Effect of mobile health intervention on perception and uptake of cervical cancer screening among nurses in Jos University Teaching Hospital

Olutomi Yewande Sodipo^1,&, Tolulope Olumide Afolaranmi², Hadiza Abigail Agbo², Ayuba Ibrahim Zoakah², Chikaike Ogbonna²

 

¹Department of Community Medicine, Jos University Teaching Hospital, Jos, Nigeria, ²Department of Community Medicine, Jos University Teaching Hospital, Jos, Nigeria

 

 

^&Corresponding author
Olutomi Yewande Sodipo, Department of Community Medicine, Jos University Teaching Hospital, Jos, Nigeria.

 

 

 

 

Cervical cancer is the fourth most common cancer in women worldwide. In 2018, an estimated 570, 000 women were diagnosed with cervical cancer globally and about 311, 000 women died from the disease [1]. Of these, Africa was home to 119,284 (20.9%) new cases, and 81,687 (26.2%) deaths. In Nigeria, there were 53.1 million women aged ?15 years old at risk for cervical cancer in 2018 [2]. The annual number of new cervical cancer cases was 14,943 (15.07%) with 10,403 (17.19%) cancer deaths in 2018 [2].

 

One of the cost-effective interventions in the fight against cancer is early detection. In spite of this, the utilization of cervical cancer screening services in developing countries still remains low compared to developed countries [3,4]. A 2015 analysis of population-based World Health Surveys indicated that cervical cancer screening coverage in developing countries averaged 19%, compared to 69% in developed countries [5,6]. Studies in developing countries such as Tanzania and Malaysia have reported screening rates of 9% and 27.2% among women in the general population respectively [7,8]. In Nigeria, screening uptake among women in the general population has been abysmally low and has ranged from 1.4% to 8.7% [4,9-11]. In Nigeria, the evidence suggests that screening uptake among women in the general population as well as nurses who are usually looked upon as role models in health promotion is low [11-13]. These low cervical cancer screening uptake rates have led to most women in developing countries being diagnosed with advanced cervical cancer, where opportunity for cure may not be ascertained [1]. This low cervical cancer screening uptake rate among nurses is worrisome because they form the largest category of health professionals directly involved in cervical cancer screening and advocacy [14]. Hence nurses need to develop the right perception themselves towards cervical cancer screening uptake as this is critical for cervical cancer prevention in addition to providing patients with requisite information [15].

 

Some studies have shown that the use of mobile health as an educational tool has been effective in improving the uptake of Pap smear test among women [16-18]. Therefore, this study assessed the effect of a health belief model-based education via WhatsApp on perceptions and cervical cancer screening uptake among nurses. The findings of this study will help to serve as a baseline for further studies in the area of mobile health education in Plateau State and Nigeria and other countries alike.

 

 

Study setting

 

Jos University Teaching Hospital (JUTH) is a Federal Government owned 600-bed capacity tertiary hospital that offers health care to clients in Jos and its environs [19]. Plateau State is in the North Central region of Nigeria. It has a land mass area of 26,899 square kilometres, with a projected 2021 population of 4,807,589 [20]. The State shares boundaries with Bauchi State (North East), Kaduna State (North West), Nasarawa State (South West) and Taraba State (South East) [20]. Plateau State has seventeen (17) Local Government Areas (LGAs) which are grouped into three senatorial zones: northern, central and southern zones. The state capital, Jos is located in the northern senatorial zone. This zone has six LGAs namely Barkin Ladi, Bassa, Jos East, Jos North, Jos South and Riyom. Majority of the inhabitants are civil servants (mainly in the urban areas), farmers (found mainly in the rural areas), miners and traders. The two major religions are Christianity and Islam [20]. The hospital was established in 1975 and serves as a referral centre for many government, faith based, non-governmental organizations and private health facilities within and outside the state [20]. The hospital has various departments such as Surgery, Orthopaedics, Ophthalmology, Theatre, Clinics, Medicine, Paediatrics, Psychiatry, Neurology, Infectious diseases and Community Medicine [20]. The hospital has an established cervical cancer screening service unit domiciled in the department of Obstetrics and Gynaecology [20].

 

Study population

 

The study population comprised of female nurses in JUTH. There were 391 female nurses currently working in JUTH. The female nurses work in the various units of the hospital: Surgery (15), Orthopaedics (23), Ophthalmology (11), Obstetrics and Gynaecology (86), Theatre (38), Clinics (27), Medicine (68), Paediatrics (60), Psychiatry (20), Neurology (22), and Infectious disease (21).

 

Inclusion criteria

 

• Nurses who had been on JUTH´s employment for at least one year. This duration enabled enough time to be aware of the availability of the cervical cancer screening service in JUTH.
• Nurses who possessed an smart mobile phone and made use of WhatsApp messenger as evidenced by the presence of the WhatsApp messenger application on their phones.
• Nurses who gave consent to be part of all phases of the study (pre-intervention, intervention and post-intervention).

 

Exclusion criteria

 

• Nurses who had been diagnosed with cervical intraepithelial neoplasia (CIN) of any stage or cervical cancer in the past or any other cancer and/or had chemotherapy for any other cancer.
• Those who had hysterectomy (as the cervix would have been removed) or were currently pregnant (pregnancy offers more opportunities to have a Pap smear being offered during visit to the Obstetrics and Gynaecology department).
• Nurses who were on any form of leave during the commencement of the study e.g., annual, study, sick or terminal leave. This was to ensure that respondents were easily accessible.

 

Study design

 

This was a quasi-experimental study to assess the effect of a mobile health intervention on the perception and uptake of cervical cancer screening among nurses in JUTH. It was conducted between April 2020 and October 2020 among female nurses in JUTH.

 

Sample size

 

The minimum sample size was 148, calculated using the formula for an experimental study for a before and after study [21]. A 95% confidence level was used for the study and a p ≤0.05 was considered statistically significant. The proportion of 0% and 5.71% as the level of uptake of cervical screening (pap smear) before and after intervention in a previous study in South Africa was used [22].

 

per group

 

Where;

 

n = minimum sample size

 

Zα = standard normal deviate corresponding to 5% level of significance =1.96

 

Z1-β = statistical power of the test at 80% = 0.84

 

P = p1+p2/2

 

p1 = level of uptake of cervical screening (Pap smear) before intervention in a previous study in South Africa = 0% = 0.0

 

p2 = level of uptake of cervical screening (Pap smear) after intervention in a previous study in South Africa = 5.71% = 0.0571

 

P = 0.0571+0/2 = 0.02855

 

p2 - p1= 5.71% - 0% = 5.71% = 0.0571

 

Minimum sample size calculated was (1.96 + 0.84) 2 x 2 x 0.02855 (1-0.02855) / (0.0571)2 = 133.4

 

The sample size was adjusted for loss to follow up using an attrition rate of 10%.

 

Adjusted sample size = Minimum sample size / 1-anticipated non-response rate

 

133.4 / 1-0.10 = 148.2

 

This gave a sample size of 148 nurses sampled per group i.e., from each hospital.

 

Sampling technique

 

Respondents were selected via a stratified sampling technique. The list of service units where nurses worked were obtained from the heads of department of Nursing services in JUTH. The list of female nurses in each of the service units were also obtained from the heads of department and the lists of female nurses were serialized and allotted unique identifiers. The lists served as the sampling frame for each service unit. The number of female nurses sampled from each of the service units was calculated using proportion to size allocation formula to ensure proper representation of each of the service units due to the heterogeneous nature of each of the unit. After the number of female nurses to be sampled from each unit was derived, simple random sampling by balloting (without replacement) was carried out to select the study participants that would be administered the questionnaire in each service unit. In the event that a nurse sampled from the random numbers was on leave or declined consent, the unique identifier number was excluded (kept aside) and another number was picked from the numbers generated by simple random sampling. This was done until the minimum sample size was met. Research assistants were trained for a day lasting 3 hours by the principal researcher on obtaining informed consent, good ethical conduct, content and method of questionnaire administration.

 

Study instrument and data collection

 

Data collection was done using a structured self-administered questionnaire. The research assistants´ role was to deliver the questionnaires to the departments and the nurses as well as follow up with the department heads to ensure all sections of the questionnaire had been filled and for retrieval of questionnaires.

 

The questionnaire was adapted from the Champion´s Health Belief Model (CHBM) scale, [23] the Cervical Cancer Awareness Measure Toolkit [24] WHO and “Improving data for decision-making: a toolkit for cervical cancer prevention and control programmes” [25] which are all validated tools. The questionnaire was pre-tested among 10% of nurses at another hospital. Specialists in the department of Obstetrics and Gynaecology, Public Health and Nursing were given copies of the questionnaire to make comments and determine if the content of the questionnaire was understandable to nurses, if the questions were structured properly and able to answer the study objectives and if the questions followed a logical sequence. Pre-intervention assessment of the perceptions and self-reported uptake of cervical cancer screening of nurses was carried out. Following the pre-intervention, a mobile health education intervention was administered via WhatsApp over a duration of four weeks. The health education intervention comprised of two messages per week, on Tuesday and Saturday for a duration of four weeks. The health education content was provided in the form of text, infographics and videos and was based on the Health Belief Model and it covered aspects on statistical facts on cervical cancer morbidity and mortality (knowledge) and information about susceptibility against the risk of cervical cancer, perceiving severity and seriousness of the disease (perceived susceptibility and severity), information about benefits of Pap smear test and other cervical cancer screening techniques, facts on cervical cancer screening rates, information on the availability of Pap smear tests (perceived benefits and health motivation) and decreasing barriers of Pap smear test (perceived barriers).. This model places emphasis on the individual´s perceptions, beliefs and awareness of a disease or preventive health behaviour [26]. Twelve weeks after, a post-intervention assessment was carried out using the same questionnaire.

 

Measurement of variables

 

Independent variables were socio-demographic characteristics. Dependent variables were self-reported uptake of cervical cancer screening as the primary outcomes and perceptions of cervical cancer (perceived susceptibility, seriousness, benefits, self-efficacy, cues to action and barriers) as the secondary outcome. Perceptions was based on the Health Belief Model scale which has six constructs; perceived susceptibility, seriousness, benefits, self-efficacy, cues to action and barriers. All items of the constructs had five-point Likert-type response choices: strongly disagree (1 point), disagree (2 points), neutral (3 points), agree (4 points), and strongly agree (5 points). Each of the subscales were assessed separately. Median construct scores were calculated for each participant. Higher scores of perception constructs indicated stronger feelings about that construct [27].

 

Data analysis

 

Data collected at pre and post intervention were processed and analysed using IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N.Y., USA). Qualitative data was presented as frequency tables and percentages. Quantitative data was presented using median and interquartile range for variables not normally distributed as evidenced by the Shapiro-Wilk test of normality (p <0.05). Frequencies and percentages were used to determine the proportion of the perceptions. These perceptions were perceived susceptibility, perceived seriousness, perceived benefits, self-efficacy, cues to action and barriers. Each perception construct was graded as high and low perceptions (based on the median score) and presented as frequencies and proportions. Chi square test was used to compare the high and low perceptions between the two groups. A 95% confidence level was used for the study and a p-value of ≤ 0.05 was considered statistically significant. McNemar´s test was calculated to compare perceptions before and after the intervention as well cervical cancer screening uptake before and after the intervention. A 95% confidence level was used for the study and a p ? 0.05 was considered statistically significant.

 

Ethical consideration

 

Ethical clearance (JUTH/DCS/IREC/127/XXX/2094) was obtained from the Jos University Teaching Hospital Human and Research Ethics Committee. Permission was obtained from the Head of Department, Nursing Services from JUTH. Written informed consent of participants was sought before enrolment into the study. Participants were assured that the information provided would be anonymous and confidential. Participants were also allowed to opt out of the study at any time without loss of any benefits of the study.

 

 

The age range of the respondents in this study was 23 - 66 years with a median age of 45.0 (35.00 - 51.75) years. Majority were married (83.8%, 124/148) and nursing officers grade level II (NO II) made up 37 (25.0%) closely followed by chief nursing officers 35 (23.6%) (Table 1).

 

The age of respondents was statistically significantly associated with uptake of cervical cancer screening (☓² = 25.520; p <0.001). Those aged 41-50 years had the highest proportion of uptake; 32 (40.0%). Cadre was also statistically significantly associated with uptake of cervical cancer screening (☓² = 16.407; p = 0.006). The Chief Nursing Officer cadre (CNO) had the highest proportion of having been screened. There was also a statistically significant association between the duration a nurse had worked in the hospital and uptake (☓² = 10.803; p = 0.005). Those who had worked for 11- 20 years had a higher proportion of those who had been screened; 32 (35.9%). Interestingly, those who had not rotated through the cervical cancer unit in the hospital had the higher proportion of cervical cancer screening uptake and this association was statistically significant (☓² = 17.914; p < 0.001) (Table 2).

 

Nurses with high perceived susceptibility decreased from 28 (18.9%) to 16 (10.8%) and this was statistically significantly different (p = 0.045). High perceived benefits increased from 118 (95.3%) to 148 (100%) and this was statistically significantly different (p <0.001). Nurses with high self-efficacy increased from 112 (75.7%) to 129 (87.2%) and this was statistically significantly different (p <0.001). Nurses with high perceived cues to action increased from 74 (50%) to 85 (57.4%) but this difference was not statistically different. The proportion of nurses with high perceived barriers decreased from 57 (38.5%) to 14 (9.5%) and this was statistically significantly different (p <0.001). There was a statistically significant difference between perceived seriousness before and after the intervention (p <0.001). High perceived seriousness decreased from 75 (50.7%) to 35 (23.6%) (Table 3).

 

After the intervention, the number of nurses screened for cervical cancer increased from 89 (60.1%) to 98 (66.2%) The difference between the screening uptake at baseline and post intervention was statistically significant (p = 0.0039) (Table 4).

 

 

Following the mobile health intervention, there was a reduction in the proportion of nurses with high perceived susceptibility. This finding was in agreement with the study in Ghana where perceived susceptibility in the intervention group reduced but differed from studies in Iran and Greece where there was a statistically significant increase in perceived susceptibility[18,28,29]. The reason for the reduction in high perceived susceptibility in this study compared to other studies could be due to the fact that respondents in this study were nurses and hence assumed to be more learned than the women who were non-health workers sampled in the other studies. Probably the information provided cleared some doubts in their mind with regards their susceptibility. It could also be that the health education enabled the nurses in the intervention group to evaluate their level of risk about cervical cancer, thereby being more equipped with adequate information about the risk factors, hence being more prepared to adopt measures that will protect them from getting the disease [28]. The reduction in perceived susceptibility could also be due to social desirability bias whereby nurses might want to provide socially acceptable responses based on the role they play in the health promotion and prevention. However, other studies have implied that the continued and prolonged exposure to educational messages can increase the perceived susceptibility to cervical cancer and to carrying out the Pap smear test and constantly sending cervical cancer messages through mobile health interventions such as WhatsApp can be effective in the prevention and control of cervical cancer [18].

 

There was an increase in the proportion of nurses with high perceived benefits. The improvement in perceived benefits was comparable to the findings from other studies [18,28,29]. This finding shows that training of nurses through WhatsApp like any other method of training could highlight the advantages of screening tests in the prevention of cervical cancer. It also indicates that the participants may have clearly understood the benefits of cervical cancer screening as a result of the mobile health education intervention[28].

 

The proportion of nurses who had high perceived self-efficacy increased from baseline. This was in agreement with the Iranian study where perceived self-efficacy increased after the intervention [18]. In this study, there was also an increase in the proportion of nurses with high perceived cues to action. This increase in self-efficacy and cues to action was also recorded in face-to-face interventions[30]. This increase in high perceived self-efficacy and cues to action indicates the effectiveness of mobile health intervention in leading to positive behavioural change. This implies that an intervention that can lead to an increase in self-efficacy is critical in ensuring individuals successfully carry out actions that can potentially improve their health [28].

 

Nurses with high perceived barriers significantly reduced following the intervention. This was in agreement with the decrease in perceived barriers in the intervention group in Iran and Greece but differed from the study in Ghana where the proportion of women with high perceived barriers increased [18,28,29]. These contrasting findings could imply that health education exposed women to the reality of the problem of cervical cancer by enlightening them on the challenges to seeking cervical cancer screening and also correcting previous misconceptions held as perceived. It also shows that correcting people´s perceptions of barriers to cervical cancer is possible not only through face-to-face interventions but also through mobile health interventions.

 

There was a reduction in the proportion of nurses with high perceived seriousness following the mobile health intervention. This differed from the findings of studies in Iran and Ghana which witnessed a significant increase in women with higher perceived severity in the intervention group compared to the control group [18, 28]. The implication of this finding could mean that the health education provided in the intervention group corrected some misconceptions the nurses had before hence the reduction in perceived seriousness. On the other hand, the increase in perceived seriousness recorded in the other studies could imply that the health education might have enabled participants to evaluate the complications associated with the disease and how these could impact their health and well-being.

 

Following the intervention, there was an increase in the number of nurses who reported being screened for cervical cancer. This increase in screening uptake was also observed following a mobile health education intervention via Telegram to women in Iran and also a mobile health education intervention via text messages in Korea[18,31]. However, the Iranian study recorded a higher increase in screening uptake than this present study as well as the Korean study[18,31]. The variations could be due to difference in the characteristics of respondents. For instance, the Iranian study sampled only married women who had never had a Pap smear test done while this present study sampled respondents irrespective of whether they had been screened before. In addition, the Korean study sampled only one married woman and other respondents were classified as “others” while this present study also sampled unmarried women which studies have shown have a lower screening uptake due to the social stigma associated with premarital sex[31]. The COVID-19 pandemic could also have played a role in this present study as nurses might not have wanted the added exposure to a test especially if they were asymptomatic. In addition, the number of nurses per shift had been significantly cut down to limit human-human interaction, hence this might have discouraged nurses from having to visit the cervical cancer unit solely for the purpose of having a Pap smear.

 

Limitations

 

• Uptake of cervical cancer screening was assessed via self-reporting hence could not be verified. Participants were encouraged to provide honest answers only.
• Sampling of unmarried respondents might have affected the results obtained on screening uptake due to social desirability bias which is a tendency of respondents to answer questions in a manner that will be viewed favourably by other respondents or the interviewer. Participants were encouraged to provide honest answers only and assured of confidentiality.
• The effect of the intervention might not be generalizable to the general population of women who might differ in terms of educational status, might not have access to the internet and/or mobile phones.

 

 

This study showed that there was a statistically significant reduction in high perceived susceptibility, high perceived barriers and high perceived seriousness following the mobile health education intervention. There was also a statistically significant increase in high perceived benefits and high perceived self-efficacy while the increase in high perceived cues to action was not statistically significant. Uptake of cervical cancer screening also increased. In view of this, mobile health interventions can be used as a vital and effective tool in improving the perceptions and uptake of cervical cancer screening among nurses.

 

 

The authors declare no competing interests.

 

 

Conceptualization: Olutomi Yewande Sodipo, Hadiza Abigail Agbo. Design: Olutomi Yewande Sodipo, TOA, Hadiza Abigail Agbo, Ayuba Ibrahim Zoakah,. Literature search and Data acquisition: Olutomi Yewande Sodipo. Data Analysis: Olutomi Yewande Sodipo, Tolulope Olumide Afolaranmi, Ayuba Ibrahim Zoakah,. Manuscript preparation, editing and review: Olutomi Yewande Sodipo, Tolulope Olumide Afolaranmi, Hadiza Abigail Agbo , Chikaike Ogbonna.

 

 

The authors thank the nurses for their participation in the study as well as the data collectors.

 

 

Table 1: Sociodemographic characteristics of study participants (n=148)

Table 2: Relationship of socio-demographic characteristics with cervical cancer screening uptake in the at baseline

Table 3: Effect of mobile health intervention on perceptions of cervical cancer

Table 4: Effect of mobile health intervention on uptake of cervical cancer screening

 

 

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