nigeria
Table 3.4: Treatment application to cervical cancer investigation in Nigeria
Table 3.5: Number of healthcare workers related to cervical cancer care in Nigeria as at 2010
LIST OF FIGURES
Figure 1.1: Estimated distribution of cervical cancer cases and mortality (in thousands) per continent
Figure 1.2: Prevalence of new cancers in women worldwide (in thousands per year) (cervical cancer in red
LIST OF ABBREVIATIONS/ACRONYMS
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ABSTRACT
Background: the prevalence of cervical cancer and mortality rates has continued over the years despite several international and local efforts to reduce it in developing countries particularly sub-Saharan Africa which have the highest prevalence rates globally. This dissertation appraised the factors responsible for cervical cancer prevalence and assayed the efficacy of these interventions with particular focus on Nigeria by identifying the risk factors causing its spread and recommending prevention strategies for best options in reducing rates of cervical cancer in Nigeria.
Methods: A systematic literature approach was used for the review of studies. This was carried out through database search on the prevalence, risk, mortality, factors and intervention for cervical cancer in developing countries with a narrative analysis to explanation for the local, national and international interventions.
Findings: The findings revealed that lack of a national policy on cervical cancer on awareness, treatment, prevention and control, limit intervention efforts. Furthermore, massive overlaps in the international intervention programme, paucity of data on the analysis of impact and efficacy of these interventions, including unavailability of vaccine for high risk HPV stymie efforts for the reduction of cervical cancer in Nigeria. It was further established that the lack of a national policy on cervical cancer in Nigeria limit ongoing strategies for its mitigation.
Conclusion: A national policy should be implemented for the intervention of cervical cancer to include measures for cervical cancer care as well as improving on current efforts on awareness, screening, prevention, treatment, and control especially in health care workers and local communities. Improvement be made in quality health care systems in terms of medical staff, screening machines and centers and the introduction of high risk vaccine for HPV serotype prevalent in Nigeria.
CHAPTER ONE: INTRODUCTION
1.0 INTRODUCTION
The incidence of cervical cancer [CC] mortality rates in the developing countries of Africa, Latin America and Asia has been a significant health issue over the years (Global Health Initiative Action against Cancer [GHIAC], (2012). The World Health Organization [WHO] epidemiological survey on CC mortality rates in 2014 revealed that in comparative terms, the incidence and burden of mortality due to the disease is lower in developed countries in contrast to developing countries where it constitutes a major health problem (WHO, 2014). According to Global Health Action [GHA] (2013), CC accounts for an estimated 266,000 deaths worldwide annually, with about nine in every ten (87%) cancer deaths occurring in developing countries.
Countries in Africa have the highest rate of CC prevalence in the world. Malawi account for the highest CC new cases and related deaths in the world with an estimated death of 2,000 women in every 3,684 women diagnosed annually (GHA, 2012). Mozambique (65%) and Comoros (61.3%) are second and third countries respectively with highest global prevalence (WHO, 2012; GHA, 2012; Jackson et al, 2014). According to World Cancer Research Fund International [WCRFI], (2012), sixteen (16) of the twenty (20) countries with the highest prevalence of CC deaths are in Africa.
According to Global Burden of Cancer Study (GLOBOCAN) 2015, the mortality rates of CC has significant health implication for public health in developing countries. The WHO National Cervical Cancer Survey [WHO-NCCS], reveal that several factors increases the mortality rates of CC in developing countries particularly sub-Saharan Africa: poor screening programs for early detection, poor medical and infrastructural facilities, low technology, poor management of CC intervention programmes which adds to the burden of the disease (WHO, 2014). However, CC is curable and preventable at a low cost if treated in its early stages (Follen et al, 2012).
1.2 BACKGROUND OF THE STUDY
Nigeria is the 25th in the world according to the Global Burden of Cancer Study matrix on CC mortality (GLOBOCAN, 2015). According to the (WHO, 2012; FMH, 2013) the disease accounts for about 26 deaths daily in Nigeria and a mortality incidence estimated to be individually deadlier than HIV, tuberculosis and malaria with about one death per hour. The Federal Ministry of Health in Nigeria in 2014, declared CC a national health epidemic (FMH, 2014).
In Nigeria, it is estimated that 60-75% of women who develop CC live in rural areas and often lack access to early detection screening and treatment due to financial reasons and geographical distance to tertiary health care facilities mostly located in urban areas (Adewole et al, 2012). This is linked to unemployment, and rural poverty due to dependence on subsistence agriculture in most rural women in Nigeria which adds to the burden of the disease (Adeola, 2008). Furthermore, the non-treatment of the disease owing to under-reporting by primary health care centers in rural areas coupled with poor recording keeping and in most cases lack of functional CC registries account for underestimation of actual CC mortality figures (Nnanna et al, 2012). Most of the figures quoted on CC mortality indices as (Chokunonga et al., 2002) notes are hospital-based, and represents a small fraction of women dying from CC, especially rural women who resort to traditional medicine and self-resignation and die at home.
Prevailing perceptions of CC in the world refer to it as a ‘disease of poverty characteristic of women with low socio-economic status’ (Matlry, 2009). Contrary literatures, however, posit that CC affects both the poor and the rich though its incidence is more with developing countries as a result of poor health systems and CC specialists to mitigate the disease (Carl, 2012; James, 2013). A study of CC in Nigeria by Onabisi et al (2015), revealed that the disease was increasingly reported in rural population with high rate of human papilloma virus (HPV), poor municipal and social conditions, high parity, and poor hygiene. Likewise, Onigbade (2014) adds that incidences of wars, political instability, internal conflicts and natural disasters increases the risk of transmission of CC. Hence, the higher the prevalence of these factors, the higher the probability of an increase in CC reporting as social vices as rape, prostitution, poverty, criminality and multiple marriages may be commonplace.
More so, the HIV epidemic in the sub-Saharan Africa region has been identified in literature to increase the problem of CC as individuals so infected have rapid progression of CC and usually with poorer outcomes (Onigbade, 2010; Adeola, 2013; Briggs et al, 2013). This is closely associated with the age of sexual debut among teenage girls and linked to the issue of female genital mutilation [FGM] where the risk of contracting sexually transmitted diseases are higher (Onibade, 2013). Likewise, HIV/AIDS prevalence has been associated with the incidence of CC cases in Nigeria with the highest rates in north-central and south-south Nigeria (NBS, 2013).
Nevertheless, developing countries particularly Nigeria have received significant resources from humanitarian and philanthropic organizations to support national and local CC intervention programmes in the form of grants for research, and training of healthcare professionals in CC awareness and prevention programmes including aids for medical equipment’s, HPV vaccines from the World Cancer Research Fund International, World Health Organization, GAVI Alliance and Belinda and Gates Foundation as well as from international and local intervention bodies (Jackson et al, 2014; Adewole et al, 2012). However, current data on CC reveals it is still prevalent in developing countries (International Agency for Research on Cancer (IARC, 2015).
The purpose of this dissertation therefore is to examine the factors responsible for the prevalence of cervical cancer in developing countries particularly Nigeria despite national and international humanitarian efforts to mitigate its prevalence. It appraises this by systematically investigating prior and existing national and local efforts on cervical cancer in Nigeria comparably with international interventions in order to recommend best policy options for effective intervention strategies to the Nigerian government.
1.3 RESEARCH QUESTIONS
i. What factors have increased the prevalence of cervical cancer in developing countries particularly Nigeria?
ii. Why has cervical cancer prevailed despite international humanitarian efforts and national programmes aimed at mitigating its prevalence?
iii. Has Nigerian government efforts been effective in mitigating cervical cancer prevalence in Nigeria?
iv. What options for effective policy recommendations can be used in mitigating cervical cancer in Nigeria?
1.4 RESEARCH AIMS AND OBJECTIVES
The aim of this research is to examine the cervical cancer mortality rates in developing countries with a particular focus despite international interventions introduced to mitigate its prevalence. The research aim will be achieved with the following objectives:
i. To examine factors responsible for cervical cancer prevalence and mortality rates in Nigeria.
ii. Document policy effort and reviews of the Nigerian government in fighting cervical cancer mortality in Nigeria.
iii. To proffer best strategies to mitigate the incidence and prevalence of cervical cancer to the Nigerian government.
1.5 RESEARCH DELIVERABLES
This research explores the epidemiology of cervical cancer in developing countries with particular focus on Nigeria to establish the factors responsible for the increase in disease burden despite national and international humanitarian intervention programmes introduced in recent years to mitigate the mortality rates. The study has policy relevance and predictive value as it will offer recommendations to the Nigerian government and by extension developing countries blighted by the disease burden to adopt effective options for best policy actions.
1.6 ORGANIZATION OF CHAPTERS
This dissertation is organized into six chapters for proper presentation of research outcomes. Chapter one is the introduction of the research, providing the background of the study, the research problem, research questions and deliverables. Chapter two critically examines literature on the cervical cancer epidemiology in developing countries, particularly in Nigeria, and appraises factors responsible for its prevalence. Chapter three provides a brief description of the research methodology adopted to be used in systematizing evidence of cervical cancer including methods of data collection. Chapter four documents the international, national and local interventions aimed at CC awareness, screening, prevention, treatment and control in Nigeria. It further examines the efficacy and the barriers of these efforts. Chapter five is the discussion of the findings while chapter six provides recommendations of the research, including the research limitations and conclusion.
CHAPTER TWO: LITERATURE REVIEW
2.0 INTRODUCTION
Cancer, generic for carcinoma (WHO, 2011) describes the malignant growth of cells and tissues (Center for Disease Control (CDC, 2009). The etiology of many cancers are still unidentified (Union for International Cancer, (UICC, 2012], however, the risk factors of cancer are known and either modifiable or non-modifiable (Gareth & Sullivan, 2010). Modifiable risk factors include tobacco consumption, physical dormancy, obesity, and ultraviolet [UV] radiation exposure and sexual intercourse or infectious exposure to the human papilloma virus [HPV], hepatitis viruses- hepatitis B virus [HBV] and hepatitis C virus [HCV] and Helicobacter pylori (WHO, 2002 cited in Nnodu et al, 2010). Non-modifiable sources include genetic heredity, ageing, immunosuppression and ethnic backgrounds (WHO, 2002).
According to the WHO as referenced in Youssefsi et al., (2016), an estimated 11 million cancer cases, 7 million cancer deaths and 25 million people worldwide are currently living with the burden of cancer. This is supported by (GHA, 2015) predictions that cancer prevalence will increase to about 27 million cases by 2050 and will account for an estimated 17 million cancer-related mortalities and 75 million living with the disease. The projections of GHA is analogous to emerging and re-emerging epidemiological studies including (Phillip et al., 2013; Onabanjo et al., 2016) affirming that cancer is increasingly reported as a major health issue in countries where they were hitherto considered rare. As indicative in figure 1.1, the estimated number of cancer related deaths are presented to confirm its mortality.
Figure 1.1: Estimated distribution of cervical cases and mortality (in thousands) per continent
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Source: IARC, (2014). Available online: http://globocan.iarc.fr, accessed on 28/7/2016.
In developing countries, cancer is one of the most dreaded non-communicable diseases (Nnodu et al., 2010). Developed countries mainly African countries account for 52% of cancer prevalence worldwide (Thun et al., 2015) and 34% of these cases linked to occurring in sub-Saharan Africa (Parkin, 2013). According to (Ikeregbe, Adeola, & Egba, 2014), 12% of all deaths in Africa are caused by cancer.
In Nigeria, poor screening, undiagnosed and unreported cases increase cancer burden (FMH, 2011 cited in Nnorom, 2016, WHO, 2006a, 2006b). In addition, the WHO, (2008) estimates that the prevalence of cancer in Nigerian men and women by 2020 will be 90.7/100,000 and 100.9/100,000; with a projected death rate of 72.7/100,000 and 76,000/100,000 respectively (WHO, 2008 cited in Adeola et al., 2012). However, there is emerging evidence that the occurrence of the disease is already reaching and may surpass this projection before the 2020 with the common forms of cancer reported among Nigerian men such as prostate, liver and lymphomas and cervical and breast cancer among women (Okwudili et al., 2014, Jackson et al., 2011).
Despite the prevalence of cancer, Nigeria has no national policy or comprehensive document on cancer control nor an organized national programme for cancer prevention (FMH, 2012 cited in Adeola et al, 2013). Intervention for the reduction of reproductive cancers is however, cited in the 2012 National Policy on Reproductive Health and Strategic Framework [NPRHSF] which contains measures to reduce HPV[1] awareness and prevalence (Nnorom, 2016). However, with an increasing aging population, low life expectancy for women (52.11 years in 2012 and 55 years in 2016 based on World Bank estimates); high rate of infections from modifiable risk factors as studies by (Thun, 2010, Onabanjo et al, 2013) affirms will pose a significant health challenge in the reduction of CC incidence and mortality rates. This is analogous to the report by (WHO, 2012) establishing the lack of cancer control programmes in Nigeria to increase risk of its prevalence especially among young persons.
2.1 CERVICAL CANCER PREVALENCE IN AFRICA
Akin to cancer, the prevalence of cervical cancer is a topical global health issue (Global Burden on Cervical Cancer [GLOBOCAN], 2012) as evidenced in the rising occurrences of cervical cancer mortality deaths in developing countries (Lee et al, 2015). It is the leading cause of 70% of cancer related deaths in women in developing countries according to the Union for International Cancer Control (UICC, 2009). CC globally is mainly caused by persistent infection of high risk HPVs especially serotypes 16 and 18 (Sloan, 2007). Prior and existing studies including (Schmauz et al., 1989, Parkin, 2013, Green et al., 2014) have identified many of the factors that encourage the oncogenic effect of the HPV virus in Africa: early start of sexual debut, male circumcision, multiple sexual partners, poverty and use of hormonal contraceptives. However, while all global incidences of cervical cancers are linked with HPV (WHO, 2012), majority of women with HPV do not always develop CC according to (IARC, 2014).
Figure 1.2 shows that cancer of the cervix uteri is the third most common cancer in the women after breast and colorectal cancers. More recent figures suggest an estimated 528,000 cases are diagnosed annually worldwide (GLOBOCAN, 2012) with squamous cell carcinoma and adenocarcinomas [SCCA] as the most prevalent cases of cervical cancer worldwide (Vaccine, 2008; IARC, 2007). Of this figure, 84% occur in less developing countries (an estimated 450,000) with over 288,000 mortality rates annually (IARC, 2014). However, while appropriate screening measures including Pap smear have been identified to prevent invasive cancer following HPV infection (Green et al, 2015), 85% of women in developing countries have not had a smear test or other related treatment options in their lifetime in contrast to developed countries (WHO, 2013).
Figure 1.2: Prevalence of new cancers in women worldwide (in thousands per year) (cervical cancer in red)
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Source: IARC, GLOBOCAN (2008). Available online: http://globocan.iarc.fr, accessed on 28/7/2016.
Sub-Saharan Africa has by far the highest burden and mortality associated with CC in the world followed by Asia (Ferlay et al., 2012). The prevalence ranges from 70/100,000 to- 100/100,000 people (IARC, 2014) and is exacerbated by HIV epidemic especially in East Africa[2] where AIDS-related cancer (known as the Kaposi Sarcoma) are growing (Parkin, 2013). Table 1.1 below is indicative of the prevalence of cervical cancer in global standardized age per 100,000.
Table 1.1: Global prevalence of cervical cancer per country in age-standardized rate (Nigeria in gray)
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Source: Ferlay J., et al (2012). Cancer Incidence and Mortality Worldwide: IARC, 2014. Available from: http://globocan.iarc.fr, accessed on 6/8/2016.
Like East Africa, high rates of CC have been reported in several African countries including Swaziland, Burundi and Guinea with South Africa having one of the lowest cancer related mortality in Africa (only one mortality case in every 29 reported incidences) (IARC, 2014). This is analogous to recent data from the WHO indicating that persons from sub-Saharan African countries have a 21% chance of surviving CC in contrast to 70% in Canada, and 58% in Thailand. As Chukwonga, (2002), affirms, CC is a death sentence for most rural women in sub-African due to poor health facilities and awareness.
However, despite the high incidence of CC prevalence and mortality, there is paucity of principal and ancillary prevention initiatives to mitigate the disease in Africa (Adeleke et al., 2014). As (Chaka, Thokozile & Matambanazo, 2016) notes, while early CC infection screening and Pap smear have reduced the frequency of CC in high and middle income countries, clinical evidence reveal its practice is low and often nonexistent in Africa. Lack of awareness, poor medical check-ups for women and poor health care facilities and services and low priority for women’s health by policy makers have been further identified as constituting as limitations to CC intervention and control in Africa (Ralinger et al, 2014).
2.2 CERVICAL CANCER PREVALENCE IN NIGERIA
In Nigeria, the estimated incidence rate of CC is 25 per 100,000 women with an estimated 8,200 new cases of cervical cancer diagnosed in the country each year (Federal Ministry of Health [FMH], 2013). In a 2007 cohort study, it was reported that 36.59 million women aged 15 years and above are at risk of developing CC in Nigeria (Mathers, et al. 2007). According to the WHO, there are currently over 9,900 cases diagnosed annually with about 8,420 deaths occurring annually with HPV 16, 31, 35 and 58 as most common in Nigeria (WHO, 2013) (see table 1.2 below for comparison of CC indicators). These prevalent HPVs altogether make for the leading cause of CC deaths in women aged 15-44 in Nigeria (Information Center on HPV and Cancer [ICOHPVC], 2016).
Table 1.2: Cervical cancer indicators in Nigeria compared to West Africa and the World
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Source: Ferlay J., et al (2012). Available from: http://globocan.iarc.fr, as cited in (Information Center on HPV and Cancer (ICOHPVC, 2016). Accessed on 2/8/2016.
A study by Finch et al (2012) identified the rate of and risks factors for CC infection in 1000 sexually active Nigerian women aged 15 and above, it determined that high risk HPV types outweighed (33.5%) far an above other risk causes with HPV 16, 31, 35 and 58 as the most occurring cause of infection. More so, HPV prevalence was observed to be higher in younger and middle aged women especially single women and illiterate women compared to aged women. This study corroborated the results of Thomas et al, (2004) study on CC prevalence in a rural area in Ibadan, Nigeria and further reinforces the study that HPV is the major cause of CC in Africa and further validated Africa’s ranking in the CC world standardized rate per thousands. This is parallel to a study by Bayo et al., (2012) which associated early marriages, bigamy, high parity and multiple sexual partners as factors for the preponderance of CC among young women. In contrast however, new evidence by the (IARC, 2015; ICOHPVC, 2016) reveal that the emergent trend in CC rate is increasing among the aged and the middle aged groups annually compared to the young.
2.3 FACTORS RESPONSIBLE FOR THE PREVALENCE OF CERVICAL CANCER IN DEVELOPING COUNTRIES, WITH AN EMPHASIS ON NIGERIA.
2.3.1 HUMAN PAPILLOMA VIRUS (HPV)
Epidemiological studies have identified HPV as the main cause of most CC cases in the world particularly in developing countries (Garett et al., 2010) with sexually transmitted genital HPVs, as the central etiologic factor in CC worldwide (Bosch et al., 1995 as referenced in Green et al., 2014). According to data on HPV variety and prevalence in the world by the WHO, (2012), HPV 16/18 is estimated to account for 70% of all CCs while HPV 31, 33, 35, 45, 52 and 58 accounting for about 20% of cervical cancers worldwide.
Developed countries have higher prevalence of HPV16/18 compared to developing countries (Bray, 2008), other varieties of HPV serotypes accounted for 75% of most occurrences reported in developing countries (Onigbade et al., 2014). This reinforces a cohort cervical cytological study by (Braimoh et al., 2013) establishing that of the 75% occurrence rate of CC, 41-67% are associated with high-grade squamous intraepithelial lesion (H-GSIL), 16–32% of low-grade squamous intraepithelial lesion (L-GSIL) and 6–27% with squamous cells of undetermined significance (SCUS). This further corroborates the study by the International Biological Study on Cervical Cancer [IBSCC], which reported HPV 16 genotype as the predominant type globally except Indonesia and Central and South America where HPV 18 and HPV 39 and 59 were common respectively. In West African countries (including Nigeria) a clustering of HPV 45 predominates (Bosch, F. in 1995 as cited in Clifford et al, 2006).
2.3.2 SOCIO-ECONOMIC FACTORS
CC is affiliated with poverty, and poor socio-economic status (WHO, 2008, Matlry, 2009). Nigeria, like most African countries, is beset with high incidence of poverty, poor rural infrastructure, unemployment and poor health care services (National Bureau of Statistics [NBS], 2012). It is estimated by the World Bank report that 80% of Nigerians live on less than a dollar a day (World Bank, 2013). Poverty indices in Nigeria as published by the NBS, (2012) estimate that states in northern Nigeria have the highest indices of absolute poverty (56.7%) in contrast with states in southern Nigeria (43.5%). This corroborates the study by the WHO, (2008) which states that 76% of Nigerians do not have access to affordable and quality health care services, with 68% of this figure in the rural areas thus, increasing the susceptibility and prevalence of CC.
However, while there exists a paucity of literature on the geographical distribution of HPV and CC in Nigeria based on poverty indices of the NBS, a recent study of three communities in north eastern Nigeria by Okereke et al., (2016) observed that within the rural population extensively infected with HPV, poor hygiene and health, high parity and socio-economic conditions were evident.
Furthermore, reports by the United Nations High Commission for Refugees [UNHCR], indicate that the incidence of Boko Haram insurgency in northern Nigeria have engendered conditions for the spread various communicable and non-communicable diseases due to forced migration and poverty (UNHCR, 2015). Likewise, the Internal Displacement Monitoring Center [IDMC] report there are over 6 million internally displaced persons in Nigeria (IDMC, 2016). Under these conditions including political instability, internal conflicts, natural disasters, famine and desertification, the transmission of HPV and by extension CC is very likely to continue in Africa and Nigeria (Nnorom et al., 2012, Palacio-Mejia et al., 2003).
2.3.3 POOR NUTRITIONAL STATUS/ HIV&AIDS
The 2015 Global Hunger Index (GHI) ranks Africa as the most hunger stricken continent (52.68%). Of the 104 countries covered in the index, 17 of the world’s most hungry nations are in Africa including Nigeria, Sudan, Liberia and Zimbabwe (GHI, 2015b). Similar indices from the Global Food Security Index (GFSI, 2015) ranks sub-Saharan Africa as the world’s most food insecure nations with an aggregate percentage of 67.1 percent. Several studies in literature have associated Africa’s food poverty crisis to the prevalence of diseases in the region (WHO, 2012). Sub-Saharan Africa harbours 67% of the world's population of people living with HIV and AIDS (Buga, 1998 referenced in Mkasa et al., 2011). Emerging and re-emerging studies including (Wright et al., 1994, Malloney, 2011) associate poor nutrition to immune susceptibility to several diseases including HPV.
Several studies including (McGareth et al., 2011) have associated HPV with HIV in Africa. HIV-positive women are more likely to have persistent HPV infections than HIV-negative women (Moodley, 2001). In a gynecological study in Lagos, Nigeria of 2,500 women who attended the family planning clinics, HIV-positive women were observed to have significantly higher prevalence of squamous intraepithelial lesion (SIL) compared to HIV-negative women (Adeleke et al., 2014). Similar studies in Kenya, by Gichangi et al (2003) reported an increase in H-GSIL in 530 women who visited family planning clinics. Also young women under the age of 35 who had invasive CC were observed to be 2.6 times more likely to be HIV positive than non-HIV women of similar age (Gichangi et al, 2003). Prior studies validated in existing studies show that women with HIV develop CC at an earlier age than women who are HIV-negative in Africa (Moodley et al, 2006 as cited in Casablanca et al., 2013).
2.3.4 POOR CERVICAL CANCER SCREENING
Evidence from several clinical studies including (Onyekwelu & Okoli, 2014, Fachii et al, 2009, Gichangi et al., 2003) indicates that very few women in sub-Saharan Africa have ever been screened for CC. In a study of two health institutions in Nigeria, none of the 500 women interviewed in the hospital reported to have been screened, while only 9% of the health care staff have had a Pap smear (Ogbuji, 2009). This is further supported by a research by Owolabi (2012) in a known Nigerian hospital that only 23% of the 545 female medical workers reported to have ever been screened for CC.
Several factors have been identified in literature for the prevalence of poor screening of CC in Nigeria including: no fear of immediate risk, absence of symptoms, general lack of interest and perception about gynaecological vaginal examination (Ayuba et al, 2006). Access to CC screening has remained a major challenge in sub-Saharan Africa (Anorlu et al., 2013) as Adesoji et al., (2012) observed most cervical screening services in Nigeria are located in tertiary hospitals and scarcely in primary health care centers which have the highest report of this disease. Furthermore, the cost of CC screening is usually higher in private health hospitals in contrast to public hospitals in Nigeria this is further exacerbated by limited, often inaccessible, government subsidies or health insurances to defray the cost of screening and treatment (Nnanna, 2012). As Adewole et al, (2010) further observed CC screening programmes in most rural areas in developing countries are mostly hampered by difficult terrain leading to the rural areas which makes access to the rural population difficult.
2.3.5 LACK OF AWARENESS AND PERCEPTION OF CERVICAL CANCER
Despite its prevalence and reputation as a ‘killer’ disease amongst women in developing countries, most national health policies in sub-Saharan Africa are yet to recognize CC as national health problem (WHO, 2012b). Over the years funding and policy priorities have been given to like malaria, tuberculosis, polio and HIV/AIDS (Anuri et al, 2004). However, while there are evidence of interventions from international humanitarian and donor agencies for CC research and treatment in Africa like the World Cancer Research Fund International [WCRFI], and Alliance for Cervical Cancer [ACC], only 5% of the global funds for cancer control is present in Africa (Jones, 1999, as referenced in Thun, 2010).
On perception of CC in Nigeria, a clinical study by Ajayi et al., (2008) in Lagos, Nigeria revealed of 139 patients surveyed in a popular hospital, 81.7% claimed they were unaware of CC while 15% claimed CC was asymptomatic of irregular menstrual cycle and urinary tract infection [UTI]. Similar studies in Kenya and Tanzania also reported very poor knowledge of the disease in patients. (Gichangi et al., 2003 & Kidanto et al., 2002). However, poor knowledge of CC observed in several studies is not only found in patients but also among health care workers who worked in secondary and tertiary care (Sarome & Wilfred, 2009). In a study of primary health care services in local government areas of rural communities in southern Nigeria by (Gbebitiou, 2014), it was observed that diagnosis and referral of CC from primary health care centers to tertiary health institutions typically took an average of 9-12 months mostly when the infection has advanced into late stages due to poor knowledge of the presentation of the disease.
On the impact of literacy level and CC awareness, a study on the knowledge of CC and HPV in three universities in northern Nigeria by Ilyasu et al, (2010) revealed that of the 375 female students included in the survey only 35.5% of the females were aware of HPV, HPV vaccination and cervix uteri. Similar studies in two universities in Ghana by (Ayoeri et al, 2010) of 500 students surveyed on why they did not attend CC screening revealed that cost (23.2%), not knowing where to go (24.3%), and belief that everyone would think they were sexually active (24.6%) were major inhibiting factors.
2.3.6 EFFICACY AND COST OF HPV VACCINE
The HPV vaccine has efficacy in the possible reduction of risk of CC in women (Carl, 2014) especially in women from sub-Saharan Africa who have reduced access to Pap smear and CC screening (Adeola et al., 2012). However, while the HPV 16 and 18 serotypes have been potent in reducing the incidence of CC in developed countries, there is evidence that the potency of these vaccines may be limited in eradicating HPV prevalence in sub-Saharan Africa and by extension Nigeria due to the prevalence of different HPV serotypes (Braimoh et al., 2014). In Nigeria, HPV 16, 31, 35 and 58 are most common. However, there are currently no vaccines for the reduction of CC produced in Africa or Nigeria.
More so, the cost of the HPV vaccine constitutes a significant concern for CC mitigation strategies in developing countries. As Gbibade, (2012) notes, the HPV vaccine is currently unaffordable for most Nigerian women and the current price mechanism by most pharmaceutical companies exacerbate the situation. Despite the cost of the vaccine, the direct visual inspection [DVI] and Visual Inspection using Lugol’s Iodine [VILI] have been adopted as an alternative to colposcopy in population based screening in sub-Saharan Africa, as subsidized by international donor agencies (Chirenje et al., 2001 referenced in Braimoh et al, 2014). Studies have shown the sensitivity of VILI to be similar to Pap smear though with lower specificity of 85% (Urasa & Darj 2011). While international donor agencies have increasingly intervened in the introduction, affordability and accessibility of these vaccines in sub-Saharan Africa including Nigeria (ACC, 2014), certain prevalent religious beliefs and cultural practices especially in northern Nigeria affect its acceptance (FMH, 2012).
However, it is not yet clear whether the advent of the HPV vaccine would impede the need for secondary prevention of CC using Pap smear and other screening processes. As (Babatunde et al, 2013) predicts, the introduction of the HPV vaccine may undermine these secondary efforts.
2.3.7 TREATMENT OF CERVICAL CANCER
Cervical cancer treatment is usually cost intensive and requires the use of high end health technologies which are in short supply in Nigeria in contrast to developed countries like the United Kingdom (Biodun, 2014). While several treatment options of CC have been identified in medical literatures including: conisation of the cervix, hysterectomy, lymphadenectomy, pelvic exenteration, chemotherapy, and radiotherapy (Urasa & Darj, 2011), it is relative based on the available resources in the health sector of each country.
Nigeria’s current poor health facilities and services has been observed to affect its capacity to use this high end health infrastructure in the treatment of CC. As Akunyili, (2008) observed, there are few cytopathologists, and cytotechnicians in Nigeria with requisite training in colposcopy especially in rural communities where the prevalence of CC is high. This is worsened by the shortage of histopathologists and scarcity of trained hands in colposcopy and other areas of cervical cancer treatment including cytoscreening (Bistros, 2011). Currently, Nigeria has less than 150 oncologists, approximately 200 pathologists and six radiotherapy centres (with seven functional radiotherapy machines), to serve it’s over 170 million population (based on the 2012 estimation). The availability of the radiotherapy machines in Nigeria compared to other parts of West Africa in indicated in table 1.3 below.
Table 1.3: Table showing availability of radiotherapy machines in West Africa including Nigeria (Nigeria in yellow)
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Source: Akinwumi, (2013).
2.3.8 MALE CIRCUMCISION
Several studies have shown HPV to be higher in uncircumcised men than in circumcised men (WHO, 2006a, and 2006b). Male circumcision is conditioned by certain religious and cultural beliefs (Vanmussadrei, 2014). It is prevalent in developing countries including the Western Asia, Northern and Western Africa. Male circumcision was strongly linked with lower cervical cancer rates and less HIV and STI cases, independent of culture and religion in several studies including (Adeola et al., 2012). In contrast, studies revealing the spread of CC exists despite male circumcision (Chaka, Thokozile & Matambanazo, 2016). In a cohort study by (Auvert et al., 2009), on the link between male circumcision and HPV prevalence, it was determined that marital status, ethnicity, sexual behaviour and HIV status lowered the risk of CC in men which could be transmitted to women through intercourse. Nigeria has the second highest people living with HIV in Africa after South Africa, with an estimated 3.5million reported to be living with the disease according to the United Nations Programme on HIV/AIDS (UNAIDS, 2014).
2.4 SUMMARY OF CHAPTER
This chapter reviewed literatures based on prior and existing studies on the nature, trend and prevalence of CC in developing countries with particular focus on Nigeria. The appraisal of literature was organized in connection with the research objectives which seeks to investigate the factors that engender the prevalence of CC in developing countries (emphasis on Nigeria) despite national and international humanitarian intervention strategies. Based on systematic exploration of published secondary data sources it was identified that perception of HPV prevalence, poor CC screening, socio-economic conditions, cost of HPV vaccine, nutrition and HIV/AIDS including HPV serotypes are the main contributing factors for the prevalence of CC in Nigeria. However, it is observed that despite the preponderance of CC cases in Nigeria, national efforts in mitigating its risks and occurrences are still low. The subsequent chapter after the methodology will identify these interventions (international, national and local) and appraise its efficacy and the barriers militating its implementation.
CHAPTER THREE: RESEARCH METHODS
3.0 INTRODUCTION
This study uses a systematic approach with the adoption of systematic review tools to examine literatures on the prevalence of cervical cancer (CC) in Nigeria despite national and international mitigation policies and strategies. It seeks to achieve this by identifying appropriate types of literature on the incidence of cervical cancer including the policy and strategy at the local, national, regional and international level.
Since the study examines the factors responsible for the prevalence of cervical cancer in Nigeria using several studies carried out locally in Nigeria and from databases to gather evidences from literature, a systematic approach was considered appropriate due to its benefit of eliminating biases and improving reliability and conclusion of the study (Caldwell, 2014).
3.1 Search Strategy
The study will use the University of De Montfort access to databases to rigorously, and electronically search three data bases including PubMed, Science direct, and Google scholar as indicated in table 2.1 below. The electronic search will use varieties of search terms like ‘cancer’, ‘cervical cancer’, ‘cervical cancer funding’, ‘humanitarian intervention’, ‘cancer prevention’, cervical ‘cancer prevalence’, ‘cervical cancer control’, ‘cancer cervical national programmes’ to access quality articles in the review with particular focus on Nigeria.
Three categories of search strings were created (location, intervention, and control) using the Boolean operators of ‘AND’, ‘OR’ and ‘NOT’ within and between categories. The search strategy will use a free text and Health Subject Heading (HSH) and Medical Subject Heading (MeSH). Using these tools, keywords enumerated are entered into search boxes and the databases provide the abstract and titles of related studies (Chang et al, 2006). Free text word from the aforementioned databases would help identify under respective HSH and MeSH classifications.
Documented qualitative literatures from the websites of the following secondary sources the World Cancer Research Fund International (WCRFI), Center for Disease Control (CDC), World Health Organization (WHO), Global Initiative against HPV and Cervical Cancer (GIAHCC), United Nations International Union against Cancer (UICC) and Cervical Cancer Action (CCA), including Federal Ministry of Health, Nigeria and its allied agencies would be included in the review of literatures.
The systematic approach includes gray literatures to ensure better retrieval of relevant literature, as most policies and programmes on CC intervention are found in gray literatures than academic literatures. The electronic search was carried out following three steps: first, titles received screening and abstracts of successfully selected titles were also screened. Second, full articles were reviewed for those whose full texts were available. Third, when decision on inclusion could not be determined from abstract and title, full texts were obtained.
Table 2.1: Selected Databases for the literature search
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Source: Adapted from Saks and Allsop, (2008).
3.2 Inclusion criteria
Interventions not written in English, and not focused on CC prevalence, control and strategies in Nigeria would be excluded in the search. Also, interventions beyond 2005 will also not be included in the literature search. The rationale for the selection of this time frame was for the identification of new data. Recent data may be more reliable (Carson et al., 1994; Dauphinee et al., 2005) because it is expected that recent data contain recent information and also time trend has the ability to change the prevalence of cervical cancer and the intervention strategies (Di Mario et al., 2007). Interventions on the prevalence of CC in Nigeria without quality data on the associated strategies were also not selected. Duplicates will be removed to avoid bias and improve reporting.
Taking into account the reporting quality and bias of each intervention, different interventions from international, national and local humanitarian agencies done in Nigeria would be selected for inclusion. Upon final selection of the studies, CASP tool (critical appraisal skills programme) will be used for assessing quality and appropriateness of intervention. Studies that were considered worthy of inclusion were those that met the following criteria: 1) information of intervention were available; 2) Type of intervention documented; 3) at least two intervention strategies for CC was assessed; 4) those studies published from 2005 until date; and 5) those where some data for funding CC interventions were available.
3.3 Data Analysis
Population, Intervention, Comparators and Control (PICO) criteria will be used to help breakdown the intervention into four parts. The use of the PICO criteria (as indicated in table 2.2) will help to direct the literature search by enabling an extensive search and presentation of sources (Bell, 2010).
Table 2.2: PICO criteria for literature data analysis
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Source: Bell, (2010)
3.4 Ethical consideration
The study is predicated extensively on existing secondary documented qualitative sources in literature and therefore no ethical concerns were implicated in this study. All sources cited have been properly documented and acknowledged.
CHAPTER FOUR: CERVICAL CANCER INTERVENTIONS IN NIGERIA
4.0 INTRODUCTION
Cervical cancer (CC) intervention refers to efforts, policies, programmes and financial aids aimed at mitigating the prevalence, and mortality of CC including facilitating options for treatment, prevention and control (Frederick et al, 2014). In Nigeria, there are several documented prior and ongoing interventions which focus on advocacy, screening, prevention, treatment and control of CC (Adeola et al, 2012). As Adekola et al (2011) notes, these interventions come from external agencies, including several non-governmental agencies and philanthropic organizations notably the Belinda and Gates Foundation (Daily Newspaper, 2016) as there is currently no vaccine treatment for CC manufactured in Nigeria, nor is there any national policy or programme to that effect.
In the absence of a documented national CC policy by the Nigerian government, preventive measures against HPV has been codified in its National Policy on Reproductive Health and Strategic Framework [NPRHSF] (FMH, 2014). However, the backbone of most CC programmes in rural areas are the local and community based interventions predominantly done in partnership with international donors (Ojo, 2012). Nevertheless, despite these intervention measures, CC still persists. This chapter appraises the interventions against CC in Nigeria and examines its impacts and its barriers in order for identify gaps in intervention and best options for recommendations to the Nigerian government in mitigating CC prevalence.
4.1 INTERNATIONAL INTERVENTIONS ON CC IN NIGERIA
Several international interventions have been identified against CC in Nigeria (WHO, 2012, GHIAC, 2011, IARC, 2014). International intervention refers to the assistance in aids, programmes, prevention, treatment and advocacy to increase awareness of CC in collaboration with local, regional, governmental and non-governmental agencies (WHO, 2013). Table 3.1 below shows the list of international sponsor agencies, the type of interventions against CC in Nigeria and its current status.
However, while these interventions have been ongoing in some states in Nigeria through the collaboration of partner agencies, implementation is weak. For example, most international donor agencies use HPV 16 and 18 vaccine in prevention of HPVs while vaccines for high risk HPV serotypes prevalent in Nigeria are still not introduced (Durosimi et al, 2012). This said, there is evidence that HPV 16 and 18 are found in most young women in Nigeria so the programmes may have some preventive efficacy (Adewole, 2014). More so, while interventions in cytological screening have been introduced in reproductive health centers in Lagos, Enugu, Kano and Ibadan, by the WHO, IARC and UICC, it has been observed to be difficult to sustain due to lack of high technologically equipped laboratories and trained cytotechnologists to facilitate and sustain colposcopy and cytology interventions (Gray, 2012; Adeosun et al, 2011). Furthermore, most of the interventions have been urban center-based with little coverage for rural areas which have the highest incidence of risk of CC (Adeola, 2012).
Table 3.1 International Interventions on Cervical Cancer in Nigeria
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Source: Author’s adaptation
Table 3.1.1: Vaccine, Screening and Treatment based interventions
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Source: Author’s adaptation
There is evidence that this programmes have been sustained in different places in Nigeria especially in Lagos and Ibadan with focus on providing screening and treatment services and other opportunistic screening programmes in different parts of these states using mobile cytological vans and medical caravans (Adewole, 2012). However, there is limited information on the amount of funds allocated used by international agencies on these programmes and other associated costs for rendering these services. In terms of resources, these agencies provide cytological screening equipment’s including for DVI (WHO, 2012). Sensitization materials are also provided, including training for facilitators and counsellors. The interventions have also provided international volunteer aid and healthcare workers to work with physician in local hospitals in strengthening prevention strategies and assisting in healthcare workers shortages (Nnanna et al, 2012).
In terms of impact, there is evidence that more women have been vaccinated with the HPV 16 and 18 vaccine especially young women within 15-34 years. Published reports also indicate that screening has increased by 35% in Lagos and Ibadan and with state governments involved in partnership with these agencies in facilitating CC programmes (FMH, 2014, ACCN, 2012).
4.2 NATIONAL INTERVENTIONS ON CC IN NIGERIA
National interventions refers to the policies, programmes by governments aimed at coordinate efforts for the awareness, prevention and control of cancers (WHO, 2012). According to the Federal Ministry of Health, Nigeria (FMH, 2014), CC control Nigeria is impossible without the prevention of HPV and other sexually transmitted infections (STI) which increases the exposure and risk of CC especially in young women. While there is no national policy or organized efforts on CC by the Nigerian government in Nigeria, Table 3.2 shows some of the other national efforts at mitigating CC.
The NCCP programme on CC in Nigeria commenced in 2010 through the Federal Ministry of Health (FMH) in designated hospitals throughout Nigeria, it focused providing one screening for women between 35-40 years and a three screening programmes for women aged 15-34 years. However, there is no CC programme for women above 40 years in Nigeria (FMH, 2012).
Table 3.2 National interventions on CC in Nigeria
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Source: Author’s adaptation
The NCCP is projected to increase the awareness and facilitate treatment of CC by potentially increasing its risk perception among women by 25-30% before 2020 (FMH, 2014). There are also efforts by the Nigerian government to include CC in the National Health Insurance [NHIS] policy and make provision for free screening for CC using VIA and VILI methods (Daily Sun, 8/9/2015). However, most of these efforts are still lacking implementation. However, while these programmes have been identified in several literatures including (FMH, 2014) there is limited information on the funding and the disbursement of these efforts by the Nigerian government for the prevention of CC. Also there is no information on its sustainability measures due to the absence of a national policy to strengthen actions against CC.
4.3 LOCAL INTERVENTIONS ON CC IN NIGERIA
Local intervention includes efforts by community based groups, non-governmental organizations and philanthropy based associations in Nigeria aimed at preventing, controlling and treating CC. The local intervention were imperative as they reached population that were not easily assessed by international and national CC efforts. Available data revealed that MWAN screened 815 women for Pap smear from 1991 to 2000, Rotary club of Nigeria facilitated 65 workshops and facilitated the screening of 862 women in Lagos, Ibadan, Enugu and Kano. SCCAN trained 70 participants in the south-West zone of Lagos, Oyo, Ondo, and Ogun states including 50 doctors on VIA, Pap smear, and colposcopy treatment services. A number of women were also screened for CC (no figures provided by SCCAN) (Abimbola, 2008). (See table 1.3 below for sponsor local agency, the intervention programme, and current status).
Table 3.3 Local interventions on CC prevalence in Nigeria
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Also, the Elizabeth Garett Anderson Institute in partnership with the University of Lagos trained/sensitized an average of 1,500 healthcare worker per week including 3,200 women educated on CC as at 2008. However, there is limited information on the funding of most of these interventions and its sustainability planning and resourcing.
4.4 EFFICACY OF CC INTERVENTIONS IN NIGERIA
Efficacy refers to the degree of effectiveness of interventions used in CC control. It is defined as the capacity to produce desired results and to determine if interventions have achieved what it intended or set out to achieve (Adeola, 2012). The efficacy of the various interventions are summarized as sustaining collaborative efforts, provide equipment’s, CC screening centers, and provision of vaccines.
4.4.1 Sustained collaborative efforts
Disease prevention and control necessitates social change and the involvement of beneficiaries of whom the change is intended especially high risk groups, government agencies, and medical personnel (McGreen, 2011). One of the factors that have aided the efficacy of most interventions in Nigeria as noted by the FMH, (2014) is the sustained working collaborations of local and international partners including foreign voluntary health workers for the possible reduction of CC prevalence in Nigeria. Due to these interventions, awareness has increased through the mechanism of many hospital based dissemination and role utilization in Nigeria (Yakmut, 2013). Furthermore, these interventions have been introduced alongside with national programme for STIs and reproductive health which have increased awareness of safe sex and contributed to the reduction of the transmission of HPV through sexual intercourse (FMH, 2014).
4.4.2 Provision of CC equipment’s
More so, interventions by partner agencies in the health department of hospitals in Nigeria have led to the provision of cytological machines needed for precancerous cells detection including facilitating pilot studies and opportunistic screening. Recent data by the FMH shows that there has been a 12.5% increase in the number of women volunteering for screening and treatment (FMH, 2014)
On cervical screening, interventions have led to the use of cheaper alternatives like Visual Inspection with Acetic acid (VIA) or Visual Inspection with Lugol’s Iodine (VILI) and HPV DNA tests compared to the cytological evaluations (mostly expensive and requires high end technology) for screening at community levels with high number of women reportedly covered (WHO, 2012). According to data by the FMH, an average of 8,200 women could be screened yearly with all necessary equipment and support in place (FMH, 2014). However, its high cost of deployment regardless, cytological screening programmes are more effective in detecting and treating precancerous lesions for reducing CC prevalence (GHIAC, 2013).
4.4.3 CC screening centers
Interventions from aid agencies have also facilitated the introduction of cytology screening centers in Nigeria currently at two teaching hospitals: University of Ibadan (in southern Nigeria) and Ahmadu Bello Teaching Hospital (in northern Nigeria). It is estimated that these centers have the capacity to annually screen 8000 women of reproductive age that are affected by the burden of CC disease (Al-Hassan, 2012). Interventions have also facilitated the introduction of cyrotherapy centers in Oyo (Ibadan) and Lagos (Sagamu) states including a Loop Electrosurgical Excision (LEEP) center in National Hospital Abuja (Nnanna et al, 2014).
4.4.4 Provision of vaccines
The introduction of HPV 16/18 vaccines in prevention strategies by international donor agencies have been effective in reducing the prevalence of these specific HPV serotypes in Nigeria. These vaccines manufactured by foreign pharmaceutical companies such as Glaxo Smith Kline’s GARDASIL and Merck and Co’s Cervarix as Adewole et al, (2012) notes, have been potent against CC and have been made affordable by tier pricing and subsidies by international donor groups.
4.5 BARRIERS TO CC INTERVENTION IN NIGERIA
Despite the mortality rate associated with CC, and the extant interventions towards its awareness, prevention, treatment and control, several factors have been identified in literature to affect its efficacy (Egba et al, 2014; Follen et al, 2010; Adewole, 2009; Abimbola, 2008).
4.5.1 Cultural, Attitudinal and Religious [CAR] barriers
Certain cultural and religious beliefs have been identified by Awosika, (2013) to affect screening programmes, these include perception in Muslim women of the screening process being invasive; that screening may affect fertility in women of child bearing age; and the view that diseases are supernatural and nothing can be done to prevent them. This perception finds credence as (Yakmut, 2013) notes with the Pfizer 1996 Trovafloxacin drug trial tragedy in Kano, northern Nigeria which killed and permanently disfigured individuals administered the drug[3]. As (Nnanna et al, 2013) notes that the common perception of CC as a death sentence incurable by western medicine affects intervention as it increases the resort to traditional or spiritual options until the CC becomes advanced.
Likewise, as Adeola, (2012) notes women’s perception of CC screening processes due to the gynecological examination may engender stigma especially when it concerns reproductive health of women as a result of its negative association with promiscuity.
4.5.2 Prioritization of CC
Nigeria currently has no national programme or community based program for prevention, treatment and control of CC prevalence though a National Consultative Committee [NCC] has been mandated to produce one since 2008 (FMH, 2012). As Abimbola (2012) notes, CC is still considered a low priority diseases compared to HIV/AIDS, malaria and polio and cancer prevention was only included in the national budget in 2009 despite its mortality rates and prevalence. Furthermore, primary prevention using health promotion to reduce risk factors for CC like safe sex using condoms and monogamous sexual relationship with an uninfected partner are not deliberate programmes in Nigeria. Instead they are contained within HIV and AIDS control programmes which have no focus on HPV control in the NPRHSF (Follen et al, 2010).
More so, there are concerns that vaccination programmes are not widely utilized in Nigeria. The country is currently rated 45% by the WHO in terms of distribution and coverage of national vaccine for DTP (Diphtheria, Tetanus and Pertussis) and other vaccines against preventable diseases in early childhood (WHO, 2012). This data as Nnorom et al (2013) notes, will pose a threat to national HPV vaccine program as the lacuna of a national health programme and poor performance in meeting its national vaccine expectations may negatively impact on HPV prevention.
4.5.3 Screening and treatment
As Service Compact (SERVICOM, 2012) notes, the waiting line for clinical examination in most tertiary care institutions in Nigeria coupled with the shortage of requisite medical equipment for diagnostic treatment of persons seeking medical attention has exacerbated the treatment and screening of CC. The lack of surgical facilities, skilled personnel with expertise in radiotherapy services for treatment of invasive CC has also been a major challenge for sustaining intervention efforts in Nigeria (Adeosun et al, 2015). As Martens-Gray, (2012) observed, treatment using hysterectomy and cone biopsy are mainly used in Nigerian hospitals for pre-cancerous lesions due to lack of equipment for milder alternatives like laser vaporization and loop electrosurgical excision (LEEP) used in developed countries.
As Nnanna et al, (2014) notes, screening is opportunistic in most tertiary health care centers due to limited screening facilities which makes gynecological examinations more of evaluation of women presenting symptoms other than proper examination of the CC. As a result physicians mostly use observation of LGSIL with follow up on HGSIL or with simple total hysterectomy and occasionally diathermy fulguration (Adewole, 2012) (see table 3.4 below). However, the use of these procedures have been associated with screening ambivalence in women especially those of child bearing age particularly wary of its effects.
Table 3.4 Treatment approach to cervical cancer investigation in Nigeria
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Source: Adewole, (2012)
4.5.4 Socio-economic issues
Socio-economic conditions (due to cost of travelling to urban centers for screening tests), lack of health insurance (as CC is not included in the NHIS scheme) and low literacy (understanding the need to get screened) have been identified by Egba et al (2014) to reduce CC interventions. This is reinforced by Obogwu (2008), lack of awareness, poor health seeking behaviour, poverty and lack of confidence in Nigeria’s public health system as affecting screening programmes in Nigeria. More so, as Adewole et al (2009) notes, the gender of health care also affect screening perceptions especially male physicians attending to females.
4.5.5 Healthcare worker shortages
Management and care of CC requires medical expertise and services of gynecologists, radiation oncologists, medical oncologists, pathologists, medical physicists, technicians, nurses and counsellors (Follen et al, 2010). However, these specialists are mostly lacking in Nigeria which negatively impacts intervention efforts. Table 3.5 shows the number of medical manpower in Nigeria available with expertise for CC care.
Table 3.5 Number of healthcare workers related to CC care in Nigeria as at 2010
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Source: Abimbola, (2012)
As Okolo, (2010) observed, there are less than 50 doctors in Nigeria [estimated population of 170 million] with specialization in surgical expertise in cancer management and very few radiotherapists, oncologists and nurses skilled in palliative care in the management of cancer.
4.6 SUMMARY OF CHAPTER
This chapter has carefully examined the international, national and local interventions in reducing the prevalence of CC in Nigeria through awareness creation, preventive vaccines, screening through simple and high end medical equipment’s including treatment services and options for control. Overall, it was observed that there are several international interventions currently ongoing, as well as local interventions as well. However, national interventions are constrained due to lack of national policy for CC control. The subsequent chapter focuses on the gaps of these interventions, what could be done about it and recommendations on how should be done.
CHAPTER FIVE: DISCUSSION OF FINDINGS
5.0 Introduction
The critical investigation into the barriers affecting CC prevention, treatment and control programmes throws up a number of significant findings that would help shape future policies and efforts. These findings would benefit local, national and international humanitarian aid and volunteer agencies in mitigating the prevalence of CC and would proffer best options for the Nigerian government in developing best options for effective strategies. The focus of this chapter is thus to identify the gaps in the various interventions on CC that would guide recommendations for best options for future strategy. These findings are identified under the following sub-headings: Focus of programmes, sustainability, coverage, engaging with policy makers, screening and vaccination programmes, and training needs.
5.1 Focus of programmes
Review of several literatures on CC and intervention, reveals the focus of these international and local interventions to be mainly on; awareness, screening, prevention, treatment and control. As Nnanna et al (2012) notes most of these agencies may inadvertently by using a ‘one-size fits all model’ without consideration for the varied nature of the environment they seek to provide assistance to may hamper the effectiveness of these interventions. Furthermore, an examination into the scope of the interventions by international aid agencies by the researcher revealed a cluster and duplication of roles in CC strategies which increases the propensity for intervention overlapping. This may pose significant constraint in tracking the number of individuals that have been successfully screened or vaccinated through these programmes especially when the poor record keeping of CC registries in most primary and tertiary health centers are considered (Adeola, 2008).
5.2 Sustainability planning, resourcing and cost of intervention efforts
Sustainability refers to the continuity of programmes after startup intervention by international agencies. Findings from literature reveal a paucity of information on the funding, efficacy, impact, and duration of these programmes. Specifically, information on how many aid workers are required for each intervention programmes, lesson learned document, and challenges faced, including the sources of these funds and the guarantee for their continuous flow are scarce. Also, most of the screening services are opportunistic and often not continuous, while some are well established with centers located in urban areas. Information on the number of cases treated, vaccines administered in the last decade and training needs assessment are also hard to assess.
There is need to for sustainable funding for CC programmes especially for screening exercises – while international donor agencies have provided the set-up funds for most interventions (WHO, 2012), it is the continuity by the local, state and national government that is significantly lacking (Nnanna et al, 2012). Future interventions should also focus on employing health economists to provide estimates for sustainability of these programmes and how to raise marketing campaigns to boost local participation and involvement especially with local government councils as well as lobbying the government to set aside special intervention funds for financing CC programmes in its budget year annually.
5.3 Coverage – rural and urban reach
In terms of coverage, findings from literature and intervention programmes, reveal a preponderance of CC screening and location offices siting in urban areas save for local interventions which are also mostly tertiary hospital based. However, most of those affected by the burden of CC live in rural communities and have only access to primary health care facilities which are poorly funded. This is in affirmation to the study by the WHO (2012) which referred to CC as a disease of poverty affecting women of low social economic status and corroborates with Ndikom (2013) argument that poor coverage of rural areas by intervention programmes affect the prevention strategies of CC, especially when the economic costs of travelling to urban areas for screening is considered. Future programmes should consider increasing the number of mobile cytological screening vans and screening programmes to rural areas to increase assess while improving on ongoing urban based interventions.
5.4 Engaging with policy makers
One of the findings from the assessment of intervention especially from the international humanitarian agencies is the lack of documentation on efforts geared towards winning the hearts and minds of policy makers in Nigeria to adopt the intervention efforts on CC. Furthermore, building up on political will and support for funding would also be imperative for future considerations of interventions, this will include using the media and other civil society groups to massively mobilize local awareness and improve possibility of funding. As Killam (2009) notes, demonstration projects such as those run by international donor agencies are a good way to show political leaders the efficacy of screening programs.
Future programmes should focus on engaging with policy makers including using such platform as the Millennium Development Goals [MDGs] 4 and 5 which focuses on the reduction of child mortality and improvement in maternal health to mobilize support.
5.5 Screening and vaccination programmes
CC is both preventable and curable if detected early. Early detection through effective screening and an increase in awareness on CC can significantly reduce the burden of the disease from its current levels (Follen et al, 2012). This would be strengthened by improving CC registers especially in primary health care centers. Records and documentation of those being screened should be kept for tracking who frequency and number of participants. This would also help to monitor whether it was simply the same people getting screened, or if the programme was succeeding in reaching new women.
Also, increasing service utilization of primary and tertiary health care workers on reporting, educating and referral of women in the local communities for screening, would help future programmes in reducing the burden of the disease. More so, while screening interventions may identify the disease, the problem of government funding to facilitate treatment processes through insurance and funding will leave so many women in limbo. In terms of treatment, future programmes should options for assessing better treatment services for CC. Milder screening option like LEEP should be introduced to reduce the apprehension of women for towards treatment due to current methods used requiring surgical incisions.
Future intervention efforts should focus on the introduction of vaccine for high risk HPVs to support existing HPV 16/18s vaccine programmes that are ongoing. However, considering the fact that other serotypes are more prevalent it is imperative that intervention efforts should be directed at addressing this gap in the vaccine programme.
5.6 Training needs
Training of health professionals to take and read smear tests would be critical in the reduction of its prevalence of CC as findings reveal that shortage in healthcare workers as a major barrier to efficacy of efforts (Adewole et al, 2010; WHO, 2012). Long term strategies for CC control should focus on addressing the short fall in healthcare workforce by strengthening expertise in core area needs as cytology, histopathologists, radiographers, and medical laboratory technicians that are in low supply. This would also include establishing a special cancer institute to encourage research into CC on how to reduce its prevalence. However, issues concerning brain drain should be addressed by ensuring these individuals trained in different capacities return to develop CC care and management to prevent a further shortage of health care personnel.
This effort can be complemented with establishing a National Cancer Institute with a primary mandate of promoting research and training in CC including ensuring the continuous training of healthcare workers on cancer detection, diagnosis, palliative care and patient management. This can be better facilitated with government making CC treatment as part of the NHIS, to significantly reduce the burden of cost associated with assessing treatment and vaccine for this disease. Also, considering the challenges encountered with screening, future interventions should focus what kind of methods would be most suitable and sustainable considering the technological deficiencies peculiar with Nigeria.
5.7 Problem of collaboration
CC treatment requires a bastion of medical professional services including different actors and stakeholders in facilitating treatment services. While FMH, (2014) have identified collaboration as contributing to the efficacy of current intervention programmes, role differentiation and description may hamper these collaborative processes by increasing friction and overlay of functions. Future programmes should consider where different actors like health care professionals, voluntary sector and indigenous local groups can work for greater harmonization of efforts.
5.8 SUMMARY OF CHAPTER
This chapter has carefully examined the findings from the studies on cervical cancer prevalence and the efficacy of the interventions to reduce its impact. Based on the strengths of this findings, recommendation for best policy options would be made to the Nigerian government for CC control strategies in the following chapter.
CHAPTER SIX: RECOMMENDATIONS AND CONCLUSION
6.1 Recommendations
The various factors that contribute to CC prevalence and mortality rates cannot be handled by government alone. There is need for continued synergistic collaboration to overcoming the burden on those affected by the disease and in protecting future generation of women in Nigeria from CC. Based on the above findings, the recommendations are made around the following: need to develop a national policy on CC, vaccination programmes, future screening interventions, awareness campaign, and addressing the shortfall of medical equipment and personnel for CC care. These would grouped under short and long term goals for different actors.
6.1.1 For the Nigerian government
Short term plans should include the immediate introduction of a national policy on CC. This would facilitate and coordinate most ongoing and future programmes aimed at the reduction of the disease. This should also include provision of subsidies by providing funds annually from the national budget to significantly reduce the high cost of the vaccines which is a source of constraint on preventive efforts. This should also include making screening and treatment part of the NHIS plan and integrating HPV prevention/screening/vaccination with ongoing national programmes for reproductive and sexual health programmes.
Long term planning would also include overhauling the health sector and the declaration of a state of emergency for the provision of critical health infrastructure and equipment. This should also include a continuous plan to keep on increasing the number of qualified specialist on CC care and management on a yearly basis for the next ten years. In the short term, however, government should seek to provide radiotherapy machines based on less sophisticated technology like the Cobalt 60 based teletherapy and brachytherapy equipment’s to facilitate the treatment of those already diagnosed with CC.
More so, long term planning would entail making organized screening and prevention programmes as part of routine care in Nigeria. This can be facilitated by introducing HPV national vaccine programmes to girls before onset of sexual activity, to potentially reduce the incidence of the disease.
6.1.2 For Health care professionals
Immediate goals in the health sector by the Federal Ministry of Health and its allied agencies would be to embark on a sensitization project for health care professionals. Short and long term goals should entail continuous training and re-training of health care professionals in the sector on CC diagnosis and screening.
Based on findings from literatures, it is known that screening programmes in Nigeria are can be influenced by cultural beliefs, the social status of women, the health care system, and women's understanding of the screening process. There is therefore need for sensitization of health workers on role utilization for the creation of CC awareness and the importance of screening among women visiting the hospitals. FMH should facilitate the production, publication and distribution of CC awareness materials across all the hospitals in Nigeria including for sponsoring adverts for CC in social media like Facebook, Twitter and Whatsapp broadcast messages.
More so, early onset of sexual debut has been found in literature to increase the propensity for transmission of HPV, there is therefore need for health professionals to promote the use of condoms and sex education among teenage girls thereby increasing their awareness of the disease.
High parity is associated with increased incidence of HPV infection leading to increased cases of cervical cancer. Most women in the region have high number of children resulting in worsening poverty and predisposition to the disease. Education on the need for reduced family size through the adoption of effective family planning methods can help in improving the general living condition of the people. This will eventually lead to sizeable population that can be easily reached with cervical cancer control programs.
6.1.3 For Aid agencies
The need for more collaboration with the Nigerian government should be the long term plan for these agencies. Future programmes by the agencies should strive to engage policy makers especially stakeholders to mobilize local support and participation in these screening exercises. More so, future screening programmes should as a matter of short term focus strategize on rural reach and the possibility of introducing mother-daughter screening and vaccination to encourage a family oriented exercise. This should also include the feasibility of providing technology and self-help kits that would enable self-screening reducing the need to travel for screening from rural areas. More so, HPV vaccines for high risk HPVs need to be developed in the long term to further reduce the prevalence of other serotypes in Nigeria.
6.1.4 For Voluntary services:
Prevention and early diagnosis through vaccination and screening requires effective mobilization of the target groups and this has been a problem. Thus, voluntary services should focus efforts in the short term on mobilization though community-based education approach as a way of building a discourse with women and promoting women’s participation will help reduce fear and misunderstanding about cervical cancer screening and treatment and strengthen prevention knowledge and practices.
6.2 Conclusion
This research has carefully examined the factors responsible for the prevalence of CC in developing countries and in Nigeria in particular by examining the interventions used for possible mitigation strategies. Based on review of academic and gray literatures, it was found that CC prevalence in Nigeria is a major public health issue and has been engendered by a plethora of factors including HPV, poor nutrition, socio-economic status, poverty and poor awareness. This has also been exacerbated by lack of national policy, perceptions about screening, poor medical facilities and shortage of health care professionals for CC care and management. After an assay of the efficacy of current efforts it was observed that several factors posed a limitation to its actualization including cultural, religious and socio-economic barriers. In the final analysis, several recommendations were made based on the findings of the research which will guide future policy and best options by the Nigerian government. It is the position of this study that the above recommendations can be made successfully through concerted efforts on the part of the Nigerian government in making CC a public health concern of national priority and increasing funding for its activity while encouraging robust partnerships with local and international humanitarian agencies and voluntary services in winning the war against CC in Nigeria and by extension developing countries at large.
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Appendix IV: PICO Assessment criterion for cervical cancer interventions
Abbildung in dieser Leseprobe nicht enthalten
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[1] HPV types include 16, 18, 31, 34, 35, 45, 54 55, 56, and 58. HPV 16 and 18 cause 70% of cervical cancer cases worldwide. High risk HPVs however, are found in Nigeria which cause 20% of cervical cancer cases. They include serotypes 31, 35 58. HPV 16 and 18 have also been reported in Nigeria.
[2] West Africa comprises of 16 countries including Nigeria, Ghana, Ivory Coast, Senegal, Benin Republic, Gambia, Mali, Guinea-Bissau, Mauritania, Cape Verde, Guinea, Burkina Faso, Sierra Leone, Liberia, Togo, Sao Tome and Principe and the island of Saint Helena. East Africa refers to the following countries Kenya, Tanzania, Uganda, Ethiopia, Rwanda, Somalia, Burundi, Seychelles and Comoros. Sub-Saharan Africa refers to countries in Africa geographically located south of the Saharan desert.
[3] The Kano Trovafloxacin drug clinical trial by Pfizer (a United States pharmaceutical company) was done during the apogee of the epidemic of meningitis outbreak in northern Nigeria. The company administered 100 Trovafloxacin to children and another 100 anti-meningitis treatment to different set of people including adults. The drug was administered short of the required US FDA dosage requirement and led to the death and disfiguration of its human subject. The 1996 meningitis epidemic killed about 12,000 in northern Nigeria and is known as the worst outbreak of this disease in sub-Saharan Africa.
- Citar trabajo
- Francis Okpaleke (Autor)Elizabeth Ogozi (Autor), 2016, Cervical Cancer Mortality Rates and the Dialectics of International Humanitarian Intervention with a focus on Nigeria, Múnich, GRIN Verlag, https://www.grin.com/document/345359
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