IMPACT OF SOURCE OF INFORMATION AND AWARENESS ON HEALTH SEEKING BEHAVIOUR OF CERVICAL CANCER PATIENTS IN DAR ES SALAAM, TANZANIA.

Transcription

1 IMPACT OF SOURCE OF INFORMATION AND AWARENESS ON HEALTH SEEKING BEHAVIOUR OF CERVICAL CANCER PATIENTS IN DAR ES SALAAM, TANZANIA. ELVIS S. ARIGA 1 AND PHARES G.M. MUJINJA 1 1 Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania Corresponding author address: elvisafary@gmail.com ABSTRACT Cervical cancer is a serious disease among women in Tanzania. A quantitative cross sectional study was conducted to determine source of information and knowledge on health seeking behavior of cervical cancer patients in Dar salaam, Tanzania. Data was collected, entered and analyzed using SPSS The relationships between variables and outcome were determined by Chi-square test, Odds ratio and Multivariate logistic regression at p<0.05. Age, perception, source of message, and knowledge of symptoms were significant in health seeking behavior. Main source of information were relatives and friends (67.5%) and media (62.9%). Awareness was high, however only 17.8% understood cervical cancer messages very well. Decision to seek medical treatment was influenced by; role of individual on treatment (OR=1.7, 95%CI ), positive perception of the disease (OR=1.3, 95%CI ) and level of understanding of the messages received. Wide community based education and awareness programs, through multi about cervical cancer is needed. KEY WORDS: information, awareness, health seeking behavior, cervical cancer patients, Tanzania 40

2 1.0 INTRODUCTION Cervical Cancer is characterized by uncontrolled growth and spread of abnormal cells that arise from the cervix (American Cancer Society, 2010). A study estimated that about 12.7 million cancer cases and 7.6 million cancer deaths have occurred in 2008 (Anorlu, 2008). Cervical cancer is a major disease burden and the highest gynecological malignant in developing countries (Holschneider, 2007 and Mosha, 2009). The same authors reported that it is the most common cancer related health problem contributing to a mortality rate of 34 deaths per 100,000/year (4 times global mortality rate of 9/100,000). The incidence of cervical cancer is very low in women under age of 25 years but increases at age of years (Anorlu, 2008). An age standardized incidence rate (ASR) of invasive cervical cancer is reported to be 42.7 per 100,000 women in East Africa, 38.2 in Southern Africa, 28 in Central Africa and 29.3 in Western Africa (Ferlay, 2004; Parkin and Bray, 2006). One of the reasons for the high incidence rate is the lack of early detection of precancerous lesions and treatment of the lesions before they progress (Anorlu, 2008). In East Africa, cervical cancer accounts for 13.7% leading among all malignant diseases and its magnitude in Tanzania is high contributing to 6000 deaths annually among women of all sub-ages (WHO, 2010). In a study conducted in Zimbabwe to investigate rural women s perception of information on cervical cancer and their understanding of symptoms and screening services, 95.8% had received some information but had never gone for screening (Mangoma, 2006). The author concluded that lack of knowledge about the need and importance of screening, poor social marketing of the local screening programs, lack of resources, men s failure to support their partners and shyness were cited as the major delaying factors to screening. However, in a study conducted in Nigeria among health workers to identify factors that influence information and utilization of screening services for cervical cancer, it was found out that 65.2% of the female health workers received information about screening services and 64.7% were aware of screening services for cervical cancer and its availability (Gharoro and Ikeanyi, 2006). Nevertheless, the same authors found poor screening uptake, concluding that awareness of information of cervical cancer screening services alone might not be a guarantee for screening services uptake. A number of factors contribute to low turn up in seeking treatment among cervical cancer patients. These factors include social-economic factors (Kerubo, 2011 and Mutyaba, 2006), limited knowledge on symptoms and signs, limited financial resources, limited accessibility and unavailability of screening facilities (Eleanor et al, 2012), lack of anti-cancer medicines and diagnostic machines (Frida, 2012), health system factors (Kristin, 2011; Mutyaba, 2006), socio-cultural, demographic, infrastructure, knowledge, attitude, belief, access, time and cancer stages (Samur, 2002). In Tanzania, Ocean Road Cancer Institute (ORCI) is the only cancer facility, which provides radiotherapy, and only few cases get combined therapy. This leads to poor outcome and congestion as it is the only one that serves as a referral facility for all regions in Tanzania (Kahesa, 2008). This study was conducted to determine impact of source of information and awareness on health seeking behavior of cervical cancer patients in Dar salaam, Tanzania. 41

3 2.0 METHODOLOGY 2.1 Research area and design The study was done at Ocean Road Cancer Institute (ORCI) in Dar Es Salaam, located along the Indian Ocean in Ilala Municipality. The study employed a cross sectional explorative design. 2.2 Study population, sample size and sampling The study population comprised of women either inpatient or outpatient with new proven cases of cervical cancer treated at ORCI from January to April The sample size n was obtained using the formula developed by Cochran (2006) for populations that are large. n = [Z² P (100- P)]/E 2 ; Where: n = minimum sample size to be estimated; Z = critical value of the standard normal distribution for the 95% confidence interval around the true population (1.96); P = Proportion of utilization of treatment among cervical cancer patients (86.5%) according to a study by OCRI, Tanzania, (2014); E = margin of error (5%). Hence, n = [ *86.5( )]/5 2 resulting in 179 households plus a non response of 10% giving a total of 197 households. In a month about cervical cancer patients are seen. All in-patients and outpatients who came for treatment within the study period were included until the sample size was obtained. 2.3 Data collection and ethical issues Quantitative data was collected during face to face interviews with respondents using semi structured closed ended questionnaires. Pre-testing of the instrument was conducted to test for clarity of the questions and where necessary questions were modified to achieve the desired outcome of the study. Ethical issues involved clearance from Research and Publication Committee of Muhimbili University of Health and Allied Sciences and authorities of Ocean Road Cancer Institute. Interviewee consent was acquired and respondents were assured of non disclosure of identity. 2.4 Data analysis and presentation Data was cleaned, entered in excel and analyzed using SPSS (20.0). Associations between dependent and independent variables were assessed by Chi-square test and Odds ratio. Multivariate logistic regression model (Table 6) was used to determine variable that significantly contributed to the outcome (Access to care). Significance level was set at p < Data was presented in frequency and percentage tables. 3.0 RESULTS 3.1 Socio-demographic characteristics of household members A total of 197 new cases of women, with cervical cancer, aged years participated in the study. The respondents mean age was 50 years (SD ±11) with a large proportion (37.1%) of them aged years old, followed by years (29.4%). Only 6.1% were 70 years and above (Table 1). Most respondents (62.9%) were married while 18.3% were divorced or separated. Those widowed were 15.7% and 3% never married (Table 2). Majority of respondents (49.2%) had primary education followed by those with formal education (32.5%). Those who achieved secondary and higher education were 14.2% and 4.1% respectively (Table 3). 42

4 More than half of the respondents (54.8%) were peasants followed by business women (23.4%), non employed (14.2%) and employed (7.6%). Number of household members (Table 4) shows that half (50.3%) of the respondents came from families with more than 6 household members, followed by those with 4-6 people (29.9%) and 1-3 people (19.8%). 3.2 Influence of socio-demographic factors on acting upon received messages to seek treatment There were significant differences among age groups and received messages about cervical cancer that induced decision to seek medical treatment (p<0.001, chi-square = and df=4). Women in the age group years old (88%) were more likely to be induced by messages that provoked them to seek medical treatment than older age groups (Table 1). Table 1: Age (years) of respondents induced by message to seek treatment Age category (years) n (%) Induced by messages to seek treatment; n (%) Statistics (12.7%) 22(88.0%) (37.1%) 58 (79.5%) χ2 = (29.4) 38(65.5%) df = (14.7) 22(75.9%) P < (6.1) 3(25.0) Total 197(100%) 43

5 Marital status was not significantly associated with induction of messages to seek medical treatment (p=0.211 chi square=6.938 and df=3). However respondents who were never married (83.3%) were more likely to seek medical treatment than those who were married (75%) as shown (Table 2). Table 2: Marital status of respondents induced by message to seek treatment Marital status n (%) Induced by messages to seek treatment; n (%) Statistics Never married 6(3.1%) 5 (83.3%) χ2 =6.938 Married 124(62.9%) 93 (75%) df = 3 Divorced/Separated 36(18.3%) 27 (74%) P = Widow 31(15.7%) 18 (58.1%) Total 197(100%) Results showed that 57.8% of married women have to ask for permission to seek medical treatment while those never married (71.4%) do not need to ask for permission to seek for medical treatment. Education level (Table 3) was significantly associated with stimulation of messages to seek medical treatment (p=0.034, chi square=4.938 and df=3). Table 3: Education level of respondents induced by message to seek treatment Education level n (%) Induced by messages to seek treatment; n (%) Statistics No formal education 64(32.5%) 46 (67.6%) χ2 = Primary education 97(42.9%) 66 (69.5%) df = 3 Secondary education 28(14.2%) 19 (90.5%) P = Higher education 8(4.1%) 12 (92.3%) Total 197(100%) 44

6 Women with higher education level (92.3%) were induced by messages to seek medical treatment than those with no formal education (67.6%). Number of household members (Table 4) was significantly associated with induction of messages to seek medical treatment (p=0.003, chi square=1.316 and df=2). Women living in household with more than 6 members (68.8%) were less likely to be influenced by the messages to seek treatment compared to those with less (1-3) members (77.4%). Table 4: No of household members by induction of message to seek treatment Household members n (%) Induced by messages to seek treatment; n (%) Statistics 1-3 members 53(19.8%) 41 (77.4%) χ2 = members 64(29.9%) 45 (70.3%) df = 2 >6 members 80(50.3%) 55 (68.8%) P = Total 197(100%) 45

7 3.3 Source of information, understanding of message and awareness of symptoms. Results (Table 5) showed that respondents (67.5%) mentioned that relatives/friends were the main source of information of cervical cancer messages. Media (TV, Radio, Newspaper and cell phones) accounted for 62.9% while books informed 9.1% and internet (6.6%). About 77.2% of women have heard and received cervical cancer messages however only 17.8% of respondents, understood the message they received very well while 21.3% most of it, 37.1% a little and 28.8 did not understand at all the message they received (Table 5). Table 5: Source of information, understanding and symptoms awareness of cervical cancer Parameter Frequency Percentage Source of information Internet Media Relatives/friends Books Level of understanding of messages received Understood message very well Understood most of it Understood a little Did not understand at all Knowledge of cervical cancer symptoms Pelvic/beck pain Heavy menstruation Abnormal vaginal bleeding Nausea/fatigue Anaemia Urinal problems

8 Women (60%) between the age group of years old understood messages they received very well than those of 70 years old and above (8.3%). Women with higher level of education (30.8%) were more likely to understand very well messages received about cervical cancer than women with no formal education level (11.8%). Respondents were tested on understanding symptoms of cervical cancer (Table 5). Women (85.8%) mentioned that abnormal vaginal bleeding was the major symptom of cervical cancer followed by pelvic/back pain (76.1%), fatigue (55%), heavy menstruation (38.6%) and urinal problems (28.9%). Multivariate logistic regression model for messages understood to induce participants to seek medical treatment revealed that age, perception, source of message, and knowledge of symptoms were significant. Family as a source of message significantly contributed to positive health seeking behavior (Table 6). Table 6: Definition of variables in Multivariate logistic regression model Variables Dependents Message Understood Utilization Descriptions Was the message received understood? 1=yes, 2=no Did you utilize health center? 1=yes, 2=no Independent Age (years) (AGE) Age of the respondents in years Marital status (MS) Respondents marital status Occupation (OCC) Occupational level of the respondents Education level (EL) Participants level of education Perception (PER) Was the perception positive or negative Household size (HHS) Number of family members in the household Message from family (MF) Messages received from family members Sources of message (SoM) Source of information Knowledge of symptoms Knowledge of cervical cancer symptoms (KS) Y 1 = α + B 1 AGE + B 2 MS+ B 3 OCC + B 4 EL+ B 5 PER + B 6 HHS + B 7 MF+ B 8 SoM+ B 9 KS 47

9 Table 7: Multivariate logistic regression model for messages understood to induce participants to seek medical treatment OR SE 95% CI p-value Age (years) Marital status Never married (Ref) 1 Married Divorced/separated Widowed Occupation Education level Perception Household size Message from family Source of message Knowledge of symptoms Number of participants log likelihood (x 2 ) a Nagelkerke R Cox & Snell R Log likelihood at p=

10 4.0 DISCUSSION 4.1 Influence of socio-demographic factors on acting on received messages to seek treatment Socio-demographic indicators such as age, marital status, occupation, level of education and dependant household members are relevant in studies associated with seeking cervical cancer treatment (Park et al., 2011). The study showed that age, level of education and number of household members haves significant role to ensure early seeking of medical treatment. This is because young women with higher education level receive cervical cancer messages from multiple sources and have better understanding of cervical cancer and hence seek early medical treatment. This association is consistent with other studies, which suggest that level of education and age induce health-seeking behavior through its effect on level of knowledge understood about cervical cancer (Nene, et al., 2007). Other socio-demographic characteristics like marital status and occupation were not significantly associated with inducing decision to seek cervical cancer medical treatment. However, a study carried out among African women revealed that employed and married women had a higher compliance to cervical cancer treatment (Singh, 2002). 4.2 Source of information, understanding of message and awareness of symptoms Cervical cancer messages received among respondents was high, however only a few of the respondents understood the messages they received very well. This was because majority of women were peasants who did not have access to any source of cervical cancer messages. Some had low level of education, and therefore could not comprehend the messages they received on cervical cancer in order to help influence them to seek treatment. Studies conducted in several Sub-Saharan African Countries among health care workers reported a low level of understanding cervical cancer screening messages that patients received (Ghororo and Ikeanyi, 2006). The low level of understanding received messages are in contrast to studies done in Developed Countries where about 60% to 80% of women reported to have knowledge on specifically cervical cancer screening messages received. This difference in perception of messages could be due to effective communication program, strong economic power, women empowerment and adequate mass media campaign found in developed countries (Ghororo and Ikeanyi, 2006). In this study majority of respondents received cervix cancer information from relatives/friends. Majority of respondents had adequate knowledge of cervical cancer symptoms and sources of information. Despite all these information, there were still a small proportion of women who seek medical treatment early. These findings are consistent to those of Were et al., (2011) which revealed a significant association between knowledge on information about cervical cancer development and better uptake of screening services. Mangoma, (2006), reported that lack of knowledge about the need and importance of medical treatment and signs and symptoms, lack of resources and poor social marketing of cervical cancer programs were the major impeding factors to seeking cervical cancer medical treatment. This concurred with Eleanor et al, (2012), who listed limited knowledge on symptoms and signs, limited financial resources, limited accessibility and unavailability of screening facilities. Another study conducted in Tanzania showed that low knowledge of basic symptoms of cervical malignancies and limited access to information did not induce decision to seek medical treatment and consequently led to delay in treatment (Kilewo, 2002). 49

11 5.0 ACKNOWLEDGEMENT The author would like to acknowledge the input, guidance and support accorded by the research study supervisor. Thanks to Professor Emmanuel Safary Ariga (CAVS, University of Nairobi) for extensive critic of this manuscript. Special thanks go to Ocean Road Cancer Institute (ORCI) for allowing the study and cervical cancer patients for volunteering information. 6.0 References American Cancer Society (ACA) Cancer facts and figures; Atlanta. Anorlu, R. (2008). Cervical Cancer: the Sub-Saharan perspective. Reproductive Health Matters Journal; 16 (32): Cochran, G. W. (2006). Sampling techniques (4 th Ed.). New York: John Wiley & Sons Ferlay, J. (2004). Cancer incidence and mortality. Annals of Oncology 16 (3): Frida, S. (2012). Effects of screening on the risk estimates of socio-demographic factors on cervical cancer. A large cohort study from Rural India. Gharoro, E and Ikeanyi, E. (2006). An appraisal of the level of awareness and utilization of the cervical cancer screening test among female health workers in a tertiary health institution. International Journal & Gynecological cancer, vol Holschneider, C. H. (2007). Pre-malignant and malignant disorder of uterine cervix. Current principle of obstetrics and gynaecology 10 th Ed New York: Mc Graw Hill Kahesa, C., Mwaiselage, J., Wabinga, H.R., Ngoma, T., Kalyango, J.N. and Karamagi, L. (2008). Association between invasive cancer of the cervix and HIV-1 infection in Tanzania: The need for dual screening. BMC Public Health, 8:262 doi: : Kerubo, D. (2011). A comparative study on the prevalence of cervical dysplasic and cervical cancer among women attending Webuye cervical cancer clinic and Marigat District Hospital, Webuye, Kenya. Kilewo, CD K.H, Moshiro, C. (2002). Knowledge and attitude of female patients admitted at Muhimbili National Hospital, Dar Es Salaam, East African Journal 79 (9): Mangoma, J.F., Chirenje, M.Z., Chimbari, M.J., Chandiwana, S.K. (2006). An assessment of rural women s know, constraints and perceptions of cervical cancer screening: The case of two districts in Zimbabwe. African Journal Reproductive Health; 10 (1): Mosha, D. (2009). Factors associated with management of cervical cancer patients at KCMC hospital, Tanzania. Tanzania Journal of Health Research, 2: Mutyaba, T, Mmiro, F.A., & Weiderpass, E. (2006). Knowledge Attitude and Practice in cervical cancer screening among medical workers of Mulago Hospital; Uganda. BMC Medical Federation 6:13 50

12 Park, M., Park, E., Choi, K., Jun, J., and Lee, K. (2011). Socio-demographic gradients in breast and cervical cancer screening in Korea: Korean National Cancer Screening Survey. BMC Cancer 11:257. Parkin, D. M., and Bray, F. (2006). The Global health burden of infection-associated cancer. Int. J. Cancer 2006 June 15; 118 (12) Samur, C. (2002). Factors involved in the delay of treatment initiation for cervical cancer patients: A nationwide population-based study, Medicine, Baltimore. Singh G.K. (2002). Socio-demographic predictors of PAP test, currency and knowledge among Australian women. Prev Med; 35: Were, E., Nyaberi, Z., and Buziba, N. (2006). Perception of risk and barriers to cervical cancer screening at Moi Teaching and Refferal Hospital, Uganda. BMC Edu; World Health Organization (2010). Comprehensive cervical cancer control: A guide to essential practice. 2 nd edition. 51