ISSN: 2320-5407 Int. J. Adv. Res.

9(10), 632-638

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/13587
DOI URL: http://dx.doi.org/10.21474/IJAR01/13587

RESEARCH ARTICLE
HEALTH FACILITY AND HUMANRESOURCE FACTORS SUPPORTING UPTAKE OF CERVICAL
CANCER SCREENING IN KAKAMEGA COUNTY, KENYA

Gregory Okonya Sakwa1, Prof. Peter Bukhala1, Dr. Zachary Kwena2 and Prof. Mary Kipmerewo3
1. Department of Health Promotion and Sports Science, Masinde Muliro University of Science and Technology.
2. Kenya Medical Research Institute, Kisumu.
3. Department of Reproductive Health, Child Health and Midwifery, Masinde Muliro University of Science and
Technology.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Main objective was to describehealth facility and human resource
Received: 28 August 2021 related factors supporting uptake of cervical cancer screening in
Final Accepted: 30 September 2021 Kakamega County.Design; descriptive cross-sectional study adopting
Published: October 2021 quantitative methods. Setting; Kakamega County within 16 community
units in 8 sub counties.Sampling;multistage sampling was used to
Key words:-
Cervical Cancer, Kakamega County, sample 48 community health volunteers and 16 health
Screening, Kenya, Health Facility, facilities.Interviewer administered questionnaire was used to collect
Human Resource data from Community Health Volunteers and the heads of link health
facilities.Validity and reliability of questionnaire was ensured through
expert review.Analysiswasby use of descriptive statistics.
Results;Majority of participants were female (91.7%) aged between 30-
50 years (75%), with primary level of education(47%) and had worked
for more than five years as Community Health Volunteers (60%). More
than 95% ofCommunity Health Volunteers visited clients’ homeson
monthly schedule(77%).Regarding cervical cancer screening,60% of
Community Health Volunteers agreed that they were involved in
referring women for cervical cancer screening.Almost all(92%)of
Community Health Volunteers had not been trained on aspects of
cervical cancer screening. Further, 94% of Community Health
Volunteers confirmed that cervical cancer screening was part of the
health education package they discuss with women. Approximately
81% of health facilities were health centers and offeredcervical cancer
screening services weekly (75%).Conclusion;Health facilities offer
cervical cancer screening adequately. Community Health Volunteers
have established network to reach women but lack capacity to sensitize
women on cervical cancer screening. Recommendation: Community
Health Volunteersshould be empowered to mobilize women for
cervical cancer screening.

Copy Right, IJAR, 2021,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Cervical cancer is of huge public health concern globally and in sub-Saharan Africa (SSA) including Kenya. It is the
second most common cancer to breast cancer globally among women aged between 15 and 49 years (World Health

Corresponding Author:- Gregory Okonya Sakwa 632

Address:- Department of Health Promotion and Sports Science, Masinde Muliro University of
Science and Technology.
ISSN: 2320-5407 Int. J. Adv. Res. 9(10), 632-638

organization, 2014).In Kenya, CC incidence and mortality has doubled over a 10-year period from 2354 reported
cases and 1600 deaths annually in 2006 to 4802 reported cases and 2451 deaths annually in 2016(Ministry of Health,
2015)(www.hpvcentre.net, 2017). Cervical cancer screening in all women is the single most powerful strategy for
the early detection of cancer of the cervix when treatment is most effective in curing the disease. Data extracted
from the county’s District Health Information System-II, (DHIS-II) show that only 3% of women in Kakamega
County were screened for cervical cancer in 2018. Out of this, 2.6% tested positive on VIA/VILI test hence the
county contributes to 3.7% of the national cervical cancer incidence. Cervical Cancer Screening uptake in
Kakamega is poor at 3% compared to the national screening rate of 3.2%. Possible reasons for low uptake could be
related to resources(Ndejjo et al., 2016).Women only screen for cervical cancer when they experience signs and
symptoms or when they are told by health care providers. Therefore screening for cervical cancer is opportunistic
and erratic.

Resources could be looked at as human resources and health facility resources which have an influence on the
utilization of CCS. Resources are an important factor in determining uptake of CCS and treatment. According to a
study done in Zimbabwe to investigate health system constraints affecting uptake of treatment and care by women
with cervical cancer(Tapera et al., 2019a), the following health system constraints were identified; limited or lack of
training for healthcare workers, weak or lack of surveillance system for cervical cancer, limited access to treatment
and care, inadequate healthcare workers, reliance of patients on out-of-pocket funding for treatment services, lack of
back-up for major equipment, high costs of treatment and care, lack of knowledge about cervical cancer and bad
attitudes of health workers, few screening and treating centers located typically in urban areas, lack of clear referral
system resulting in inflexible processes, and limited screening and treating capacities in health facilities due to lack
of resources. This is in agreement to findings by Maseko et al., (2015) in a study done in Malawi on health systems
challenges in cervical cancer prevention program in which it was established that there existed health system
challenges in areas of health workforce and essential medical products and technologies. Only 30% of health
facilities provided both screening and treatment. There was inadequate service providers, those available were
poorly supervised, lack of basic equipment and stock-outs of basic medical supplies in some health facilities and
inadequate funding of the program. In most of the health facilities, service providers were not aware of the policy
which govern their work and that they did not have standards and guidelines for cervical cancer screening and
treatment(Maseko et al., 2015).

Community Health Volunteers (CHVs), are part of the human resources at the community level. They have been
used successfully in the community to encourage women access maternal and Child Health services. As a result,
there is improved utilization of skilled delivery, family planning services, immunization and antenatal services.
Therefore, CHVs are a potential human resource that can be used in task shifting to reach eligible women for
screening. Within the Kenyan context, CHVs operate under Community health strategy. This is an initiative of the
ministry of health to empower communities to participate in their own health promotion activities through
CHVs.The Ministry of Health developed and adopted it as a basic component of the Kenya Essential Package for
Health (KEPH) in 2006 (Ministry of Health, 2014). In some other countries, the method is known as the Community
Health Worker Program (CHWP). Under this arrangement, Community Health volunteers (CHVs) are the members
of the community who provide the services (Olaniran et al., 2017).The establishment and deployment of CHVs was
spurred by governments' inability to reach the Millennium Development Goals (MDG) and a continuous scarcity of
Human Resource for Health (HRH) in low and middle income countries (LMIC) (World Health Organization,
2007).Evidence has accumulated on the usefulness of CHVs in delivering various health interventions (Lewin et al.,
2010).Community Health Strategy (CHS) serves as a conduit between the community and the health-care system. It
has governance structures provided by Community Health Committees (CHC) (Kimani-Murage et al., 2016).Under
CHS, the community is stratified into Community Units (CUs) and further into Villages. Within a community Unit,
there are 10 villages. Each village comprises of 30 to 100 households. One CHV is in charge of one village. One
Community Health Extension Worker(CHEW) supervises ten CHVs. For outreach at the community level, Kenya's
community health strategy relies on community health Extension workers and Community Health Volunteers
(CHEWs and CHVs). Through the detection and referral of cases by CHVs, CHS serves as a link between the
community and public health facilities and also brings services closer to the people that need them. CHVs have a
role to mobilize community members to utilize these services.These responsibilities, however, do not include
specific and standardized cervical cancer and screening (CCS) communication to eligible women. CHVs can be
utilized as part of Kenya's community health strategy to organize, educate, and raise awareness about cervical cancer
among eligible women in the community, resulting in increased demand for and use of CCS services (Ministry of
Health, 2014).

633
ISSN: 2320-5407 Int. J. Adv. Res. 9(10), 632-638

The main objective was to describe the existing resources that either support or have the potential to support
screening of cervical cancer in Kakamega County. Specifically the study sought to describe capacity of CHVs to
participate in CCS and capacity of health facilities in providing cervical cancer screening services within Kakamega
County.

Materials and Methods:-

Study Design
The study adopted descriptive cross-sectional research design employing quantitative approaches, where
interviewer-administered questionnaire was used to collect data from both heads of link health facilities and
community health volunteers. This was part of a larger cluster randomized trial (CRT)on integrating cervical cancer
awareness creation for screeningin community health strategy in Kakamega County.

Study setting:
The study was carried out in Kakamega County, Kenya. Kakamega County is in the western side of Kenya. It
borders Siaya, Busia, Bungoma, Trans Nzoia, Vihiga, and Kisumu counties. Women aged 25 to 49 years constitute
208,905 (11.3%) (KNBS, 2016)&(KNBS, 2013).The County health system avails Cervical Cancer
Screeningservices through a network of 299 public health facilities including; 1 County Referral Hospital, 9 sub-
county hospitals, 32 health centers, 140 dispensaries and outreach clinics. In addition, it has 39 and 72 faith-based
and private health facilities respectively, (DHIS-II, 2017).The county has 12 sub counties and 422 community units.
Each community units has between 40 to 110 villages. Community health strategy within the county is well
established and active. It is implemented through the 422 community units (CU) serving 355,679 households (HH)
currently.

Sampling and Sample Size

Target Population
Heads of link health facilities and community health volunteers.

Sampling Design
A sample size of 48 community health volunteers and 16 heads of link health facilities was used.A multistage
sampling method was used. Eight out of 12 sub counties were randomly selected.Two Community Units were
randomly selected from each sub county. From each of the Community Unit, three villages were randomly selected.
Each village had one Community Health Volunteer hence the respective CHVs from each village was selected. All
health facilities which acted as link facilities for the community units were included.

Data Collection
Data was collected usinginterviewer administered questionnaires, from Community Health Volunteers and heads of
link health facilities. The questionnaire gathered information on sociodemographic characteristics including age,
gender, marital status, and education level. It also assessed informationon human resource related factors and health
facility related factors supporting delivery of cervical cancer screening.

To increase validity and reliability of the instrument, the questionnaire was evaluated by experts from the
department of reproductive health, Kakamega County Referral Hospital. Based on feedback, the final questionnaire
was prepared for pre-test. The pretest study was conducted on 3 CHVs and two heads of facilityin one community
Unit which was not included in the study.The questinnaireon human resource and health facility had Cronbach’s α
of 0.729 and 0.639 respectively.

Ethical Approval
Ethical approval was obtained from Masinde Muliro University of Science and Technology Ethics Review
Committee, National commission for science, technology and Innovation, NACOSTI and permission granted by
County government of Kakamega.

Data Analysis
Data analysis was done using the statistical program for social sciences (SPSS) version 25. Descriptive statistics
were used to analyze both human resource and facility related resource factors.

634
ISSN: 2320-5407 Int. J. Adv. Res. 9(10), 632-638

Results:-
Socio-demographic characteristics of Community Health Volunteers
Table 1 showsthe socio-demographic characteristics of Community Health Volunteers. The characteristics described
include gender, age, education level, marital status, and period worked as CHV. There were a total of 48 CHVs
included in the study, all responded to the questionnaire hence 100% response rate. Almost all participants were
female (91.7%) aged between 30-50 years (75%). Majority had primary education as their highest level of education
(47%) followed by those who had post primary education (39%). Most participants were married (81%) and had
worked for more than five years as CHVs, (60%).

Table 1:- Demographic characteristics of community health volunteers.

Characteristic (N=48) Frequency (%)
Gender Female 44 (92)
Male 4 (8)
Age group 20-30 yrs. 8 (16)
31-40 yrs. 16 (33)
41-50 yrs. 20 (42)
Over 50 yrs. 4 (8)
Education level Informal 6 (13)
Primary 23 (48)
Post primary 19 (39)
Marital status Single 2 (4)
Married/Living together 39 (81)
Divorced/separated 2 (4)
Widowed 5 (10)

Human Resource factors supporting uptake of cervical cancer Screening

Table 2 describes experiences and practices of Community health volunteers which are considered as useful
attributes of human resources to support cervical cancer screening. This information is important to establish
capacity of CHVs to mobilize community members in utilizing Health care services. Currently, CHVs are lay health
workers involved in mobilizing community members in utilizing maternal and Child Health Primary services (safe
motherhood). As shown in the table, majority of CHVs had worked for more than 5 years as CHVs, served less than
100 households and almost all (96%)had a scheduled home visit to their clients.Of those with scheduled home visits,
77% visited the households monthly.

Table 2:- Human resource factors supporting uptake of cervical cancer Screening.
Variable (n=48) Frequency (%)
Years worked as CHV Up to 5 years 19 (40)
> 5 years 29 (60)
Number of House Holds served 100 HH and less 28 (58)
> 100 HHs 20 (42)
Mode of contacting clients Home visit on request of client 2 (4)
Scheduled Home visit 46 (96)
Frequency of contacting each household Weekly 9 (19)
Monthly 37 (77)
Only when needed 2 (4)
Heard of CCS Yes 48 (100)
No 0
Source of information Media 6 (14)
Friend 2 (3)
Health care worker 40 (83)
Your work as a CHV involve referring Yes 29 (60)
women for CCS? No 19 (40)
CCS messages in Health education Yes 0
package No 48 (100)

635
ISSN: 2320-5407 Int. J. Adv. Res. 9(10), 632-638

Been trained on cervical cancer screening Yes 4 (8)

No 44 (92)
Key health messages given to clients Antenatal, post natal, child health and family 48 (100)
planning
Cervical cancer screening health messages 0
Perform CCS Yes 0
No 48 (100)

All CHVs (100%) had heard of cervical cancer screening, mainly from Health Care Workers (83%). Most (60%)
CHVs reported that their work involved referring women for cervical cancer screening. All (100%) CHVs
confirmed that cervical cancer and screening was not included in the health education package they discuss with
women. None of the community health volunteers had been trained on Cervical Cancer Screening.Similarly, none of
the CHV reported to perform cervical cancer screening.When asked which key health messages they give to clients,
88% (n=42) reported that they gave maternal, child health and family planning messages only.

Health Facility factors supporting Cervical Cancer Screening

Table 3 shows the proportion of health facility related factors supporting Cervical Cancer Screeningin terms of type
of health facility, whether it offers CCS, has referral forms to refer cervical clients, training approach required to
improve staff on CCS, and frequency of conducting outreach services for cervical cancer screening. This
information was important to assess the capacity of Health facilities to conduct CCS within the respective catchment
areas. A total of 16 Health facilities participated in the study out of which 81% were health centers. Majority of the
health facilities (75%) offered cervical cancer screening services on a particular day per week within a designated
clinic (75%). Approximately 63% of health facilities had referral forms designed for cervical cancer patients. About
94% of link-health facilities conducted outreach services for cervical cancer screening monthly.

Table 3:- Health Facility related factors supporting cervical cancer screening.
Characteristics Frequency (%)
Type of health facility
County hospital 1 (6)
Sub county hospital 2 (13)
Health center 13 (81)
Cervical cancer screening offered
No 4 (25)
Yes 12 (75)
Designated clinic/room to conduct screening
Yes 12 (75)
No 4 (25)
Availability of referral forms to refer cervical clients
Available 10 (63)
Not available 6 (37)
Training required to improve staff on CCS
A practical training 14 (87)
Theoretical training 2 (13)
Frequency of conducting outreach services for CCS
Monthly 11 (68)
After 3 months 2 (13)
After 6 months 1 (6)
Annually 2 (13)

Discussion:-
The objective of the study was to describehealth facility and human resource related factors supporting uptake of
cervical cancer screening in Kakamega County. Majority of CHVs were aged between 35 to 51 years, married and
had a secondary education. Being married and having a basic education are part of a criteria for one qualifying to be
chosen as a community health volunteer(Ministry of Health, 2007). This is on assumption that those already married

636
ISSN: 2320-5407 Int. J. Adv. Res. 9(10), 632-638

in the area are unlikely to change residence. Further, the married are accorded respect by majority of community
members hence can be confided with personal health information. The attribute enables the CHVs to interact with
community members confidently. Further, most CHVs had more than 5 years working experience. Experience
increases ones skill, confidence and tust by others. Almost allCHVs had not been trained on cervical cancer
screening. Without training CHVs have poor knowledge regarding CCS and this can limit their potential to sensitize
women on CCS.This is contrary to findings bySrisuwan et al., (2015) in Thailand among Village Health Volunteers
in which participants had a high level of knowledge about cervical cancer screening with overall mean score of
0.70points(Srisuwan et al., 2015). Being trained on CCS and hence knowledgeable on the same enables lay health
workers sensitize women on CCS with confidence. This may contribute to high uptake of cervical cancer screening
as reported by previous studies (Mukama et al., 2017).The study revealed that aspect of CCS is not included in the
work manual of CHVs. This limits the scope of CHVs hence their capacity in community mobilization. This is
supported by a study done at Kenyatta National Hospital byNjuguna et al., (2017)in which it was observed that
Women were more likely to report CCS if recommended by a staff, and the main barrier to screening included lack
of proper communication on screening procedures.

Most link health facilities had referral forms however the forms were not specific for referring cervical cancer cases.
Lack of specific referral forms cause Cervical Cancer patients not to receive the immediate attention required.
Health care referrals and services increases regular use of cervical cancer screening, which potentially results in a
reduction in cancer treatment costs and in lives lost to cervical cancer among women(Borrayo et al., 2004).

Almost all health facilities conducted outreach services for cervical cancer screening monthly. Outreach services
increase screening utilization because screening services are taken near to the women. This was supported by a
study done under the FACES program in which the uptake of CCS services was impressive after a rigorous
community awareness coupled with care giver capacity building. In a pre-test- post-test study design in Taiwan
seeking to compare the up-take of cervical screening in a new outreach and pre-existing hospital-based setting to
assess if an outreach service would lead to increased utilization; it was found that the outreach service independently
provided screening to almost all eligible women (Chang et al., 2007). A research conducted among Iraqi immigrant
women living in Malaysia showed that lack of awareness of the availability of screening services, cost of Pap smear,
are one of the reasons for not doing Pap smear (Osman, 2013). Outreaches increases people’s awareness of CCS.
With regards to frequency of cervical cancer screening outreaches, it has been demonstrated that higher frequency
has better results. In a study done by Jolly et al., (2015)in Portland, several factors were explored that could be
associated with the uptake of cervical cancer screening.Regularawareness and visits by a healthcare provider,access
to clinics,age, marital status, monthly income, knowledge, barriers, acculturation and insurance status were found to
be significant predicators of uptake of screening.

Conclusion and Recommendation:-

The study established that health facility and human resource factors play an important role in uptake of cervical
cancer screening by the public.Awareness oncervical cancerscreening in the community should be increased through
a multipronged strategy; health education, public awareness campaigns, and formal school intervention.Community
Health Volunteers are a potential resource to increase knowledge and practice of cervical cancer screening. They
need capacity building. The health facilities have the capacity to conduct and manage cervical cancer screening.
Recommendations;community health volunteers need to be trained on aspects of cervical cancer screening in order
to increase their capacity to mobilize communities on behaviorchange towards cervical cancer screening.

Reference:-
1. Borrayo, E. A., Thomas, J. J., & Lawsin, C. (2004). Cervical Cancer Screening Among Latinas: The Importance
of Referral and Participation in Parallel Cancer Screening Behaviors. Women & Health, 39(2), 13–29.
https://doi.org/10.1300/J013v39n02_02
2. Chang, H.-C., Hsiung, H.-Y., Chen, S.-I., Yen, A. M.-F., & Chen, T. H.-H. (2007). Comparison of a community
outreach service with opportunity screening for cervical cancer using Pap smears. Journal of Public Health,
29(2), 165–172. https://doi.org/10.1093/pubmed/fdm003
3. Jolly, P., Bessler, P., Ncube, B., Bey, A., & Knight, J. (2015). Factors associated with the uptake of cervical
cancer screening among women in Portland, Jamaica. North American Journal of Medical Sciences, 7(3), 104.
https://doi.org/10.4103/1947-2714.153922
4. KNBS. (2013). Statistical abstract 2013.

637
ISSN: 2320-5407 Int. J. Adv. Res. 9(10), 632-638

5. KNBS. (2016). STATISTICAL ABSTRACT 2016.

6. Maseko, F. C., Chirwa, M. L., & Muula, A. S. (2015). Health systems challenges in cervical cancer prevention
program in Malawi. Global Health Action, 8, 26282. https://doi.org/10.3402/gha.v8.26282
7. Ministry of Health. (2007). Community Strategy Implementation Guidelines for Managers of the Kenya
Essential Package for Health at the Community Level. Ministry of Health.
8. Ministry of Health. (2015). National Cervical Cancer Prevention Program; strategic paln2012-2015 (Issue
January 2012).
9. Mukama, T., Ndejjo, R., Musabyimana, A., Halage, A. A., & Musoke, D. (2017). Women’s knowledge and
attitudes towards cervical cancer prevention: A cross sectional study in Eastern Uganda. BMC Women’s Health,
17(1), 9. https://doi.org/10.1186/s12905-017-0365-3
10. Ndejjo, R., Mukama, T., Musabyimana, A., & Musoke, D. (2016). Uptake of Cervical Cancer Screening and
Associated Factors among Women in Rural Uganda: A Cross Sectional Study. PLOS ONE, 11(2), e0149696.
https://doi.org/10.1371/journal.pone.0149696
11. Njuguna, E., Ilovi, S., Muiruri, P., Mutai, K., Kinuthia, J., & Njoroge, P. (2017). Factors influencing cervical
cancer screening in a Kenyan Health Facility: A mixed qualitative and quantitative study. International Journal
of Reproduction, Contraception, Obstetrics and Gynecology, 6(4), 1180. https://doi.org/10.18203/2320-
1770.ijrcog20171381
12. Srisuwan, S., Puapornpong, P., Srisuwan, S., Bhamarapravatana, K., & Suwannarurk, K. (2015). Knowledge,
Attitudes and Practices Regarding Cervical Cancer Screening Among Village Health Volunteers. Asian Pacific
Journal of Cancer Prevention, 16(7), 2895–2898. https://doi.org/10.7314/APJCP.2015.16.7.2895
13. Tapera, O., Dreyer, G., Kadzatsa, W., Nyakabau, A. M., Stray-Pedersen, B., & Sjh, H. (2019). Health system
constraints affecting treatment and care among women with cervical cancer in Harare, Zimbabwe. BMC Health
Services Research, 19(1), 829. https://doi.org/10.1186/s12913-019-4697-6
14. World Health organization. (2014). Comprehensive Cervical Cancer Control: Aguide to essential practice.
15. www.hpvcentre.net. (2017). Kenya Human Papillomavirus and Related Cancers, Fact Sheet 2017 (Vol. 2017).
16. Ajayi, I.O., Adewole, I.F. (1998). Knowledge and attitude of general outpatient attendants in Nigeria to cervical
cancer. Cent Afr J Med, 44, 41-3.
17. Arevian, M., Noureddine, S., Kabakian, T. A. (1997). Survey of knowledge, attitude, and practice of cervical
screening among Lebanese/Armenian women. Nurs Outlook, 45, 16-22.
18. Burns, H; & Groove, S.K. (2011). Understanding nursing research: building on Evidence – based practice. 5th
ed. Arlington: Texas.
19. Megan, J., Huchko, E. A, Bukusi, C. R. (2011). Cohen successful integration of a cervical cancer screening and
prevention. Int J Gynecol Obst, 114, 2,106-10.
20. Ministry of Health (2014) Strategy for Community Health
21. Ministry of Health (2015) National Cervical Cancer Prevention Program; strategic paln2012-2015
22. Osman, M.T., Redhwan, A.A., Balsam, I.T. (2013). Knowledge and awareness of cervical cancer screening
among Iraqi immigrant women living in Malaysia. World J Med Sci, 8, 123-9.

638