Cervical cancer is a major public health issue; it is the second most common cancer among women in the world, and one of leading cause of death by gynaecologic malignant tumour in developing countries. (I. Shahramian and colleagues 2011)
Besides, cervical cancer is one of the most preventable and curable cancer when it is detected early, and this is due to its slow progression, since it take several years to grow from a detectable precursor lesion.
This key feature provides a large window of about ten years or more for effective early detection of the precancerous lesion, and preventing its progression to invasive cancer.
From this perspective, well organised prevention approaches have been applied by high income countries over the past 50 years, and have resulted in a remarkable decline in morbidity and mortality from this invasive disease.
The screening program is a successful example for effective prevention from cervical cancer, it has been used in the Nordic countries (Denmark, Finland, Iceland and Sweden); this program was examined by the International Agency for Research on Cancer (IARC) in 1960s and it was found that the mortality rate in these countries fell by about three- fourth, The most drastic decrease was marked in Iceland by 84 % and this was due to the wide target age range for screening in this country.(whomb people)
However, over the same period, developing countries have failed through using the same program to reduce the burden of the disease, and cervical cancer continues to menace the lives of thousands of women, this may be due to the lack of an effective prevention strategy.
We will try in this paper to review the determinants of cervical cancer screening among Algerian women, to elucidate the salient barriers regarding screening and to highlight the principal factors influencing the individual health behaviour, for this study, we will use the Health Belief Model as a conceptual framework, we will explain the structure of the Health Belief Model (Becker) and how the different constructs of the model could predict the women's health behaviour regarding cervical neoplasm screening , finally the application of this model as a guiding framework to ground behavioural interventions and to improve attitude of women regarding cancer screening will be discussed.
Epidemiology of cervical cancer/ global burden of the disease
Worldwide, cervical cancer is the second most common cause of death among women (ACCP2004) with an estimate of 493,000 new cases, and 274,000 deaths occurring every year according to the statistics of the International Agency for Research on Cancer (GLOBOCAN, 2002)
In 2008, 530000 new cases were diagnosed, more than 85% of the global burden were registered in developing countries (where it remains the most common cancer seen in women and it accounts for 13% of all female cancers),
In the same year, the cervical cancer was responsible for 275000 deaths, about 88% of which occurred in developing countries
53000 cases in Africa, 31700 in Latin America and the Caribbean, and 159000 cases in Asia. (GLOBOCAN 2008)
The figure below shows incidence of cervical cancer by country, it should be noted that data from developing countries might be underestimated as the official statistics in these countries are not reliable.
Algeria is a large North African country, extended from the Mediterranean Sea down to the Sahara, with about 37 million inhabitants.
Algeria has a population of 11,51millions of women whose ages are 15 years and older, (WHO/ICO2010) which means that about the third of the Algerian population is at risk of developing cervical cancer.
Cervical cancer is the second most common cancer among Algerian women after the breast cancer, "Current estimates indicate that every year 1398 women are diagnosed with cervical cancer and 797 die from the disease" (WHO/ICO2010)
About 10, 5% of Algerian women are estimated harbour cervical HPV, and about 77, 1% of cervical cancers in Algeria are related to HPV 16 or 18. (WHO/ICO 2010)
But we should note that even these statistics might be underestimated,
The economic impact of cervical cancer is significantly heavy for the state. The treatment of a single patient returns to about 2.5 million dinars (â‚¬ 20,000), with this cost we
we can achieve 2000 smears (smear test cost 20 â‚¬) and vaccinate 30 women.
Natural history of cervical cancer
Understanding the process of developing cervical cancer is a crucial step to design an effective program of prevention.
More than 99% cases of cervical cancer are attributed to cervical HPV infection, which is a sexually transmitted disease (STD), the virus is acquired by both men and women through sexual activity, the infection is usually asymptomatic and transient.
HPV is the most common STD in the world; it affects "about 50% to 80% of sexually active women at least once in their lifetime" ( ACCP 2004), they contract it in their teen, 20 or early 30s.
There are more than 100 genotypes of HPV that have been identified, and which are numbered by order of their discovery, about 13 types can lead to invasive cervical cancer and they are known as high oncogenic risk ( 16,18,31,33,35,39,45,51,52,56,58,59,66) (WHO 2007)
The two most common are 16 and 18 causing approximately 70% of all invasive cervical carcinoma (60% related to HPV 16 and 10% to HPV 18) the whom people
The others types of HPV are known as low risk and they usually associated with genital warts (especially 6 and 11) which can grow in the genital part in both men and women (cervix, anus, vulva, vagina, penis, and scrotum) and they cause a significant morbidity.( WHO2007), They are very rarely associated with cervical cancer, but can lead to low grade changes in cervical cells which are very similar to those caused by high risk types. These low lesions are asymptomatic and temporary, however, in some circumstances can evolve and lead to high lesion or invasive cancer.
Table: summarizes the different stages leading to cervical cancer ( ACCP2004)
HPV infection is extremely common among women of reproductive age. The infection can persist, lead to cervical abnormalities, or resolve on its own.
Low-grade lesions are usually temporary and disappear over time. Some cases, however, progress to high-grade lesions.
High-grade lesions, the precursor to cervical cancer, are significantly less common than low-grade lesions. High- grade lesions can develop from low-grade ones or directly from persistent HPV infection.
Invasive cancer develops over the course of several years and is most common among women in their 50s and 60s.
Source: Adapted from PATH 2000.
HPV is a necessary cause but not sufficient to progress from HPV infection to invasive cervical cancer, there are other lifestyle factors that increase the probability to develop the cancer including high parity, young age at first delivery, being in polygamous marriage, women with husband's extramarital sexual relationship (D. Hammouda and colleagues 2004, 2011), long term use of oral contraception, tobacco smoking, certain dietary deficiencies, poor sanitation, multiple sex partner, low socio economic status, and living in a rural environment. In addition, co-infection with HIV, Chlamydia Trachomatis, and Herpes Simplex Virus type 2 (HSV 2)., ( whomb people)
HPV was incriminated in many other anogenital cancer (anus, vulva, vagina, and penis) and cancers of the head and neck.
Understanding that HPV is the primary underlying cause of cervical cancer has focused attention on the potential of early detection of the infection through the cervical screening.
Screening for cervical cancer is based on the use of the Papanicolaou cytology technic (Pap smear test) in which physicians or nurses expose the cervix by speculum and remove cells from the squamous epithelium and transformation zone to detect abnormal precancerous cells.
The American College of Obstetrics and Gynaecology suggest that women should receive the first screening test 3 years after the first sexual intercourse
They also recommend that women should continue receiving cytology screening yearly until the age of 30, from than they can receive it every 3 years.
According to the same college, menopausal women have a lower chance to develop abnormal cervical cells; however, there is no upper age limit to stop the screening. ( Whom people)
Primary prevention have focused on hygiene and reducing risks factor by "reducing the number of sexual partners and encouraging the use of barrier contraceptive especially condoms,"( ACCP2004)
Recently a new vaccine which has the potential to protect against certain type of HPV infection (16 and 18) has been licensed to underpin the preventive program against cervical cancer. The vaccine has been used in many developed countries and shown great results in reducing the burden of the disease, but it has not been introduced in Algeria yet
Pap smear as a cervical cancer screening test
Algeria is one of the developing countries where cervical cancer remains a major health public issue. although the application of screening program, a large population remain under screened, the outcome are very modest and the incidence of cervical cancer is always high and this could be contributed to the lack of awareness about screening test among women and some specific cultural health beliefs barriers, not surprisingly that large proportion of the patients are diagnosed with advanced stage of the invasive cervical cancer, interestingly, even most of the health care providers have never had a pap smear.( ref risk factor ).
Studies show that comprehensive cervical cancer screening is modest in low resources countries; hence a low participation in Pap smear and a low follow up when it is done the first time. It has been stated that screening program in these countries and even among minorities and aboriginal women faced many obstacles; lack of sufficient laboratory infrastructure, high cost of health care, inadequate trained health care providers, absence of provider's recommendation and a lack of appropriate educational programs in these countries that indicate the risk factors of this disease, the importance of screening at early stage, and the power of the Pap smear test to detect the disease in its premalignant stage and so the possibility of full cure and prevention. (S.T. Tavafian 2012)
In addition to these funds and human resources deficiencies that can hindrance an effective and organised screening intervention, there is also the lack of knowledge from the patients regarding preventable cervical cancer as well as the socio-cultural status barriers , such as embarrassment from pelvic examination that have been argued as one of leading obstacle to not receiving screening test,(S.T. Tavafian 2012) another factor is the fear of subject and the entrenched belief that cancer cannot be cured , the lack of optimal knowledge about screening practices ; this extreme fatalistic attitude about cancer among different countries lead women to consider diagnosis as a "death sentence" and so the avoidance of the test,(V.Thomas and colleagues 2005) there is also projects identified religious beliefs, the limited language ability as another major perceived barrier, the lack of social support, the low socio economic status and the inadequate functional health literacy.
There is a study that has been conducted in Spanish among low income Latinas, that found that women with inadequate functional health literacy are 16 times less likely to receive a Pap smear test (S.T. Tavafian 2012)
It has been illustrated that Individual's beliefs, ethnic background, knowledge about a particular illness are significantly interconnected with the healthcare seeking and health promotional behaviour, Al-Neggar and his colleagues concluded that some misconceptions and wrong beliefs may conduct to the poor practice of cervical cancer screening among women, despite the adequate knowledge regarding the risk factors (Al-Neggar and colleague (2010).
One of theoretical models that could be used to identify the determinant of cancer screening and assess the influence of people's beliefs on their decisions to take up cancer screening is the health belief model.
According to the concepts of this model, individuals are more likely to take up screening if they are motivated enough about their health, and they regard themselves as susceptible to develop cancer, believe that effective intervention would be beneficial to reduce the susceptibility and the severity of the condition.
Health belief model as a theoretical framework for predicting behaviour
The health belief model is one of the theory the most commonly used in health promotion and health education, (chapter 4) it was developed in the early 1950s by a group of social psychologists to explain the widespread failure of people to adopt the disease preventive programs suggested and screening test recommended to detect and prevent the disease at its asymptomatic stage,
Later it was applied to study the response of patients to diagnosed disease and their compliance with prescribed medical regimens.(Nancy and colleagues 1984)
This model aims to explain the patient's thoughts process behind his preventive attitude rather than his behaviour after getting the illness.
The underlying concept of the model is that health behaviour and willingness of people to engage in a preventive program or to take up a screening test are determined by personal beliefs and perception of the disease in addition to the different resources available to prevent its occurrence, (chapter 4)
The model provides guidelines to develop strategies for effective intervention and implementation by allowing planners to understand the reasons for not compliance with the recommended suggested preventive systems.
This model assumes that individual's health behaviour is determined by five psychological factors: perceived susceptibility, perceived seriousness, ref perceived benefits and perceived barriers to effective compliance; cues to put into action, recently, there are others constructs that have been added to the model called modifying or motivating factors such as mass media initiatives, campaign, personal materials, social support, health professional and self-efficacy.(V.Thomas and collegues 2005)
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Articulation of cervical cancer screening behaviour to the HBM framework
In this section; I will try through the constructs of the Health Belief Model to explain the relationship between women's belief and health behaviour in Algeria
Perceived susceptibility: personal risk or susceptibility is referred to the personal belief about the likelihood of contracting a disease (S.T. Tavafian 2012), it is one of the most powerful factor that influence people to adopt a healthy behaviour, "the greater the perceived risk, the greater the likelihood of engaging in behaviours to decrease the risk( chapter4).
For screening program, woman will be interested to take up a smear test if she is aware enough of the possibility to get cervical cancer by contracting HPV infection, and that she is exposed to this risk as long as she is sexually active.
The HBM predicts that women are more likely to comply with cervical cancer screening recommendation if they believe that they have risk factor of cervical cancer (Glanz et and colleagues 2008), and vice versa, the belief of not being at risk for cervical cancer or HPV infection preclude (deter, empeche) women to engage in such program, And this is why most virgin women in Algeria underestimate the necessity( believe the futility) of smear test as they think they are protected from the risk of HPV infection because they are not married. Or in other words , because there is no sexual intercourse, virgin woman does not perceive her vulnerability to cervical cancer, although studies show that HPV has been found in some female virgins, which means that the virus does not always need penetrating sex to be transmitted, And that it may be spread through non penetrating sexual contact; and even within married women, the concept that HPV infection is related to multiple sex partner make them believe they are safe from the risk since they have one partner, ignoring the husband sexual behaviour, as many men in Algeria have extramarital sexual relationship underground that the wife unawares, and so she doesn't see herself as susceptible to the risk.
Another worrying factor is that youngest women consider cancer to be an elderly disease, while older women according to cervical screening age limit might think that they are no longer at risk ref( V.Thomas 2005), and so there is a wrong perceive of susceptibility.
Perceived severity: refers to the seriousness of the disease as assessed by the patient, it is usually based on medical information or personal knowledge from television, radio or leaflets, or it may come from the belief of a person about the consequences that would create a particular disease whatever clinical such as death, disability, or social like family life and social relations (chapter4), (S.T. Tavafian 2012),
For screening test, if women believe that cervical neoplasm is a severe disease that would lead to serious difficulties for her and her family, she will view prevention as a priority and so she is more likely to receive a Pap smear test. Also having knowledge about Pap smear test and its importance to detect the invasive disease at early stage will motivate her to receive one, because many women realise the severity of cervical cancer but lack knowledge of screening program, and available service.
Despite the recognition that cervical cancer is a serious issue, most of women in Algeria believe that there is no treatment, which make them see screening test as futile and this perhaps reflects the religious beliefs and the cultural background that may influence their attitude,
Algeria population as most of Muslims agree that illness, recovery and death are all determined from God, so "The majority believe that screening would not prolong their lives and when the time of death comes no one can push it away"( K,Salman2011)
Another point is that the fear from possibility of identification abnormal cells would necessarily lead to other investigations often influence the willingness of the women to attend, especially when there is no one to watch the children during the screening and the lack of significant support. (chapter4)
In Algeria, as in many other Arabic countries, "cancer screening is usually recommended for diagnostic purposes rather than being used as a tool for secondary prevention" ( K,Salman2011) most of women consider the absence of visible symptoms as a sign of good health hence they do not seek health care unless the disease manifests itself and starts to disable her daily activities, and so the cancer is often diagnosed at its advanced stage.
Perceived benefits is about the person's opinion on how much may new behaviour decrease the risk of a particular disease, the HBM predicts that most people have tendency to adopt new behaviour which is seen as a healthy behaviour when they believe the capability of this new behaviour to decrease their risk of developing a disease (Glanz and Colleagues 2008)
Perceived benefits play a major role in the adoption of secondary preventive interventions such as screening, for example, if women believe that Pap smear is important for early detection of the precancerous lesions and prevention of cancer that will motivate them to participate in secondary prevention practice by seeking checks up and periodic screening.
Therefore women are not expected to engage in any screening program unless they perceive that this program is potentially beneficial to reduce the risk, and so health care providers should explain to the patient the ability of screening test to detect changes in cervix before they develop to cancer, which make treatment easier and prevention effective.
Perceived barriers: relate to the individual's vision of the obstacles he will face if he decides to adopt a new behaviour.
In order to undertake a recommended behaviour, a person needs to believe that the benefits expected from it outweigh the outcomes of his old behaviour; this enables him to overcome the perceived barriers and to adopt the new behaviour (chapter4)
For example, if woman believes that benefits of undergoing a screening test outweigh the obstacles that she may face, she is more likely to obtain Pap test.
Previous studies have showed that women who perceived the Pap smear testing as a painful and embarrassing process were less likely to obtain cervical cancer screening, in the same studies women reported many cause that deter them to take the action, such as a negative previous experience, included pain, bleeding, or being faced with inexperienced practitioner who didn't explain the procedure to them during taking the sample, language difficulties was another barrier due the perceive that she will be unable to communicate properly with the health care provider, and to build a trusting relationship.
Even those who appreciated the necessity of the screening, the fear of the test process was a great obstacle for them, as most of women find it uncomfortable, and perceive the metal speculum as a painful instrument. (Abdullah 2009)
Shyness is another major hindrance that may deter screening process, and It is very common for women to refuse to reveal her body parts to undergo a physical exam or a medical procedures especially when the health provider is a man, and even the discussion about a sensitive health issue like marital relationship, sexual activity and reproductively is regarded as very private, and shouldn't be disclosed to other people , especially men, and even husband may sometimes not be involved in his wife's health issue if it is related to her reproductive organs.( K,Salman2011)
Cues to action: are the ensemble of events, things, people that motivate a person to change his behaviour, and this can be mass media such as television, radio, advice from a family or friends, leaflets, information brochure, campaigns, recommendation from health provider,(chapter4)
Women are more likely to take up a pap test if she receives enough information about the benefits of the test from her GP or Gynaecologist, if she receives advice from another woman who had the test, if she is encouraged by a member of her family especially the husband or if she knows someone in her entourage with a history of cancer, all those factors are susceptible to reduce the perceived barriers to cancer screening.
Perceived self-efficacy: it refers to the belief of the person in his own ability to adopt the behaviour required, because people generally don't engage in doing something unless they believe they are able to achieve it. (Chapter 4)
Modifying factors: in addition to what it has been already said, There are other factors that seem to influence the willingness of women to take up the test such as inadequate knowledge about the screening, lack of trusting relationship with the health provide , lack of confidence in the importance of the test, high cost of the test, fear of the result of the test and superstition that talking about cancer would bring it, some stigmata imposed by the community and even sometimes the family that cervical cancer is related to promiscuity, Perception of the Pap smear as a threat for the woman's virginity, some fatalistic attitude that illness, recovery and death are relating to "god's will" and that screening test is futile, Low socioeconomic status, lack of social support, poverty, lack of health insurance (J.Hatcher and colleagues 2011), childhood sexual abuse, obesity, low levels of education, child care, lack of transportation.
Cervical cancer screening- promotion interventions based on HBM
Today, the HBM is used by many researchers to guideline the development of strategies for effective health intervention, In this section, I will try to summarise some finding from the different interventions based HBM that push me to suggest this model to improve women's behaviour in Algeria.
The health belief model has been used by several study, alone or combined with other health promotion models to and to improve belief and behaviours among women regarding the screening program, an example of this study, has been conducted in Iran, in 2010, this study showed that the "HBM has formed the basis for an interventional program to improve behaviour among Iranian women",(S.Tavafian2012),The study was conducted with 70 volunteers- aged between 16 and 54 years, and they had never received Pap test, the participants were divided into many small groups, and each group underwent a session of 2 hour training. For the data collection tool, a self-administered multi-choice questionnaire was developed based on the concepts of the HBM. The personal belief and health practice of all the women were assessed pre intervention and four months later, the findings reported that health education based on HBM construct was effective, and could promote the participant's knowledge and improve the different components of the model (perceived susceptibility, severity, benefits, and barriers).The training program that has been used enhanced the willingness of women to practice the screening test significantly. The study concluded to the fact that education program based on HBM constructs can change women's health beliefs, enhance their knowledge about the cervical cancer and the screening test, and motivate them to adopt a new behaviours. (S.Tavafian2012)
Another study in Somali was about an educational programme about the purpose of the screening test, to encourage Somalis to undertake the test. The participants praised the initiative and suggested that such information should be provided in a community setting, because it would help women to perceive the value of the test, and to overcome the different fatalistic barriers to screening. further, Participants suggested improving the awareness of screening among women via mass media: TV, radio, video, DVDs, CDs and audiotapes (Abdullahi , 2009),
Health promotion (ACCP 2004)( review the title)
There is a lack of information regarding health promotion models that have been used to influence health behaviour among women in Algeria, and even there is no description how the intervention methods were selected,
Alliance for Cervical Cancer Prevention (ACCP) consists of five international health organizations who share all the same goal to prevent cervical cancer in limited-resource countries.it aims through its projects to implement an effective prevention strategies to minimise the burden of the cervical cancer .unfortunately ,Algeria has not been included in this initiative, through my review of this manual , I would suggest it as an approach to improve women's health is Algeria and to promote health service delivery.
Many method of diagnostic, screening and treatment are currently used. And each of them has strengths and limitations, this method should be reviewed to pick up the most appropriate for the patient,
for the screening for example the Pap smear test is the most commonly used, this test requires multiple and regular visit from the client, which can be a barrier for the woman to attend it,
The ACCP suggest some alternative approach with better sensitivity and specificity such as Human papillomavirus (HPV) DNA testing, or visual screening, a low cost method with an immediate result.
As a health care facility, they suggest to combine the treatment of precancerous lesions to the screening process, and propose some effective and safe methods that should be performed by physician and not physician. These treatment methods allow cure and histological verification at the same time, it has been shown that this initiative was praised by women and providers as well, and it has a great result to lower rate morbidity.
The combination of both effective screening approach and treatment would overcome the limitation.
Facility women's access to precancer treatment services, through selecting a program to link screening services to precancer treatment services. This would increase the effectiveness and encourage woman to follow up.
Achieving widespread screening coverage of the target population by selection of well-organised prevention approach. And this may include the policymakers and authorities who should encourage the investment in cervical cancer prevention
Planning an effective prevention intervention: Planning a prevention program requires a coordination between a multidisciplinary management team, that include clinical, administrative, and training specialists.
To achieve the program's objective, the team members should follow a participatory process which includes also the perspective of lay people who are concerned by the outcome of this program, and this will allow achieving a high screening coverage with satisfactory result.
Improving health services and laboratory infrastructures: delivery services should be accessible, acceptable, affordable, and reliable to satisfy the client and ensure a high coverage of the population target
Training: Ensuring Performance to Standard Ensure to qualify a competent staff and health provider, to attract client to use the facilities available and this would happen by training session that enable provider to confidently offer reliable services
Providing Information and Counselling to Address Community and Client Needs
Women target group should be informed enough the benefits of screening and availability of prevention services to increase the effectiveness of the program, and this could happen by direct contact between woman and health worker or through mass media and campaign, Social network interventions, mailed invitation letter for screening and reminders, information brochure which are very popular to spread information about health topics. It has been stated that direct provider contact is more effective to increase the use of prevention services as the individual counselling will address concerns and emotional need and should be more convincing
Overview of screening, treatment and Palliative Care services of cervical cancer Cervical cancer screening services, cervical cancer treatment, and palliative care services should be continuously linked to ensure the effectiveness of the program