Cervical Cancer

Risk Factors and Uptake of Screening among Expectant Mothers in Abakaliki

Abstract

Context: 

cancer remains the most common reason for death from gynaecological malignancy in Nigeria while screening remains opportunistic. Pregnancy provides a veritable ample opportunity for screening for this malignancy.

Aim: 

to evaluate the risk factors for cervical cancer among antenatal clinic attendees at a tertiary centre and assess their uptake of cervical screening.

Methods: 

This was a cross sectional descriptive study using questionnaires.

Result: 

Three hundred and eighty five out of the 400 questionnaires distributed were analysed. The mean age of respondents was 31.3+6.8 years. Majority 73.2% had tertiary level of education. Only 54% have ever heard of cervical cancer screening. Knowledge was gained mainly via health workers and the media. Of these, only 32 (8.3%) have ever been screened. Many of them (48.3% to 62.5%) knew of some of the risk factors but most of them had no established risk factors.

Conclusion: 

While knowledge of cervical cancer screening is average amongst antenatal clinic attendees at the Federal Teaching Hospital Abakailki is average, the uptake is quite abysmal. Antenatal clinic visits provide an opportunity to increase awareness and uptake of cervical cancer screening among women of reproductive age.

INTRODUCTION

Cervical cancer is a malignant neoplasm of the cervix uteri.[¹] There are two types of cells on the surface which includes the squamous and columnar. Cervical cancer usually develops very slowly; it starts as a precancerous condition called dysplasia.[¹] This precancerous condition can be detected using a screening test (Pap smear) and can be treatable when detected at this stage. It takes years for a proportion of precancerous lesions to turn into cervical cancer. This is the basis for screening for women of reproductive age. Worldwide, cervical cancer is the third most common cancer in women and the fifth most deadly cancer. It affects about 16/100,000 women per year and kills about 1/100,000 per year. Approximately 80% of cervical cancers occur in the developing countries.[²] Almost all cervical cancers are caused by human papillomavirus (HPV) which is a common virus spread through sexual intercourse. There are many different types of HPV, and the high-risk types include HPV 16, 18, 31, 33, and some others. About two-thirds of all cervical cancers are caused by HPV 16 and 18.[²]

Risk factors for cervical cancer include having sex at an early age, multiple sexual partners, sexual partners who have multiple partners, early age at the first birth, multiparty, smoking, long-term use of oral contraceptive pills, immunosuppressed states such as HIV/AIDS, renal allograft transplantation, or Hodgkin's disease, and low social class.

Pregnant women attending antenatal clinics form a pool of at-risk population and provide an opportunity with well-motivated group. This study aims to assess the risk factors and uptake of available cervical screening services among expectant women attending prenatal clinic at a tertiary care center in Abakaliki metropolis.

METHODOLOGY

Study background

The Federal Medical Centre (FMC) was one of the two tertiary hospitals situated in Abakaliki, the Ebonyi State capital and the other being the Ebonyi State University Teaching Hospital. It served as a referral center for the entire state and her neighbors. The two centers were merged in December 2011 to form what is now known as the Federal Teaching Hospital, Abakaliki.

The Obstetrics and Gynecology Department of the hospital was then staffed with nine consultants and twenty resident doctors. The annual delivery rate was about 2,000. Ebonyi State comprises mainly a rural population, having only one urban local government area and another semi-urban unit; the rest are rural. Literacy level though improving in the past decade is low within the population also with a high poverty rate. Christianity, animism, and traditional beliefs are the various religious inclinations. Superstitions and myths are rife and are used to explain many medical conditions.

Study population

This comprised all women booked for and attended antenatal care clinics at the center and gave consent for the study.

Study design

This was a questionnaire-based cross-sectional study. Literate participants self-administered their questionnaires while research assistants assisted those who were less literate. Participants were consecutively recruited in July 2011 until the desired sample size was attained. The sample size of 291 was arrived using the formula as follows:[³]

Applicable to a population of <10,000.

However, a total of 400 participants were enrolled to increase the power of the study.

Data were analyzed using Epi info 7.1.5 of the CDC Atlanta, Georgia USA 2015 statistical software package of the Centers for Disease Control, Atlanta, USA.[⁴] Simple frequencies were calculated and presented in tables. Ethical approval was obtained from the Health Research and Ethics committee of the FMC, Abakaliki.

RESULTS

A total of 400 questionnaires were retrieved from the participants. Fifteen were discarded for inconsistencies in entries, leaving 385 (96.1%) suitable for analysis. The participants' ages ranged from 16 to 45 years, mean 31.3 ± 6.8 years. Nulliparas accounted for 21.6%, primiparas 41.3%, multiparas 24.9%, and grand multiparas 12.3%. These are presented in [Table 1].

Table 1: Sociodemographic characteristics of sample population

Majority of the participants had tertiary level education (73.2%).

Two hundred and eight of this women or 54% had heard of cervical cancer from various sources as shown in [Table 2].

Table 2: Sources of awareness about cervical cancer

Of the 208 respondents, between 43.3% and 62.5%, knew that having multiple sexual partners, smoking, early coitus, long-term use of oral contraception, immunosuppression, low socioeconomic status, and multiparity, respectively, and a history of sexually transmitted infections were risk factors for cervical cancer.

Many of the respondents had known risk factors for cervical cancer including early coitache, multiple sexual partners, and a history of previous sexually transmitted infections [Table 3].

Table 3: Prevalence of risk factors for cancer of the cervix among the participants

A total of 106 of participants (27.5%) believed that the early detection of cancer will be beneficial in management, 155 (40.3%) thought that it would not be beneficial, whereas 124 (32.2%) had no opinion. Only 32 (8.3%), all of whom have heard of cancer of the cervix, had ever screened for cervical cancer, majority (15; 46.9%) less than a year from the time of the study [Table 4].

Table 4: Participants who ever screened for cancer of the cervix

Ninety (23.4%) respondents did not know of any center where screening can be performed, 10 (2.6%) said that they could not afford the cost, 52 (13.5%) said that they were not at risk for cancer, and 56 (14.5%) personally believed that it was not useful.

DISCUSSION

Cervical cancer is a major cause of cancer-related morbidity and mortality among women and the most common genital cancer in the developing countries including Nigeria.[²] In spite of this statistics, it is surprising that only 54% of the respondents in this study in a State capital city had heard of cervical cancer, even when over 93% of them had at least secondary level education. It is left to imagine what the awareness would be in the rural communities of the State where majority reside. In similar studies at Afikpo, a semi-urban area of the State and Enugu, the capital city of Enugu State, the level of awareness among the participants were 37.5%[⁵] and 55.2%.[⁶] The Afikpo study result was lower than in the present study probably due to the fact that majority of our respondents were literate, and Afikpo was more of a semi-urban settlement. The result from Enugu, a similar capital city in the same geographical zone was compatible to that of this study. A window of opportunity exists in modalities of awareness creation.

It is noted in this study that medical personnel was the major source of information among the population and this is to be commended, encouraged, and intensified. The media houses (electronic and print) seem not to be optimally utilized as a means of information related to cervical cancer. Acknowledging the wide reach of the media in any community, it becomes necessary that these be further explored to improve awareness of this distressing condition in the population. This study did not evaluate churches and faith-based organizations in the dissemination awareness. Some studies in Nigeria emphasized their role in health information dissemination.[⁵⁶]

All the participants were sexually active (antenatal clinic attendees), and almost all had one or more other risk factors for cervical cancer. That notwithstanding, <9% has ever been screened for the malignancy; lack of organized screening protocol has been held responsible for paucity of screening among the Nigerian population.[⁷] However, it is noted that in Abakaliki, an organized screening protocol has been in place since 2012 at the Federal Teaching Hospital. This may be responsible for the fact that three-quarters of those that ever screened did so in the past 2 years. Organized screening is responsible for the low incidence of cervical cancer in the western countries.[⁵] However, the low utilization of screening services in this study population might have derived from the fact that many of the participants did not see themselves at risk for cervical cancer and many too were not aware of the commonly associated risk factors. Access was also hindered by lack of knowledge of the availability of screening services and affordability. Above these was the fact that many either believed that screening was not beneficial or did not know anything about it. Only 27.5% knew that the early detection could be beneficial, while only 28.1% knew that screening was indicated for all sexually active women.

In Zaria, North Central Nigeria, only 43% of their study respondents were aware of cervical cancer screening and only 15.4% ever screened. This was higher than among our study respondents but still low.[⁸] In Afikpo, 25% were aware of the existence of cervical cancer screening, but the uptake was by 0.6% of the respondents.[⁵] Eze et al.[⁵] in Afikpo, Ebonyi State as well as Ahmed et al.[⁸](Zaria, Kaduna State) noted that lack of the availability of screening centers around the localities and cost was factored militating against uptake of such services. Ezem in Owerri, Imo State, recorded an awareness level of cancer screening of 52.7% but an uptake of 7.1%.[⁹]

Of great concern is the lack of awareness of the risk factors for cervical cancer among the participants. Individuals can only adopt preventive measures if they realize the implication of such risk factors. More than three-quarters have had multiple sexual partners, and coincidentally, that same number has had one form of sexually transmitted infection or the other. Cervical cancer is a deemed a sexually transmitted infection due to HPV.[¹⁰]

This article did not access for the prevalence of HIV among the participants, another cofactor in oncogenesis due to immunosuppression.

CONCLUSION/RECOMMENDATION

This study has shown that awareness of cervical cancer among a largely literate urban population as well as the importance of screening is unarguably low. Both print and electronic media can be better utilized to disseminate this information while intensifying efforts of health workers in that direction. The citizenry deserves education on the associated risk factors, to be better disposed to adopting preventive measures. Furthermore, the availability of an organized screening center and protocol should be widely disseminated to elicit better uptake. Government and nongovernmental organizations should also partner the public sector to make cancer screening services affordable to all. A community-based evaluation in the rural areas will be an appropriate focus for further research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.