Nigerian Journal of Clinical Practice

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 22  |  Issue : 6  |  Page : 745--749

Does introduction of user fees affect the utilization of cervical cancer screening services in Nigeria?


TK Nyengidiki, N Inimgba, G Bassey, RN Ogu 
 Department of Obstetrics and Gynecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria

Correspondence Address:
Dr. T K Nyengidiki
Department of Obstetrics and Gynecology, University of Port Harcourt Teaching Hospital, Rivers State
Nigeria

Abstract

Background: Screening for cervical cancer improves outcome. This comes at an economic price which some may not be able to afford. Objective: To evaluate the influence of user fees on the utilization of cervical cancer screening services in Port Harcourt. Materials and Methods: A cross sectional study of clients presenting for cervical cancer screening. Data on the number, socio-demographic characteristics, distance from screening center following 1 month of free cancer screening and 7 months of user fee introduction, was collated and analyzed using SPSS version 20 statistical software. Results are presented in percentages, tables and charts with test of significance set at P < 0.05. Results: Of the 167 women who presented for cervical cancer screening during the study period, the mean age was 42.08 ± 8.9 years and range was 20–70 years. The average parity of patients was 2.83 ± 2.24. Clients' utilization of cervical cancer screening facilities was negatively affected by the introduction of user fees P < 0.001). There is no association between the distance of patients' home from the hospital and the utilization of facility (X2 = 0.24, P = 0.887). There was sustained decrease in number of clients with the introduction of fees. Conclusion: The introduction of user fees had a negative impact on the utilization of cervical cancer screening facilities. Eradicating user fee and improving the socioeconomic status of patients may improve the utilization of screening services.



How to cite this article:
Nyengidiki T K, Inimgba N, Bassey G, Ogu R N. Does introduction of user fees affect the utilization of cervical cancer screening services in Nigeria?.Niger J Clin Pract 2019;22:745-749


How to cite this URL:
Nyengidiki T K, Inimgba N, Bassey G, Ogu R N. Does introduction of user fees affect the utilization of cervical cancer screening services in Nigeria?. Niger J Clin Pract [serial online] 2019 [cited 2019 Jun 26 ];22:745-749
Available from: http://www.njcponline.com/text.asp?2019/22/6/745/260031


Full Text



 Introduction



Worldwide, cervical cancer comprises approximately 12% of all cancers in women.[1] It is the second most common cancer in women worldwide, but the commonest in developing countries. Global estimates of 528,000 new cases and 266, 000 deaths from cervical cancer annually had been reported from 2012 report of GLOBOCAN[1] with 80% of patients presenting late in developing countries.[2] In most countries in North America and Western Europe, the incidence of cervical cancer has been falling.[3] In many developing countries, however, cancer of the cervix incidence has changed little except for those countries that have achieved the demographic (epidemiological) transition with increasing affluence from industrialization.[4] Evidence of successful organization of screening programs abound in most developed countries where morbidity and mortality had been significantly reduced.[5] The success of these programs can be attributed to the establishment of organized screening by the various health authorities accomplished by legislative backing and enough political will on the part of the various Governments. These moves enable assigning of specific budgetary allocation to the prevention of gynecological cancers in addition to the incorporation of screening programs as part of the National Health insurance schemes of the various countries hence reducing cost and improving access to the use of cervical cancer preventive strategies.

There are several factors that have been put forward that mitigate against the various screening programs in third world countries such as poverty, ignorance, the presence of conflicting demands for the limited resources for the populace, poor economic state of most of the countries, lack of legislative backing and absence of political will.[6],[7],[8]

The traditional screening test in most centers in Nigeria for cervical cancer is the Papanicolaou test whose average cost in most developed countries is about 30 USD. Most women have favorably accepted this test because it is an easy outpatient procedure that is well tolerated by them. It has also been noticed to have a sensitivity of 41–78% and a specificity of 91–96%.[9] In addition, the test has the following strengths: decades of experience in its use, high specificity, relatively low cost, qualified manpower, and laboratory resources exist in most countries. However, there are limitations of the test. These include: the test is embarrassing and is difficult to comprehend in many cultures, requires trained personnel, smear adequacy not intrinsically obvious, it may be necessary to recall women for further tests if the smear is inadequate or for evaluation if an abnormality is suspected. Effective national Papanicolaou Smear screening has been shown to reduce cervical cancer incidence by 80% only when it has at least 70% coverage.[10],[11],[12]

In the light of the above, this study evaluates the impact of the introduction of user fees to accessing Papanicolaou smear screening method in a newly opened screening facility in a tertiary health facility in Port Harcourt, Nigeria.

 Materials and Methods



This was a cross sectional descriptive study of women presenting for Pap smear screening at the University of Port Harcourt Teaching Hospital from the 1 February 2014 to 1 March 2014. The sample size was determined using the Fish Formula for cross sectional descriptive studies,[13] using a utilization of cervical cancer services of 21%[14] at 95% confidence interval and desired precision rate of 7.5% a minimum sample size of 114 was estimated, however a total of 167 women were recruited. All women who presented to the cervical cancer-screening center and were screened were recruited into the study during the duration of the study. All patients who presented to the screening center for the month of February were offered free Pap smear test as part of the celebration of world cancer day. Data on the number, sociodemographic characteristics and distance of screening center from patients' residence were collated. After the one-month period, a Pap smear screening fee of 4,000 Nigeria Naira (25USD) was introduced and the number of clinic attendees, sociodemographic characteristics, and distance of patients' residence from center was collated over a 7-month period from 2 March to 2 October 2014. There was no publicity made regarding the cost of the procedure; women who presented to the screening center were informed of the free nature of the screening for the one month of February. Subsequent months, had fees introduced without prior information to the patients. Data collated was analyzed using SPSS version 20 statistical software. Results are presented in percentages, tables and charts with test of significance set at P < 0.05.

Ethical and institutional approval was obtained from the Ethics Committee of the University of Port Harcourt Teaching Hospital with ethical approval number ADM/90/S11/VOL 357. Informed consent for the Pap smears was also obtained from the patients before the procedure.

 Results



During the 8-month period, a total of 167 women with mean age of 46.24 ± 12.34 years presented to the center for Pap smear screening. The average parity of patients was 2.83 ± 2.24. A greater proportion (72.5%) of the clients who utilized the cancer screening service were multiparous (Multipara and grandmultipara) [Table 1]. A total of 81 (48.5%) women presented the same month when free cervical cancer screening was introduced as against 86 (51.5%) women who presented in the subsequent 7 months after a fee was attached. Following the introduction of user fees of $25, 23 (13.8%) clients presented for screening for the month of March, 10 (6.0%) for the month of April, 14 (8.4%), 12,(7.2%), 9,(5.4%), 7 (4.2%), 12,(7.21%) for the month of May to September respectively [Figure 1]. There was no association between the clients' utilization of cervical cancer screening facilities and the distance of patients' home from the hospital (X2 = 0.24, P = 0.887) [Table 2]. [Table 3] showed there was significant association between the clients' utilization of cervical cancer screening facilities and the introduction of user fees (Fisher'exact P value <0.001).{Table 1}{Figure 1}{Table 2}{Table 3}

 Discussion



Successfully organized, population-based cervical cancer screening programs have not yet been implemented in most developing countries. This is in spite of the fact that age standardized incidence rate for cervical cancer in developing countries range from 15 to 55 per 100 000 people compared to less than 10 per 100 000 people in the developed countries.[15] It is recognized that stage per stage,morbidity, and mortality of cervical cancer is significantly reduced the earlier the treatment is instituted and thus the importance of early and effective screening.

Reasons adduced for none use of facility for cervical cancer screening include presence of conflicting demands for the limited resources for the populace, poor economic state of most of the countries, lack of legislative backing and absence of political will among others.[6],[7],[8]

The key finding in this study was the precipitous decline in the utilization of the cervical cancer screening facility with the introduction of user fee. This finding is however expected because in most African societies women have a status subservient to men, with less control over family resources, minimal access to money and, in general, inferior social power.[16] This was in agreement with the finding in 2003 by Tornberg et al. in Sweden who reported a decline in cervical cancer screening of 15% after a policy change was made which required patients to pay for services.[17] The finding was however contrary to that by Alfonzo et al. (2016) also in Sweden, who reported that the abolishment of a modest screening fee in socially disadvantaged urban districts with low coverage did not increase attendance in the short term.[18] This disparity between and within countries can be explained by the difference in gross national income (GNI) per capita. According to the World Bank, the GNI per capita of Nigeria in 2014 when this study was conducted stood at 2,980USD while it was 61,030USD for Sweden for the same period.[19] Sadly, competing healthcare priorities posed by the burden of infectious diseases, coupled with a trend of shrinking public health budgets, is overwhelming in many developing countries, and makes cancer screening less of a priority. Evidently, increasing affluence of a society impacts positively on their readiness to access healthcare services, because although Tornberg et al. in 2003 reported a decline of 15% for cervical screening attendance (GNI per capita: 32,480USD), Alfonzo et al. reported no change in attendance despite abolishment of screening fees (GNI per capita: 54,590USD).[19]

The association between travel distance to the screening site and participation rates has been studied internationally, but the results have been inconclusive. We found that distance had no effect on the uptake of cervical cancer screening in our study population. This finding was similar to that by Coughlin and King,[20] but at variance with reports by other investigators who reported that a longer distance was associated with a higher risk of non-attendance in some studies.[21],[22] The disparity in findings may be related to the methods used to assess the distance which vary from using women's self-reports, to applying various types of geographical software to calculate the distance. Distance calculation in these studies was based on women's complete addresses, postal codes, a combination of the two or self-reported county of residence.

Limitations of this study

This is a cross-sectional study with limited study population and a fairly high precision rate and may not be a very accurate representation of the factors affecting uptake of cervical cancer screening services by the entire female population. A population-based qualitative study with a large sample will ensure a high level of statistical precision.

 Conclusion



Non-attachment of user fees to cancer screening programs encouraged the presentation of women for screening with the aim of detecting precancerous lesions of the cervix hence reducing the incidence of frank cervical cancers. The introduction of user fees statistically influenced the utilization of cervical cancer screening facilities with a significant drop in the number of patients presenting. Improving the socioeconomic status of patients or eradicating user fees will go a long way to improving the utilization of screening services in developing countries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136:E359-86.
2Jemal A, Center MM, DeSantis C, Ward EM. Global patterns of cancer incidence and mortality rates and trends. Cancer Epidemiol Biomarkers Prev 2010;19:1893-907.
3Coleman M, Estève J, Damiecki P, Arslan A, Renard H. Time trends in cancer incidence and mortality. IARC Sci Publ 1993;121:1-806.
4Cervical cancer screening in developing countries- Report of a WHO consultation. Available from: www.who.int/cancer/media/en/cancer_cervical_37321. [Last assessed on 2018 Jan 29].
5McCrory DC, Matchar DB, Bastian L, Datta S, Hasselblad V, Hickey J, et al. Evaluation of cervical cytology. Evid Rep Technol Assess (Summ) 1999:1-6.
6Akinola SE, Awotunde OT, Attansey AC, Adeyemi AS, Atanda OO. Gynaecological consultations at the Bowens University Teaching Hospital Ogbomoso, Nigeria. Savan J Med Res Pract 2012;1:32-6.
7Were E, Nyaberi Z, Buziba N. Perceptions of risk and barriers to cervical cancer screening at Moi Teaching and Referral Hospital (MTRH), Eldoret, Kenya. Afr Health Sci 2011;11:58-64.
8Ndejjo R, Mukama T, Kiguli J, Musoke D. Knowledge, facilitators and barriers to cervical cancer screening among women in Uganda: A qualitative study. BMJ Open 2017;7:e016282.
9Sankaranarayanan R, Gaffikin L, Jacob M, Sellors J, Robles S. A critical assessment of screening methods for cervical neoplasia. Int J Gynaecol Obstst 2005;89(Suppl 2):S4-12.
10Lăără E, Day NE, Hakama M. Trends in mortality from cervical cancer in the Nordic countries: Association with organized screening programmes. Lancet 1987;1:1247-9.
11Quinn M, Babb P, Jones J, Allen E. Effect of screening on incidence of and mortality from cancer of cervix in England: Evaluation based on routinely collected statistics. BMJ 1999;318:904-8.
12Adegoke O, Kulasingam S, Virnig B. Cervical cancer trends in the United States: A 35-year population-based analysis. J Womens Health (Larchmt) 2012;21:1031-7.
13Jekel JF, Katz DL, Elmore JG. Sample size randomization and probability theory. In: Jekel JF, Katz DL, Elmore JG, editors. Epidemiology, Biostatistics and Preventive Medicine. 2nd ed. Philadephia: WB Saunders; 2001. p. 196-204.
14Neema MK, Denna M, Nyasule MN, Candida M. Ultilization of cervical cancer screening services and its associated factors among primary school teachers in IIala Municipality Dares Salaam Tanzania. BMC Health Serv Res 2015:15:552.
15Curado MP, Edwards B, Shin HR, Storm H, Ferlay J, Heanue M, et al. Cancer Incidence in Five Continents. Vol. IX. Lyon: IARC Scientific Publications; 2007.
16Makama GA. Patriarchy and gender inequality in Nigeria: The way forward. Eur Sci J 2013;9:115-44.
17Tornberg S, Lidbrink E, Henriksson R. Free of charge mammography gets more people to the examination. Study in Stockholm County shows good efficacy in socioeconomically disadvantaged areas. Lakartidningen 2014;111:278-81.
18Alfonzo E, Andersson EA, Nemes S, Strander B. Effect of fee on cervical cancer screening- screen fee, a Swedish population-based randomised trial. PLoS One 2016;11:e0150888.
19World Bank. World Bank Classification According To GNI. 2014. Available From: http://data.worldbank.org/country. [Last accessed on 2018 Mar 30].
20Coughlin SS, King J. Breast and cervical cancer screening among women in metropolitan areas of the United States by county-level commuting time to work and use of public transportation, 2004 and 2006. BMC Public Health 2010;10:146.
21Mupepi SC, Sampselle CM, Johnson TR. Knowledge, attitudes, and demographic factors influencing cervical cancer screening behavior of Zimbabwean women. J Women's Health 2011;20:943-52.
22Cunningham MS, Skrastins E, Fitzpatrick R, Jindal P, Oneko O, Yeates K, et al. Cervical cancer screening and HPV vaccine acceptability among rural and urban women in Kilimanjaro Region, Tanzania. BMJ Open 2015;5:e005828.