CHAPTER TWO
LITERATURE REVIEW
2.0 Introduction
This chapter presents a review of relevant literature related to the evaluation of knowledge and
awareness of cervical cancer screening among women of child-bearing age. The review is
organized under two major sections: the conceptual framework and the empirical review. The
conceptual framework discusses key concepts such as cervical cancer, cervical cancer screening,
knowledge, awareness, and factors influencing screening among women of child-bearing age.
The empirical review examines findings from previous studies conducted globally and within
Nigeria on knowledge, awareness, and utilization of cervical cancer screening services. This
review helps to identify gaps in existing literature and provides justification for the present study
conducted in Wusasa Community, Zaria Local Government Area of Kaduna State.
2.1 Conceptual Framework
2.1.1 Concept of Cervical Cancer
Cervical cancer is a malignant tumor that originates from the cervix, the lower part of the uterus
connecting to the vagina. It develops gradually over time, often beginning with precancerous
lesions that may progress to invasive cancer if untreated. According to the World Health
Organization (WHO, 2023), cervical cancer is largely preventable through early detection and
treatment, yet it remains one of the leading causes of cancer-related deaths among women in
low- and middle-income countries. In Nigeria, cervical cancer is a major public health problem
due to low screening coverage, late diagnosis, and limited access to preventive health services
(Bray et al., 2020).
2.1.2 Causes and Risk Factors of Cervical Cancer
The World Health Organization (WHO), through the International Agency for Research on
Cancer (IARC), postulated in 2007 that persistent infection with high-risk Human
Papillomavirus (HPV) is a necessary cause of cervical cancer, with virtually all cases attributable
to HPV infection. Despite this primary causative role, several additional biological, behavioral,
and socio-economic factors influence the persistence of HPV infection and the progression to
cervical cancer.
1. Persistent Human Papillomavirus (HPV) Infection: Persistent infection with
oncogenic HPV types, particularly HPV-16 and HPV-18, is responsible for the majority
of cervical cancer cases. These high-risk strains express viral oncoproteins (E6 and E7)
that inactivate tumor suppressor genes, leading to uncontrolled cellular proliferation and
malignant transformation of cervical epithelial cells.
2. Early Age at First Sexual Intercourse: Early initiation of sexual activity increases the
risk of cervical cancer due to greater susceptibility of the immature cervical epithelium to
HPV infection and persistence.
3. Multiple Sexual Partners: Having multiple sexual partners, or a sexual partner with
multiple partners, increases exposure to HPV and raises the likelihood of acquiring high-
risk HPV infections.
4. Poor Genital Hygiene: Poor genital hygiene may promote chronic cervical inflammation
and infection, creating a favorable environment for persistent HPV infection and
carcinogenic changes.
5. Prolonged Use of Oral Contraceptives: Long-term use of oral contraceptives has been
associated with an increased risk of cervical cancer, possibly due to hormonal effects that
enhance HPV persistence and cervical cell proliferation.
6. Cigarette Smoking: Smoking introduces carcinogenic substances into cervical mucus,
which impair local immune defenses and facilitate the progression of HPV-related
cervical lesions to malignancy.
7. Immunosuppression: Immunosuppressive conditions, particularly Human
Immunodeficiency Virus (HIV) infection, reduce the body’s ability to clear HPV
infections, thereby increasing the risk of persistent infection and cervical cancer
development.
8. Low Socio-Economic Status: Socio-economic factors such as poverty, low educational
attainment, and limited access to health care services contribute significantly to the risk
of cervical cancer. These factors limit access to HPV vaccination, cervical cancer
screening, early diagnosis, and effective treatment, especially in developing countries
(Adewole et al., 2017).
2.1.3 Signs and Symptoms of Cervical Cancer
The American Cancer Society (ACS) in 2022 reported that cervical cancer is often
asymptomatic in its early stages, which underscores the importance of routine cervical
screening for early detection. Clinical manifestations typically appear as the disease progresses
and varies according to the stage of the cancer.
1. Asymptomatic Early Stage: In the early stages, cervical cancer usually presents without
noticeable signs or symptoms, making routine screening methods such as Pap smear and
HPV testing crucial for early diagnosis.
2. Abnormal Vaginal Bleeding: Abnormal bleeding is one of the most common symptoms
and may occur between menstrual periods, after sexual intercourse, or following
menopause. This results from tumor invasion of cervical blood vessels.
3. Post-Coital Bleeding: Bleeding after sexual intercourse occurs due to friability of the
cancerous cervical tissue and is often an early warning sign of cervical malignancy.
4. Post-Menopausal Bleeding: Any vaginal bleeding after menopause is considered
abnormal and may indicate advanced cervical pathology, including cervical cancer.
5. Foul-Smelling Vaginal Discharge: Persistent, watery, blood-stained, or foul-smelling
vaginal discharge may occur due to infection or necrosis of cancerous cervical tissue.
6. Pelvic Pain: Pelvic pain may be present as the cancer spreads to surrounding tissues and
pelvic structures, causing inflammation and nerve involvement.
7. Pain During Sexual Intercourse (Dyspareunia): Pain during intercourse can result
from local tumor growth and inflammation of the cervix and adjacent tissues.
8. Advanced Disease Manifestations: In advanced stages, cervical cancer may lead to
complications such as urinary obstruction, weight loss, severe pelvic pain, leg swelling,
and renal failure due to compression of surrounding organs (American Cancer Society,
2022).
2.1.4 Concept of Cervical Cancer Screening
The World Health Organization (WHO) in 2023 defined cervical cancer screening as the
systematic use of medical tests to identify precancerous lesions and early-stage cervical
cancer in asymptomatic women. The primary objective of screening is early detection and
timely treatment of cervical abnormalities before progression to invasive cervical cancer.
Cervical cancer screening plays a crucial role in cancer prevention by interrupting the natural
history of the disease. By detecting cervical intraepithelial neoplasia (CIN) and early malignancy,
screening allows for effective intervention that significantly reduces cervical cancer incidence
and mortality.
According to the WHO (2023), regular cervical cancer screening has been shown to substantially
reduce both the incidence and mortality of cervical cancer, particularly when combined with
appropriate follow-up, treatment of detected lesions, and integration into national health
programs. Screening is especially important in low- and middle-income countries, where late
presentation and limited access to healthcare services contribute to high cervical cancer–related
deaths.
2.1.5 Methods of Cervical Cancer Screening
The World Health Organization (WHO) in 2023 recommends several methods for cervical
cancer screening, aimed at detecting precancerous lesions or early-stage cervical cancer in
asymptomatic women. The choice of screening method often depends on resource availability,
cost, and population needs.
1. Papanicolaou (Pap) Smear Test: The Pap smear involves collecting cells from the
cervix and examining them cytologically for abnormal changes. It is highly effective in
detecting precancerous lesions but requires laboratory infrastructure and trained
personnel, which may limit its use in resource-constrained settings.
2. Visual Inspection with Acetic Acid (VIA): VIA involves applying 3–5% acetic acid to
the cervix and visually inspecting for acetowhite changes that indicate abnormal cervical
tissue. This method is inexpensive, simple, and provides immediate results, making it
suitable for low-resource settings.
3. Visual Inspection with Lugol’s Iodine (VILI): VILI uses Lugol’s iodine solution to
stain the cervix. Normal cells absorb iodine and turn brown, whereas abnormal or
precancerous cells do not stain. Like VIA, VILI is low-cost, easy to perform, and
provides rapid results, making it practical for screening in developing countries.
4. HPV DNA Testing: HPV DNA testing identifies the presence of high-risk HPV strains in
cervical samples. This method is highly sensitive and can detect infections before cellular
changes occur. However, it requires laboratory support and is more expensive than VIA
or VILI.
In resource-limited settings, such as Nigeria, VIA and VILI are commonly preferred due to
their affordability, simplicity, and ability to deliver immediate results, facilitating same-day
treatment and reducing loss to follow-up (Akinyemiju et al., 2018).
2.1.6 Concept of Knowledge of Cervical Cancer Screening
Knowledge of cervical cancer screening refers to a woman’s awareness and understanding of
cervical cancer, including its causes, risk factors, and signs and symptoms (Okunowo et al.,
2018). Understanding these fundamental aspects helps women recognize the importance of early
detection and the potential consequences of delayed diagnosis.
It also encompasses an understanding of preventive measures, such as HPV vaccination, safe
sexual practices, and lifestyle factors that reduce risk. Women who are aware of these preventive
strategies are more likely to adopt behaviors that lower their chances of developing cervical
cancer.
A key component of knowledge involves familiarity with available screening methods, such as
the Pap smear, Visual Inspection with Acetic Acid (VIA), Visual Inspection with Lugol’s Iodine
(VILI), and HPV DNA testing. Being informed about these techniques enables women to make
informed choices regarding which screening method is appropriate and accessible for them.
Knowledge further includes awareness of recommended screening intervals and guidelines. For
example, women should understand how frequently they need to be screened based on age, risk
factors, and local health recommendations. Such awareness helps ensure regular screening,
which is crucial for early detection and treatment of precancerous lesions.
Additionally, knowledge involves understanding where screening services can be obtained,
including hospitals, clinics, or community health programs. Awareness of accessible and
affordable services increases the likelihood that women will attend screening programs and
follow through with necessary follow-up care.
Finally, adequate knowledge of cervical cancer screening is strongly associated with positive
health-seeking behavior. Women who are well-informed are more likely to participate in
screening, adhere to follow-up recommendations, and seek timely treatment when abnormalities
are detected. Conversely, lack of knowledge remains a significant barrier to screening uptake,
particularly in low- and middle-income countries, contributing to late presentation and higher
mortality rates (Okunowo et al., 2018).
2.1.7 Concept of Awareness of Cervical Cancer Screening
Awareness of cervical cancer screening refers to a woman’s recognition that cervical cancer
exists and that screening services are available (Eze et al., 2019). It is the first step toward
informed health behavior, as women cannot seek preventive services if they are unaware of both
the disease and the interventions that can detect it early.
Awareness can be generated through various channels, including health workers, who provide
direct education during clinic visits, community outreach, and counseling sessions. Health
workers play a critical role in conveying accurate and reliable information that can motivate
women to participate in screening programs.
Mass media campaigns are also important in raising awareness. Television, radio, newspapers,
social media, and online platforms can reach large audiences and disseminate messages about the
importance of cervical cancer screening, signs and symptoms, and the availability of local
services.
Community health campaigns, such as health fairs, workshops, and awareness rallies, serve to
educate women in their local environment. These interventions often involve interactive sessions,
demonstrations of screening procedures, and distribution of informational materials, which help
reinforce understanding and retention of key messages.
Interpersonal communication, including discussions with family, peers, or community leaders,
further strengthens awareness. Such interactions can address cultural misconceptions, reduce fear
or stigma associated with cervical cancer, and encourage women to act on the information they
receive.
Although awareness alone does not guarantee utilization of screening services, it is an essential
precursor to informed decision-making and preventive health behavior. Women who are
aware of cervical cancer and the availability of screening are more likely to seek early detection,
participate in regular screening, and adopt other preventive measures, thereby contributing to the
reduction of cervical cancer incidence and mortality (Eze et al., 2019).
2.1.8 Women of Child-Bearing Age and Cervical Cancer Screening
Women of child-bearing age, generally defined as those between 15 and 49 years, represent a key
population in cervical cancer prevention (WHO, 2023). This age group is typically sexually
active, which increases their exposure to Human Papillomavirus (HPV), the primary causative
agent of cervical cancer. Understanding the risk profile of this population is critical for effective
screening and early intervention.
Cervical cancer screening programs often prioritize women within this reproductive age range
because early detection can prevent the progression of precancerous lesions to invasive cancer.
Screening in these years allows for timely treatment, reducing the likelihood of complications
that may affect reproductive health and future fertility.
Women of child-bearing age are also more likely to engage with health services, such as
antenatal care, family planning, and reproductive health clinics. These settings provide
opportunities for integrating cervical cancer education and screening services, thereby increasing
access and uptake among this high-risk group.
Health education targeting this population emphasizes the importance of routine screening,
awareness of symptoms, and the benefits of early detection. By fostering knowledge and
awareness in this age group, programs can encourage women to actively seek screening services
and adopt preventive behaviors.
Additionally, prioritizing screening in women of child-bearing age contributes to broader public
health benefits. Early detection and treatment reduce the burden of cervical cancer on families
and communities, lower healthcare costs associated with advanced disease management, and
improve overall maternal health outcomes.
In conclusion, women of child-bearing age are a priority population for cervical cancer screening
programs due to their increased risk of HPV infection, their engagement with health services,
and the potential for early detection to prevent morbidity and mortality (WHO, 2023). Targeted
interventions in this group are essential for effective cervical cancer prevention and control.
2.1.9 Factors Influencing Knowledge and Awareness of Cervical Cancer Screening
Knowledge and awareness of cervical cancer screening among women are influenced by a
variety of socio-demographic, cultural, and health system factors. Studies have shown that these
factors significantly determine whether women understand cervical cancer, its risk factors, and
the importance of screening, as well as whether they are willing or able to utilize screening
services (Abiodun et al., 2014; Eze et al., 2019). Understanding these factors is crucial for
designing effective health education programs and interventions aimed at increasing cervical
cancer screening uptake.
The major factors influencing knowledge and awareness can be itemized as follows:
1. Level of Education: Education plays a key role in shaping women’s understanding of
cervical cancer and its prevention. Women with higher educational attainment are more
likely to comprehend health information, recognize the importance of screening, and
actively seek preventive care. Conversely, women with little or no formal education may
have limited knowledge and awareness of cervical cancer screening (Okunowo et al.,
2018).
2. Cultural and Religious Beliefs: Cultural norms and religious teachings can either
encourage or discourage women from seeking cervical cancer screening. In some
communities, discussions about sexual and reproductive health are considered taboo,
making it difficult for women to access information about cervical cancer (Abiodun et al.,
2014). Religious beliefs may also influence perceptions of illness and the acceptability of
medical interventions.
3. Socio-Economic Status: Women with higher socio-economic status generally have better
access to health information, transportation, and healthcare services. Low-income women
may prioritize other basic needs over preventive health services, limiting their knowledge
and awareness of cervical cancer screening (Akinyemiju et al., 2018).
4. Availability and Accessibility of Health Facilities: Proximity to healthcare facilities that
offer cervical cancer screening is a critical factor. Women living in rural areas or
communities with few health centers may have limited exposure to screening programs,
resulting in low awareness and utilization (Adewole et al., 2017).
5. Cost of Screening Services: The cost of screening tests can be a barrier for many
women. Even when women are aware of the benefits of screening, high costs may
discourage them from accessing services, particularly in low-resource settings (Eze et al.,
2019).
6. Fear of Diagnosis: Psychological factors such as fear of receiving a positive diagnosis
can negatively affect women’s willingness to undergo screening. Some women avoid
screening due to anxiety about cancer, potential stigmatization, or misconceptions about
treatment (Okunowo et al., 2018).
7. Attitude of Health Care Providers: The approach and communication style of health
workers influence women’s knowledge and awareness. Positive interactions, clear
explanations, and culturally sensitive counseling can enhance awareness, whereas rude,
dismissive, or judgmental attitudes can discourage women from seeking information or
services (Abiodun et al., 2014).
8. Misconceptions and Lack of Health Education: Misunderstandings about cervical
cancer, its causes, and the purpose of screening remain widespread. Inadequate health
education and limited community outreach programs mean that many women are
unaware of the importance of regular screening, perpetuating low uptake in Nigerian
communities (Abiodun et al., 2014).
2.2.5 Empirical Studies Related to Cervical Cancer Screening in Nigeria
Several empirical studies conducted across Nigeria have highlighted low levels of knowledge,
awareness, and utilization of cervical cancer screening services among women. These studies
indicate that despite the availability of screening methods such as Pap smear, VIA, and HPV
DNA testing, uptake remains limited, particularly in rural and underserved communities
(Adewole et al., 2017; Okunowo et al., 2018).
Adewole et al. (2017) conducted a nationwide assessment and observed significant regional
disparities in cervical cancer awareness. Women residing in rural northern communities exhibited
lower knowledge of cervical cancer and screening services compared to women in urban areas.
This disparity reflects differences in educational attainment, access to health facilities, and
exposure to health education programs.
In a similar study, Okunowo et al. (2018) reported that knowledge about cervical cancer causes,
symptoms, and prevention was positively associated with screening uptake. Women who
demonstrated adequate knowledge were more likely to participate in regular screening,
underscoring the importance of educational interventions in promoting preventive health
behavior.
Eze et al. (2019) investigated awareness of cervical cancer screening among women in
southeastern Nigeria and found that less than half of the respondents had heard about cervical
cancer screening, and even fewer had utilized the services. The study highlighted the role of
mass media, community health campaigns, and interpersonal communication in generating
awareness and motivating women to seek screening.
Studies in rural communities further emphasize the challenges of accessibility. Akinyemiju et al.
(2018) reported that VIA and VILI were the most commonly used screening methods in
resource-limited settings, due to their low cost and simplicity. Despite this, utilization remained
low, suggesting that availability alone is insufficient without concurrent awareness and education
campaigns.
Regional studies have also documented the influence of socio-economic factors on screening
uptake. According to Adewole et al. (2017), women with higher levels of education, better
income, and urban residence were significantly more likely to participate in cervical cancer
screening programs compared to their rural or less-educated counterparts. This finding
emphasizes the need for targeted interventions in disadvantaged communities.
Several studies have explored the relationship between reproductive age and screening practices.
WHO (2023) and local studies indicate that women of child-bearing age (15–49 years) are the
primary target for screening programs due to increased sexual activity and higher risk of HPV
infection. However, research in Nigeria shows that even within this high-priority group, uptake is
constrained by low awareness and cultural barriers (Eze et al., 2019).
Barriers to cervical cancer screening in Nigeria extend beyond knowledge and awareness.
Okunowo et al. (2018) identified fear of the procedure, perceived pain, cultural beliefs, and
mistrust of health workers as major deterrents. These findings suggest that behavioral and socio-
cultural factors must be addressed alongside educational interventions to improve screening
rates.
Community-based studies, such as those conducted in northern Nigeria, demonstrate that locally
tailored health education programs can significantly improve screening uptake. For example,
health campaigns that involve community leaders, peer educators, and integration with existing
maternal and reproductive health services have shown promising results (Adewole et al., 2017;
Akinyemiju et al., 2018).
Given these findings, it is evident that targeted empirical studies in specific communities are
critical to understanding local barriers and facilitators of cervical cancer screening. The present
study in Wusasa Community, Zaria LGA, aims to contribute to this body of knowledge by
assessing knowledge, awareness, and utilization of screening services among women of child-
bearing age, thereby informing context-specific interventions and policies to improve cervical
cancer prevention in Nigeria.
2.2.6 Summary of Empirical Review and Research Gap
The reviewed literature reveals that knowledge and awareness of cervical cancer screening
among women in Nigeria are generally low, particularly in rural settings. Most previous studies
focused on urban or hospital-based populations, leaving a gap in community-based research in
areas such as Wusasa Community. This study therefore seeks to fill this gap by evaluating the
knowledge and awareness of cervical cancer screening among women of child-bearing age in
Wusasa Community, Zaria Local Government Area, Kaduna State.
REFERENCES
Abiodun, O. A., Fatungase, O. K., & Olu-Abiodun, O. O. (2014). Knowledge, perception and
predictors of uptake of cervical screening among rural Nigerian women. Journal of
Public Health and Epidemiology, 6(3), 119–124.
Adewole, I. F., Benedet, J. L., & Brian, T. C. (2017). Cervical cancer control in Nigeria:
Challenges and the way forward. International Journal of Gynecology & Obstetrics,
138(1), 10–13.
Akinyemiju, T., Ogunsina, K., Sakhuja, S., & Ogbhodo, A. (2018). Life-course socioeconomic
status and cervical cancer screening in Nigeria. BMJ Global Health, 3(3), e000761.
American Cancer Society. (2022). Cervical cancer: Signs and symptoms. , 5(2), 55–59.
Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R. L., Torre, L. A., & Jemal, A. (2020). Global
cancer statistics 2020. CA: A Cancer Journal for Clinicians, 70(4), 313–331.
Eze, J. N., Umeora, O. U. J., Obuna, J. A., Egwuatu, V. E., & Ejikeme, B. N. (2019). Cervical
cancer awareness and screening uptake in Nigeria. African Journal of Reproductive
Health, 23(4), 85–94.
Okunowo, A. A., Daramola, E. S., Soibi-Harry, A. P., et al. (2018). Women’s knowledge of
cervical cancer and screening uptake in Nigeria. Journal of Cancer Research and
Practice, 5(2), 55–59.
World Health Organization (WHO). (2023). Cervical cancer fact sheet. Geneva: WHO.