Thesis (M Med.(Obstetrics and Gynaecology))--University of Limpopo, 2010. / STUDY RATIONALE: Cervical cancer is the most common cancer of women on the African continent and the second most common cancer of women worldwide and in South Africa ’. It has been estimated in 1997 that, among women who received no cervical screening in South Africa, 1 in 26 women were likely to develop cervical cancer . Screening will probably decrease the incidence of cervical cancer by 60% or more . There is a direct relationship between the number of women screened by Pap smears and the decreased incidence of cervical cancer. In Iceland, where more than 90% of women were screened in that time, the incidence decreased by 80%. In Norway, where only 5% of the women were screened, the incidence only decreased by 10% . In South Africa, it is estimated that Pap smears were taken in 18.8% of white women and only 2.6% of black women in 2002 . Real-world obstacles to successful cervical cancer prevention in develo- ping countries involve people more than technologies 3. This can be ma- naged by focusing on system quality management 3. The root causes of poor quality must be examined. Suba et al 3 found causes such as obso- 7 lete supplies, poorly maintained microscopes, insufficient training and suboptimal working conditions. Successful follow-up for screen-positive women has been achieved through the allocation of budgets for dedicated personnel to recontact women with positive test results 3. Human Papillomavirus (HPV) infection is known to cause cervical can- cer. Human Papillomavirus (HPV) infection is also regarded as the most common sexually transmitted infection worldwide, with an estimated life- time risk of 79% for women to contract at least one infection between the ages of 20 and 79 years . Although some men have anal or genital lesions associated with HPV 16 and 18, most men serve as vectors of oncogenic HPV. Male partners may be important contributors to their female partners’ risk of cervical cancer . The 15 HPV types, which are classified as high risk virus types, cause 95 % of all cervical cancer. The High Risk HPV Genotypes are: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73 and 82. HPV 16 and 18 together cause around 70 % of all cervical cancer ’. Squamous cell cervical cancer constitutes approximately 80% of cervical cancers . Adenocarcinoma is the second most common histological type and shows a rising incidence, even in developed countries . 8 There is geographical variation in type-specific HPV prevalence 9. HPV16 is the most common type associated with adenocarcinomas, except in Southeast-Asia, where the prevalence of HPV 18 exceeds that of HPV 16. HPV 16, 18, 35, 45and 59 are present in 96% of adenocarci- nomas of the cervix 10. A pooled analysis by Clifford et al 9 showed that the prevalence of high risk HPV types is around 18 % in sub-Saharan Africa, with HPV 16 and HPV 35 present in 8% of women. HPV 31 and HPV 33 were present in 7% of women and HPV 18 was present in 4% of women. Sub- Saharan Africa had the highest prevalence of all HPV types and Europe the lowest. The variation in prevalence of HPV 16 across regions was smaller for HPV 16 than for the other high-risk types. The next common high- risk types were HPV 33 and HPV 56 in Asia, HPV 58 in South America and HPV 31 in Europe 9. This study’s rationale was to ascertain the HPV types prevalent in pa- tients with abnormal Pap smears seen at the Gynaecological Outpatients Clinic at Dr. George Mukhari Hospital, the Gynaecological Oncology Clinic at Dr. George Mukhari Hospital, the Tshepang Clinic at Dr. George Mukhari Hospital and the Setshaba Research Centre of the University of Limpopo – Medunsa Campus in Soshanguve. 9 This study can also act as a pilot study for future studies to test the ef- fectiveness of using high risk HPV types screening as a primary screening method, instead of Pap smears, to identify patients who are at a higher risk to develop cervical cancer and who need further investigations such as Colposcopically directed biopsies.

Excerpt: Use of a nylon brush (Cytobrush and others) with spatula to obtain Papanicolaou (Pap) smears from pregnant women is more likely to obtain sufficient endocervical cells, without adverse consequence for the mother or for the fetus.

BACKGROUND : Cervical cancer is the second most common malignancy in women worldwide, and the leading cause of mortality among women. It affects approximately 500 000 women each year with about 270 000 deaths. Almost 80% of the mortalities occur in developing countries. The National Department of Health in South Africa introduced a cervical cancer screening policy in the year 2000. The aim of the policy was to screen more that 70% of the women aged 30 – 59 by the end of 10 years. Women aged 30 – 59 years are offered 3 Pap smears per life time, with an interval of 10 years between the smears. AIM: The aim of the study was to determine the uptake of cervical cancer screening among eligible women (age 30 – 59 years), their practice, knowledge and attitude, as well as the capacity of the facility and the service providers to offer cervical cancer screening service. METHODS: A health systems descriptive study. A two stage sampling technique was done. Purposeful sampling of the healthcare facilities in the defined area was done, targeting the Provincial Health clinics. Records were reviewed at the facility to determine the percent of women aged 30 – 39 years, who used the facility and had Pap smears over the period: August 2003 to July 2007. Facility managers at the Holani clinic and Stanza Bopape Community Health Center were interviewed. Self administered questionnaires were distributed to doctors and professional nurses at both facilities. Questionnaires were also distributed to the women aged 30 – 59 years who visited the facilities during data collection to determine the knowledge, attitude and practice of these women concerning Pap smear. Data entry was done using Epi-Info and Microsoft Excel. Data was analyzed using STATA version 9. Methods applied were frequencies, percentages and cross tabulations. Differences between groups were examined using Fisher’s exact test and Chi-square test. Results were presented in tables and graphs. RESULTS : Record review at Holani clinic indicated that the percent of women aged 30 – 59 years who had undergone Pap smears while attending clinic from January 2004 to July 2007 was 8%. Stanza Bopape had incomplete records. Only about 50% of the women interviewed had undergone Pap smear. Socio-demographic factors like age, education and employment did not have a significant effect on the knowledge, attitude and practice of cervical cancer screening by the targeted service users. Women of lower parity had undergone more Pap smears than those of higher parity. Women of lower parity had more knowledge about Pap smear (p-value=0.05). The knowledge and practice of Pap smear among women aged 30 – 59 years who attended the clinics were significantly associated with getting information from the nurse (p=0.01). Knowledge of the National Cervical Cancer Screening Policy by the service providers was limited. Both facilities had adequate resources for performing the procedure. The number of trained staff per facility was adequate for the performance of the procedure. There was enough privacy to do the procedure. Specimen transportation was adequate, and turn around time was acceptable. CONCLUSION : The extent of Pap smear investigation at the facilities is inadequate. The Service Providers need to calculate the minimum number of Pap smears needed per day to reach the required targets. Nurses at the primary healthcare setting play a major role in improving the uptake of cervical cancer screening. There is a need to actively recruit women to come for Pap smear, while at the same time strengthening health education. Copyright / Dissertation (MMed)--University of Pretoria, 2010. / School of Health Systems and Public Health (SHSPH) / Unrestricted

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