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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 18-25

Perspectives of visual inspection of the cervix with acetic acid as an alternative to Pap smear test as a preventive measure of cervical cancer among female nurses in University College Hospital, Ibadan, Nigeria


1 Department of Nursing, Ladoke Akintola University of Technology, Osogbo, Osun State; Department of Clinical Nursing, University College Hospital, Ibadan, Nigeria
2 Department of Nursing, Ladoke Akintola University of Technology, Osogbo, Osun State, Nigeria

Date of Submission19-Aug-2018
Date of Decision23-Nov-2018
Date of Acceptance27-Nov-2018
Date of Web Publication1-Mar-2019

Correspondence Address:
Mrs. Christene E Umukoro
Department of Clinical Nursing, University College Hospital, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCRP.JCRP_10_18

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  Abstract 


Background: Visual inspection of the cervix with acetic acid (VIA) has been recommended by the World Health Organization as an alternative to the Pap smear test in preventing cervical cancer in low-resource healthcare settings. However, the level of awareness and uptake is still very low in Nigeria. In this study, the awareness and acceptance of VIA as a preventive measure against cervical cancer among female nurses at the University College Hospital (UCH), Ibadan was assessed. Materials and Methods: A pretested questionnaire on the knowledge of the risk factors of cervical cancer, uptake of the Pap smear test, and awareness and acceptance of VIA was administered to 301 female nurses at UCH, Ibadan. Results: The majority of the respondents (99%) knew about cervical cancer, but only 62.4% of them were aware that human papilloma virus is a causative agent. Early marriage (73.6%), high parity (64.0%), multiple sexual partners (91.1%), smoking (54.8%), and poor socioeconomic status (42.9%) were identified as risk factors for the disease. The proportion of those that had heard of VIA (43.6%) was low when compared with the Pap smear test (99%). However, 72.4% of them thought that female staff at the screening centers should promote VIA. Moreover, 61.5% believed that definitive treatment of cases could commence immediately after a VIA test. The age, duration of service, and educational qualification did not significantly (P > 0.05) influence the respondents' awareness of VIA as a cervical cancer screening technique. Conclusion: Adoption of VIA as part of routine checkups during postnatal visits and its integration into the nation l healthcare policy is recommended.

Keywords: Cervical cancer, national healthcare policy, Pap smear test, visual inspection of the cervix with acetic acid


How to cite this article:
Umukoro CE, Makinde OY. Perspectives of visual inspection of the cervix with acetic acid as an alternative to Pap smear test as a preventive measure of cervical cancer among female nurses in University College Hospital, Ibadan, Nigeria. J Cancer Res Pract 2019;6:18-25

How to cite this URL:
Umukoro CE, Makinde OY. Perspectives of visual inspection of the cervix with acetic acid as an alternative to Pap smear test as a preventive measure of cervical cancer among female nurses in University College Hospital, Ibadan, Nigeria. J Cancer Res Pract [serial online] 2019 [cited 2019 Sep 15];6:18-25. Available from: http://www.ejcrp.org/text.asp?2019/6/1/18/253244




  Introduction Top


Cervical cancer is the second-most common cancer among women worldwide, and the leading cause of cancer-related deaths among a large proportion of middle-aged women in developing countries including Nigeria.[1],[2],[3] About 85% of deaths from cervical cancer are known to occur in developing countries.[4] However, this disease is preventable, if women at high risk are screened for precancerous lesions and treated promptly.[5],[6] The key reason for the high mortality rate from cervical cancer in developing countries is the shortage of efficient, high-quality, and affordable screening programs.[4],[7] In developed countries, the incidence and mortality of the disease have been drastically reduced as a result of systematic cytological screening efforts. Previous studies have shown that there is a wide disparity in rates of screening for the disease, with the average screening coverage in developed countries being 63% compared to 19% in developing countries.[7] The cytology screening process is characterized by delays between screening, provision of test results, and ultimate treatment (including necessary repeat visits), which are major barriers to the success of cytology-based programs in low-resource settings.[5] The need for women to make multiple visits in low-resource settings has also been reported to reduce the success of screening programs as some of them will be lost to follow-up.[2],[5] However, using visual inspection of the cervix with acetic acid (VIA) during a single-visit can saves time, and can therefore effectively reach more women with screening and treatment services.[5],[6] Most importantly, VIA is known to be safe, cost-effective and can readily be done by nurses or midwives with appropriate training.[5],[8]

VIA is a simple, highly accurate, and affordable technique, being recommended as an alternative to cervical cytology in low-resource settings as in most African countries.[7],[8],[9],[10],[11] Thus, it can easily be implemented as an effective measure to reduce the incidence of cervical cancer in Nigeria. However, there is a need to assess the level of awareness and acceptance of VIA practice among the nurses who are expected to play a major role in screening the population at risk before advocating for its adoption into national healthcare policy with a view to reducing the burden of the disease in Nigeria. There is also a need to identify the reasons that may lead to nonparticipation in VIA as a preventive healthcare program in Nigeria. Thus, this study was designed to assess the level of awareness and acceptance of VIA as an alternative to the  Pap smear More Details test in preventing cervical cancer among female nurses at the University College Hospital (UCH), Ibadan, Nigeria.


  Materials and Methods Top


Study population and location

This study focused on female nurses at UCH, Ibadan, who worked in various specialized wards, including accident and emergency. The nurses form the largest category of staff at UCH and are always in close contact with patients attending the hospital. UCH is a tertiary institution located in Ibadan North Local Government Area, Oyo State, Nigeria.

Study design and sample determination

This was a descriptive cross-sectional, and pretest questionnaire-based study carried out to assess the knowledge, acceptance, and recommendations of the practice of VIA as an alternative to Pap smears in detecting and preventing cervical cancer among female nurses at UCH. The questionnaire contained both closed- and open-ended questions, and a total of 301 were administered. The main inclusion criteria were female nurses working at UCH between August and December 2015, who gave informed consent to participate in the study. Female nurses who were not staff at UCH were excluded from participating in the study. The sample size was determined based on case fatality rate of cervical cancer in Nigeria, which has been reported to be 22.9% deaths/100,000[12] using the formula described by Kasiulevicius et al.[13] The estimated sample size was adjusted to allow for nonresponses and wrong/incomplete responses.

Ethical considerations

Ethical approval for this study was obtained from the University of Ibadan/UCH Ethics Committee (UI/EC15/0370). Participation of respondents was voluntary, and only those who gave their consent were given the questionnaire.

Data analysis

Data obtained were coded and entered into a spread sheet. The analysis was performed using IBM SPSS Statistics for Windows, Version 20, Armonk, New York, USA. Descriptive statistics such as frequency counts and percentages were used to summarize and present the results. The Chi-square test was used to determine whether there was any statistical significance among the variable of interest at P < 0.05.

Theory

There is an increasing number of cases of cancer of the cervix, resulting in the deaths of a large proportion of middle-aged women in Nigeria.[14],[15],[16] However, this terminal disease is preventable if women at high risk are screened for precancerous lesions and treated promptly.[17],[18],[19] Nurses who form the largest category of staff at our tertiary health institutions and are also in close contact with the patients most of the time are expected to be major sources of information on health-related issues. Thus, they should have adequate information about screening procedures as measures for the prevention of cervical cancer and play an active role in the screening of the population at risk, thereby contributing to reductions in disease burden and mortality. However, available data suggest otherwise among female staff in several tertiary health institutions in Nigeria.[15],[20] It is, therefore, imperative to assess the level of awareness and acceptance of the practice of VIA among nurses working in health institutions with a view to adopting VIA as a cost-effective screening test in preventing cancer of the cervix.


  Results Top


Social demographic factors of the respondents

Most of the respondents were aged 26–39 years (56.4%), 85.8% were Christians, and 13.2% were Muslims. The majority of the respondents were married (86.5%) and 83.8% were Yoruba. Of the 301 respondents, 51.8% were both registered nurses (RN) and midwives, whereas 2.6% were only RN. In addition, 32.7% had a BNSc degree and also 6.5% had an MSc degree. Overall, 31.4% of the respondents had 6–10 years of practice, and 9.6% had over 20 years of practice [Table 1].
Table 1: Sociodemographic characteristics of respondents; (n=301)

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Respondents' knowledge of the causes and signs of cervical cancer

Most of the respondents (99%) were aware of cervical cancer, and 86.5% agreed that the disease is common in Nigeria [Figure 1]. The majority of the respondents (91.1%) also knew that cervical cancer is caused by multiple sexual partners, whereas 76.9% believed that the disease has genetic predispositions. Moreover, 62.4% knew that the disease is due to sexually-transmitted infection caused by human papillomavirus (HPV). The respondents had good knowledge of the symptoms and signs of cervical cancer, as 93.1% and 85.5% were aware that postcoital bleeding and offensive vaginal discharge were signs of the disease [Figure 1].
Figure 1: Respondents' knowledge of cervical cancer and signs of the disease

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Respondents' knowledge of the risk factors for cervical cancer

The respondent's knowledge of the risk factors for the disease was very good as they knew that multiple sexual partners (91.1%) and previous infections and inter-course with HPV-infected partners (88%) were risk factors for cervical cancer. Moreover, the majority believed that early marriage (73.6%), high parity (64.0%), age at first sexual activity (68%), and history of infertility (60.1%) were also risk factors for the disease [Table 2]. As presented in [Table 2], poor hygiene (47.5%), smoking (54.8%), and low level of education and poor socioeconomic status (42.9%) were also highlighted as risk factors for the disease.
Table 2: Respondent's knowledge of the risk factors of cervical cancer; (n=301)

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Respondents' knowledge of the Pap smear test and perception of those who do the test

A majority of the respondents (99%) had heard about the Pap smear test but, only 29.4% have ever done the test [Table 3]. Most of the respondents (70.3%) expressed willingness to have a Pap smear test. Moreover, 85.5% of the respondents agreed that women of childbearing age should have a Pap smear test, whereas 11.9% felt that only women with symptoms suggestive of a cancerous cervix should have the test [Table 3]. However, 85.8% disagreed that only women with a promiscuous lifestyle should have the Pap smear test.
Table 3: Distribution of respondents by uptake of pap smear test; (n=301)

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Reasons for the low uptake of the Pap smear test

As shown in [Figure 2], only a few respondents (5.6%–14.5%) identified cost, fear of positive result, risks involved in the procedure, lack of adequate information, and the need for repeated tests as barriers to Pap smear test. Although the age of the respondents influenced the uptake of the Pap smear test, the differences were not statistically significant (P > 0.05) among the age groups [Table 4]. In addition, the duration of service did not significantly (P > 0.05) affect the willingness of the respondents to do the Pap smear test. However, as shown in [Table 5], educational qualifications significantly (P < 0.05) affected the willingness of the respondents to do the Pap smear test.
Figure 2: Distribution of respondents by reasons for not doing Pap smear test

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Table 4: Effect of some sociodemographic characteristics of respondents on their awareness of visual inspection of the cervix with acetic acid

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Table 5: Effect of social demographic factors of respondents on willingness to do pap smear test; (n=301)

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Respondents' awareness of visual inspection of the cervix with acetic acid as an alternative to the Pap smear test

The proportion of the respondents who had heard of VIA (43.6%) as a cervical cancer screening technique was quite low compared with the Pap smear test (99%) [Figure 3]. However, age, educational status, and duration of service of the respondents did not significantly (P > 0.05) influence the levels of awareness of VIA as cervical cancer screening procedure [Table 4]. As shown in [Figure 3], only 37.0% of the respondents knew that VIA was recommended by the World Health Organization (WHO) for low resource economic settings such as Nigeria. In addition, the age, educational status, and duration of service of the respondents did not significantly (P > 0.05) influence the levels of awareness of the WHO recommendation of VIA for low-resource economic settings [Table 6].
Figure 3: Distribution of respondents by reason of awareness of visual inspection of the cervix with acetic acid

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Table 6: Effect of age, educational status, and duration of service of respondents on the awareness of the World Health Organization recommendation of visual inspection of the cervix with acetic acid for low-resource economic settings

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Perceived factors that could influence the uptake of visual inspection of the cervix with acetic acid

The knowledge of the respondents on the cost-effectiveness of VIA (23.3%) and the ease to carry out the procedure at all tiers of healthcare settings (33.3%) was very poor [Table 7]. However, 46.7% agreed and 25.7% strongly agreed that female staff at screening centers should promote the practice of VIA. Moreover, 35.6% of the respondents agreed, whereas 19.5% of them strongly agreed that VIA will reduce the high level of defaults associated with the Pap smears test. As also shown in [Table 7], a good proportion of the respondents thought that VIA had favorable features that will encourage its uptake when compared with the Pap smear test.
Table 7: Distribution of respondents by perceived factors that may encourage uptake of visual inspection of the cervix with acetic acid; (n=301)

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Perceived features associated with the practice of visual inspection of the cervix with acetic acid

As shown in [Table 8], 46.7% of the respondents agreed and 25.7% strongly agreed that female staff at screening centers should promote the practice of VIA. Of the 301 of respondents, 41.6% agreed and 24.8% strongly agreed that definitive treatment of cases could commence immediately after the VIA test.
Table 8: Distribution of respondents by recommendations of practice and adoption of visual inspection of the cervix with acetic acid; (n=301)

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Respondents' recommendation of visual inspection of the cervix with acetic acid

As presented in [Table 8], 41.9% of the respondents agreed and 20.1% strongly agreed that VIA should be adopted as an alternative to Pap smears. In addition, 40.9% agreed and 37.0% strongly agreed that public education on its use should be carried out before adoption. Moreover, adequate training of personnel and nationwide campaigns were also recommended by the respondents before its adoption. Furthermore, 38.6% of the respondents agreed and 31.4% strongly agreed that VIA should be part of routine checkups during postnatal visits [Table 8]. Of the 301 respondents, 40.9% agreed and 23.1% strongly agreed that VIA should be recommended for low-resource economic settings such as Nigeria [Table 8].


  Discussion Top


The results of this study showed that the majority of the respondents had heard about cervical cancer and believed that the disease is very common in Nigeria. The respondents had good knowledge of the causative factors and symptoms and signs of cervical cancer disease. Overall, the respondents' knowledge of the risk factors for cervical cancer was generally very good as they knew that intercourse with HPV-infected partners, early marriage, high parity, and multiple sexual partners were the major risk factors for developing the disease. These findings are in agreement with previous studies which showed that most women in healthcare professions in Nigeria were aware of the nature and consequences of the disease.[15],[21] However, in rural and nonprofessional settings, knowledge of HPV as the main cause of cervical cancer among women in Nigeria has been shown to be very low.[14] HPV infection is known to be an important factor for the development of cervical cancer.[22],[23] HPV is transmitted through sexual contact with an infected person and can leads to the development of cervical intraepithelial neoplasia, with subsequent progression to cervical cancer.[22],[23],[24] HPV Types 16 and 18 are known to cause high rates of cancer of the cervix whereas Types 6 and 11 produce genital warts.[22] Other infections that compromise the immune status of patients such as HIV have also been reported to contribute to the progression of the disease to invasive cancer by encouraging the persistence of HPV over time due to reduced immunity.[22] During persistent HPV infection, precancerous changes occurring in the cells lining the cervix may be readily detected and treated.[5],[22],[23] Thus, early detection and treatment is an effective strategy for the prevention of cervical cancer and forms the basis of cervical screening programmes.[5],[22],[23]

Although the efficiency of regular Pap smear tests in reducing the mortality rate of cervical cancer has been established, its uptake in Nigeria is still very low. The major reason for this is that the women believe they are not susceptible to the disease.[6],[14],[25] This false belief will continue to hinder any cervical screening policy that could lead to a significant reduction in the burden of cervical cancer in Nigeria, especially in rural settings. Other identified factors for low uptake of the Pap smear test include cost, fear of a positive result, risks involved in the procedure, lack of adequate information, and the need for repeated visits.[14],[21],[25] However, the results of this study did not highlight any of these factors as barrier to uptake of the Pap smear test, which suggests the need for public enlightenment of the devastating nature of the disease. This is obvious from this study, as although, the majority of the respondents (70.3%) expressed willingness to have a Pap smear test, only a few (29.4%) had actually done it. This observation points to the need for the integration of cervical cancer screening as a routine component of antenatal visits for all women of childbearing age.

Smoking and poor socioeconomic status may also contribute to the risk of cervical cancer disease; however, only 54.8% and 42.9% of the respondents believed that smoking and poor socioeconomic status play a role in cervical cancer disease, respectively. Previous studies have identified smoking to be one of the main factors associated with an increased risk for the development of high-grade cervical lesions in women with persistent high-risk HPV infection.[23],[24] Tobacco smoke has been reported to contain carcinogenic compounds which are believed to influence the course of cervical cancer.[22],[23] Benzo(a)pyrene, a major carcinogenic constituent of cigarette smoke, has been shown to increase HPV viral titers and impair immune function, thereby encouraging the progression of the disease.[22],[23],[24] Poverty, poor hygiene, and low level of education have also been identified as contributing factors to increased cervical cancer via predispositions to HPV infection and low uptake of screening procedures.[20] Moreover, poor socioeconomic status of women may encourage sexual promiscuity and other lifestyles that may expose them to the risk of HPV infections.[21]

The results of this study showed that the majority of the respondents (99%) were aware of the Pap smear test, and this may be because it has been used for over 60 years and perhaps because of its effectiveness in reducing the burden of the disease in developed countries. The high level of awareness of the Pap smear test among the respondents in this study may also be related to the fact that it is the most common screening method in teaching hospitals in Nigeria.[21] Other screening methods such as liquid-based cytology and HPV-DNA tests, which are newer tests used in developed countries, are not yet widely available because of the high financial and technological requirements. Although the majority of the respondents were aware of the Pap smear test, only a few had ever done the test. The reasons for this were not apparent from the results of this study but suggest the need for an alternative screening procedure such as the VIA. VIA has been recommended by the WHO as an alternative to Pap smears for mass cervical cancer screening programs in poor economic resource settings such as Nigeria.[1],[21] VIA offers various advantages over Pap smear in low-resource settings, particularly in terms of increased screening coverage, improved follow-up care, and overall program quality.[1],[5] Due to the need for fewer specialized personnel, infrastructure, and equipment, VIA can easily be implemented in remote healthcare settings. Furthermore, the results of the test can be shared with patients immediately, making it possible to screen and treat at the same visit.[1],[5] Thus, VIA overcomes the need for repeated visits associated with Pap smears, which has been identified as a major challenge to the success of this screening procedure in low-resource settings.[5],[26] Meanwhile, the purpose of VIA is to highlight precancerous lesions so that they can be viewed with the “naked eye,” thus shifting the identification of precancerous lesion from the laboratory to the clinic for immediate treatment of patients.[1] Health personnel including doctors, nurses, midwives, and paramedic health workers can be trained to perform VIA in short courses of 5–10 days duration, making it an attractive screening test in preventing cervical cancer in low-resource settings.[1],[27]

The results of this study showed that the respondents had low levels of awareness of VIA as an alternative to the Pap smear test for low-economic settings, emphasizing the need for nationwide campaigns of its cost-effectiveness for the detection of cervical cancer disease. The proportion of those who had heard of VIA (43.6%) as a cervical cancer screening technique was quite low compared with the Pap smear test (99%). Overall, 37.0% of the respondents knew that VIA was recommended by the WHO for low resource economic settings such as Nigeria. Furthermore, the knowledge of the respondents on the cost-effectiveness of VIA (23.3%) and the ease of carrying out the procedure at all tiers of healthcare settings (33.3%) was poor. However, most of the respondents believed that female staff at screening centers should promote the practice of VIA. Moreover, the majority thought that definitive treatment could commence immediately after the VIA test. However, age, duration of service, educational qualification, and knowledge of the disease did not significantly influence the respondents' awareness of VIA as an alternative to the Pap smear test for screening cervical cancer disease. Of the 301 respondents, 62.0% recommended adopting VIA as an alternative to the Pap smear test for screening cancer of the cervix. However, the majority thought that public enlightenment and adequate training of personnel should be done before adopting VIA as a part of routine checkups during postnatal visits and its integration into national healthcare policy at all levels in Nigeria.

Several studies carried out across different geopolitical regions in Nigeria reported that an insignificant number of women had ever done the Pap smear test.[4],[25] The present study showed that only 18% of the respondents had done the Pap smear test, which further confirmed the previous reports that even health care professionals who are expected to play active roles in screening the population at risk of developing the disease are yet to embrace the preventive measure offered by the screening test.[15],[20],[28] This finding has led to the belief that increased awareness of the Pap smear test or the disease may not influence its uptake in Nigeria.[4],[21] The low level of uptake of the Pap smear test even among healthcare professionals indicates the need for the Nigerian government to consider VIA as an alternative to the Pap smear test as recommended by the WHO for low-resource settings. Adoption of VIA is justifiable, given the complexity of implementing cytology-based screening, especially in primary healthcare settings. Above all, policymakers should adopt the aggressive measures of Chile, a developing country like Nigeria that has achieved > 50% increase in screening coverage and close to 50% reduction in cervical cancer mortality.[26] This was achieved in Chile by the translation of strong political commitment into action through training of motivated public sector health workforce and intensive public enlightenment.[26] Thus, in Nigeria, achieving the goal of high coverage rates in the target population should begin with the health care providers, who will play a major role in sensitizing the general populace of the deadly nature of the disease. One of the most effective ways of raising awareness identified in this study was through seminars, and thus regular seminars and workshops may enhance the uptake of cervical screening among health professionals and other categories of women in general. However, cervical cancer screening is a sensitive issue involving both the risk of a potentially life-threatening illness and a medical examination that affects emotions and beliefs, sexuality, privacy, and womanhood. Disparities between the perception of screening programs by beneficiaries and those providing them can lead to poor or minimal effects on screening behavior.[29] Thus, a crucial step toward improving cervical cancer screening behavior requires that healthcare policymakers, healthcare providers, and women themselves share a common perspective about preventive measures.


  Conclusion Top


The results of this study revealed that the level of awareness of VIA as an alternative to the Pap smear test for low-economic settings is low among female nurses in UCH, emphasizing the need for nationwide campaigns of its cost-effectiveness and ease in detecting cervical cancer disease in Nigeria.

Acknowledgments

The authors would like to thank Dr. A.M. Ajayi of the Department of Pharmacology and Therapeutics, University of Ibadan, Ibadan, Nigeria for data analysis. The authors are also grateful to the respondents for their voluntary participation in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sahasrabuddhe VV, Parham GP, Mwanahamuntu MH, Vermund SH. Cervical cancer prevention in low- and middle-income countries: Feasible, affordable, essential. Cancer Prev Res (Phila) 2012;5:11-7.  Back to cited text no. 1
    
2.
Shastri A, Shastri SS. Cancer screening and prevention in low-resource settings. Nat Rev Cancer 2014;14:822-9.  Back to cited text no. 2
    
3.
Dim CC. Towards improving cervical cancer screening in Nigeria: A review of the basics of cervical neoplasm and cytology. Niger J Clin Pract 2012;15:247-52.  Back to cited text no. 3
  [Full text]  
4.
Arbyn M, Castellsagué X, de Sanjosé S, Bruni L, Saraiya M, Bray F, et al. Worldwide burden of cervical cancer in 2008. Ann Oncol 2011;22:2675-86.  Back to cited text no. 4
    
5.
Sherris J, Wittet S, Kleine A, Sellors J, Luciani S, Sankaranarayanan R, et al. Evidence-based, alternative cervical cancer screening approaches in low-resource settings. Int Perspect Sex Reprod Health 2009;35:147-54.  Back to cited text no. 5
    
6.
Nwozor CM, Oragudosi AL. Awareness and uptake of cervical cancer screening among women in Onitsha, South-East, Nigeria. Greener J Med Sci 2013;3:283-8.  Back to cited text no. 6
    
7.
Ibrahim A, Rasch V, Pukkala E, Aro AR. Cervical cancer risk factors and feasibility of visual inspection with acetic acid screening in Sudan. Int J Womens Health 2011;3:117-22.  Back to cited text no. 7
    
8.
Sauvaget C, Fayette JM, Muwonge R, Wesley R, Sankaranarayanan R. Accuracy of visual inspection with acetic acid for cervical cancer screening. Int J Gynaecol Obstet 2011;113:14-24.  Back to cited text no. 8
    
9.
McGregor D, Olaitan A. Fighting cervical cancer in under-resourced countries. Obstet Gynaecol 2010;12:49-52.  Back to cited text no. 9
    
10.
Moon TD, Silva-Matos C, Cordoso A, Baptista AJ, Sidat M, Vermund SH. Implementation of cervical cancer screening using visual inspection with acetic acid in rural Mozambique: Successes and challenges using HIV care and treatment programme investments in Zambézia Province. J Int AIDS Soc 2012;15:17406.  Back to cited text no. 10
    
11.
Quentin W, Adu-Sarkodie Y, Terris-Prestholt F, Legood R, Opoku BK, Mayaud P. Costs of cervical cancer screening and treatment using visual inspection with acetic acid (VIA) and cryotherapy in Ghana: The importance of scale. Trop Med Int Health 2011;16:379-89.  Back to cited text no. 11
    
12.
Okoye I. Case Fatality Rate of Cervical Cancer in Nigeria and Sub-Saharan Africa; 2014. Available from: http://www.thisdaylive//home//new. [Last assessed on 2016 Dec 28].  Back to cited text no. 12
    
13.
Kasiulevicius V, Sapoka V, Filipaviciute R. Sample determination in epidemiological studies. Gerontologija 2006;7:225-31.  Back to cited text no. 13
    
14.
Ajah LO, Iyoke CA, Ezeonu PO, Ugwu GO, Onoh RC, Ibo CC. Association between knowledge of cervical cancer/screening and attitude of teachers to immunization of adolescent girls with human papilloma virus vaccine in Abakaliki, Nigeria. Am J Cancer Prev 2015;3:8-12.  Back to cited text no. 14
    
15.
Dim CC, Ekwe E, Madubuko T, Dim NR, Ezegwui HU. Improved awareness of Pap smear may not affect its use in Nigeria: A case study of female medical practitioners in Enugu, Southeastern Nigeria. Trans R Soc Trop Med Hyg 2009;103:852-4.  Back to cited text no. 15
    
16.
Goddy B, Kennedy NT, Michael O. Profile and retrospective analysis of the use of preventive strategies in patients with cervical cancer in South-South Nigeria. Niger Med J 2015;56:109-12.  Back to cited text no. 16
[PUBMED]  [Full text]  
17.
Bradford L, Goodman A. Cervical cancer screening and prevention in low-resource settings. Clin Obstet Gynecol 2013;56:76-87.  Back to cited text no. 17
    
18.
Paul P, Winkler JL, Bartolini RM, Penny ME, Huong TT, Nga le T, et al. Screen-and-treat approach to cervical cancer prevention using visual inspection with acetic acid and cryotherapy: Experiences, perceptions, and beliefs from demonstration projects in Peru, Uganda, and Vietnam. Oncologist 2013;18:1278-84.  Back to cited text no. 18
    
19.
Wright TC Jr., Kuhn L. Alternative approaches to cervical cancer screening for developing countries. Best Pract Res Clin Obstet Gynaecol 2012;26:197-208.  Back to cited text no. 19
    
20.
Eze GU, Obiebi IP, Umuago IJ. Perspectives of cervical cancer and screening practices among staff of a teaching hospital in South-South Nigeria. J Cancer Res Pract 2018;5:67-73.  Back to cited text no. 20
    
21.
Chinaka CC, Udeajah VN. Awareness of cervical cancer and cervical cancer screening among women visiting federal teaching hospital Abakaliki, Nigeria. J Med Appl Biosci 2012;4:47-66.  Back to cited text no. 21
    
22.
Ibeanu OA. Molecular pathogenesis of cervical cancer. Cancer Biol Ther 2011;11:295-306.  Back to cited text no. 22
    
23.
Jensen KE, Schmiedel S, Frederiksen K, Norrild B, Iftner T, Kjær SK. Risk for cervical intraepithelial neoplasia grade 3 or worse in relation to smoking among women with persistent human papillomavirus infection. Cancer Epidemiol Biomarkers Prev 2012;21:1949-55.  Back to cited text no. 23
    
24.
Perez-Plasencia C, Duenas-Gonzalez A, Alatorre-Tavera B. Second hit in cervical carcinogenesis process: Involvement of Wnt/beta catenin pathway. Int Arch Med 2008;1:10.  Back to cited text no. 24
    
25.
Ahmed SA, Sabitu K, Idris SH, Ahmed R. Knowledge, attitude and practice of cervical cancer screening among market women in Zaria, Nigeria. Niger Med J 2013;54:316-9.  Back to cited text no. 25
[PUBMED]  [Full text]  
26.
Sepúlveda C, Prado R. Effective cervical cytology screening programmes in middle-income countries: The Chilean experience. Cancer Detect Prev 2005;29:405-11.  Back to cited text no. 26
    
27.
Blumenthal PD, Lauterbach M, Sellors JW, Sankaranarayanan R. Training for cervical cancer prevention programs in low-resource settings: Focus on visual inspection with acetic acid and cryotherapy. Int J Gynaecol Obstet 2005;89 Suppl 2:S30-7.  Back to cited text no. 27
    
28.
Nwobodo EI, Malami SA. Knowledge and practice of cervical screening among female health workers in Sokoto, North Western Nigeria. Niger Postgrad Med J 2005;12:255-7.  Back to cited text no. 28
  [Full text]  
29.
Pender NJ. Health promotion: An emerging science for self care and professional care. Qual Nurs 1997;3:449-54.  Back to cited text no. 29
    


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