International Journal of Medicine and Health Development

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 27  |  Issue : 3  |  Page : 270--276

Predictors of knowledge of cervical cancer screening among pregnant women attending antenatal clinic in Enugu, Nigeria


Chidiebere J Otti1, Emmanuel O Izuka2, Chinelo E Obiora-Izuka3, Okechukwu C Ifebi1, Lawrence C Ikeako4, Uchenna I Nwagha2,  
1 Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria
2 Department of Obstetrics and Gyanecology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu State, Nigeria
3 Department of Paediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria
4 Department of Obstetrics and Gynaecology, Chief Odumegwu Ojukwu University Teaching Hospital (COOUTH), Amaku, Awka, Anambra State, Nigeria

Correspondence Address:
Emmanuel O Izuka
Department of Obstetrics and Gynecology, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu
Nigeria

Abstract

Background: One per cent of women diagnosed with cervical cancer are pregnant or postpartum at the time of diagnosis. Therefore, awareness during pregnancy is of utmost significance. Objective: To determine predictors of knowledge of cervical cancer screening among pregnant women who attended antenatal clinics in Enugu, Nigeria. Materials and Methods: It was a descriptive cross-sectional study of 419 pregnant women who attended antenatal care at the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu (139) and the Mother of Christ Specialist Hospital, Enugu (280). A multistage random sampling method was used to select the study centres and the participants. The questionnaires were administered by the interviewers and the data collected included sociodemographic characteristics, knowledge, and practice of cervical cancer screening. Data were analyzed using SPSS version 23. Results: The mean age of the participants was 28.86 ± 5.69, Christians (92.7%), and married (82.5%). Most of the respondents (82.3%) heard about cervical cancer screening methods through their gynecologists and of the 198 respondents who have heard about cervical cancer screening, 151 (76.3%) knew about Pap smear. One hundred thirty-eight (69.7%) of the participants believe that screening for premalignant lesions of the cervix can be performed during pregnancy. Only 37.9% of the participants had ever done Pap’s smear in the past 3 years. Respondents with higher social status (Civil/Public servants) were 10 times more likely to know about cervical cancer screening than those with lower social status (Trader/farmer/artisan) (P = 0.027, OR = 9.957, 95% CI = 1.301 – 76.191). Conclusion: Higher social status is more predictive of knowledge of cervical cancer screening amongst pregnant women attending antenatal clinics. Gynaecologist disseminate the information on cervical cancer screening more and Pap’s smear remain the main screening modality known to pregnant women. Efforts should be made by other health workers and the media to disseminate appropriate information on screening modalities for the prevention of cervical cancer



How to cite this article:
Otti CJ, Izuka EO, Obiora-Izuka CE, Ifebi OC, Ikeako LC, Nwagha UI. Predictors of knowledge of cervical cancer screening among pregnant women attending antenatal clinic in Enugu, Nigeria.Int J Med Health Dev 2022;27:270-276


How to cite this URL:
Otti CJ, Izuka EO, Obiora-Izuka CE, Ifebi OC, Ikeako LC, Nwagha UI. Predictors of knowledge of cervical cancer screening among pregnant women attending antenatal clinic in Enugu, Nigeria. Int J Med Health Dev [serial online] 2022 [cited 2022 Aug 13 ];27:270-276
Available from: https://www.ijmhdev.com/text.asp?2022/27/3/270/346425


Full Text



 Introduction



Cervical cancer is one of the gynaecological cancers of the female genital tract caused by sexually transmitted human papillomavirus (HPV). One-third of all cervical carcinomas occur during the reproductive period.[1] Cervical cancer in pregnancy is the most common occurring malignancy. Nearly 3% of all cases of newly diagnosed cervical cancer occur in pregnant women, probably because it is one of the few cancers for which screening is part of routine prenatal care.[2] However, it is still the main cause of cancer-related deaths among women in areas where routine and regular screening is not available.[3]

Pregnant women should undergo cervical cytology screening during the antenatal period, as this is the only time most women of reproductive age are in the hospital. The age bracket of people prone to invasive cervical cancer is between 30 and 49 years, and about half of the new cases of invasive cervical cancer are found in women under 49 years of age4. Again, the average age of pregnant women with advanced cervical cancer is 31.8 years.[5] Considering that a sizable number of women with invasive cervical cancer are in the reproductive age group, pregnancy becomes an ideal time for screening, especially for women who do not go for regular gynecologic examination. Unfortunately, a considerable number of women receive neither routine gynecologic examination nor early prenatal care. Ideally, at the initial evaluation of the antepartum period, each woman should have a detailed and proper evaluation that includes a vaginal speculum examination to assess the cervix, a bimanual pelvic examination, and a Pap smear as a routine component of the prenatal evaluation. Cervical screening during pregnancy has been found to be safe and effective.[6]

According to the World Health Organization, about 4/5th of women between 25 and 49 years should have cytological screening so as to effectively forestall cervical cancer.[7] Furthermore, screening for cervical cancer should be done at least once for every woman in the target age group of 30 to 49 years where the greatest benefit can be obtained.[8]

Regardless of this, there have been reports of obstacles to cervical cancer screening, especially due to inequalities in socioeconomic standing. An attempt to study the role of different socioeconomic factors in this process could go a long way in accomplishing definitive actions to wade into social inequalities and minimize their impact on health at various stages of life. The large disparities in health that can be measured within and between countries are a huge challenge to the world. However, social health inequalities are abolishable, and limiting them will represent an achievable target and an ethical order.[9]

Screening for cervical cancer gives protective benefits and is associated with a decrease in the occurrence of invasive cervical cancer and the mortality of cervical cancer. However, the rate of acceptance of cervical cancer screening is poor in low- and middle-income countries.[10] Since the antenatal period is considered an opportune moment to perform cytology screening to prevent cervical cancer, it becomes necessary for healthcare providers to maximize the opportunity of antenatal care to provide health education and screen women to detect early states of disease and begin proper treatment.

In developed countries such as the United States of America, the death rate from cervical cancer has decreased due to regular cervical screening and treatment that are available and easily accessible. In developing countries such as Nigeria, most cervical cancer patients present late because few women carry out cervical cancer screening.[11] The practice of cervical cancer screening among our women is even worse during pregnancy, and this poses a great danger to society, as they present late with invasive disease and its attendant poor prognosis. This study was therefore designed to find out the knowledge of cervical cancer screening amongst pregnant women attending antenatal clinics in Enugu, Nigeria and to determine the factors that predict their knowledge. This could impact the need to intensify awareness creation and could influence policies as well.

 Materials and Methods



Setting and study population

The study was conducted in the antenatal clinics of the University of Nigeria Teaching Hospital (UNTH) and the Mother of Christ Specialist Hospital (MOCSH). The participants were pregnant women who attended antenatal care and were selected in a 1: 2 ratio based on the average number of pregnant women attending antenatal care of 150 and 350 women per month at the University of Nigeria Teaching Hospital and the MOCSH, respectively. The hospitals are two major providers of healthcare / antenatal care to women in the state of Enugu and the surrounding area.

Study design and sample size determination

The study was a descriptive cross-sectional study conducted on booked antenatal women who attended antenatal care in the two study centres. At 95% confidence interval (CI), the minimum sample size required to power the study was 419 making allowance for 10% attrition.

Sampling technique

A multi-stage cluster sampling technique was used to select the study subjects. First, a random selection was made from a box containing all the tertiary health institutions in the state that offer antenatal care, and the two study centres (UNTH and MOCSH) were selected. The sample size was divided by the ratio of 1:2 derived from the average number of pregnant women who access antenatal care monthly at UNTH (150) and MOCSH (350). Subsequently, the samples for each of the hospitals were randomly selected for the study. The random sampling employed was the ballot method (Yes or No picks). Therefore, 139 participants were selected from UNTH while 280 were selected from MOSCH.

Data collection

The distribution of the questionnaire copies to pregnant women in the two study centers was conducted only on days of antenatal visits. The distribution and collection of the questionnaires lasted for six months (4 May 2020 to 30 October 2020) using antenatal visit days in each of the hospitals. The questionnaire was interviewer-administered and was collected on the spot. Information on the sociodemographic characteristics, their knowledge of cervical cancer screening and their practice of cervical cancer screening were sought. Informed consent for the study was obtained from the pregnant women who picked yes after randomization and agreed to participate in the study. Ethical clearance was obtained from the Teaching Hospital of the Ethics Committee of the University of Nigeria Teaching Hospital.

Validity and reliability of the instrument

Two research experts validated the questionnaire: a consultant gynecologist and a statistician. A pilot study was conducted at the polyclinic. Twenty (20) questionnaires were administered to test for internal consistency of responses using a measure of reliability known as Cronbach’s Alpha. Ideally, to obtain a good estimate of the reliability of a survey, we split the items into two groups and then compare these groups as if they were two separate administrations of the same survey. This is called the split-half test. This test is used instead of the test-retest technique to avoid bias. The result shows that the Cronbach’s Alpha coefficients for each of the split halves 1 and 2 are 0.753 and 0.835, respectively, and the correlation between the forms is 0.829, indicating strong reliability.

Method of data analysis

Data were analyzed using the statistical package for the computer software for social sciences version 23.0 for windows. Descriptive statistics, including frequency and percentages, were used to summarize categorical variables, while means and standard deviations were obtained for continuous variables. Association between sociodemographic factors and knowledge of cervical cancer screening was done using logistic regression. P-values less than 0.05 were considered statistically significant.

 Results



[Table 1] shows that the majority of the respondents (62.5%) were within the age bracket of 21 and 30 years of age. The mean age was approximately 28.86years (SD = 5.69) while the age range was 16 - 60 years. They are predominantly Christians (92.7%), while 82.5% of them are married. More than half of the pregnant women (59.4%) have 1 to 3 deliveries, 19.7% have more than 3 deliveries while 20.9% of them were primigravida. The table also shows that 65.7% of pregnant women had reached the tertiary level of education, while 30.2% had reached the secondary level of education. Of 346 women with partners, 58.4% of them (partners) had attained a tertiary level of education while 37.3% had attained a secondary level of education. Most of the participants were employed (66.2%) and predominantly civil/public servants (64%).{Table 1}

[Table 2] shows that most of the respondents (82.3%) heard about cervical cancer screening methods through their gynaecologist. Just 8.6% and 9.1% of them heard through family planning and nurses, respectively. Of 198 respondents who have heard about cervical cancer screening, 151 (76.3%) know about Pap smear, 30 (15.2%), 22 (11.1%), 14 (7.1%) and 14 (7.1%) know about Colposcopy, Visual inspection with acetic acid, Visual inspection with Lugol’s iodine and Liquid-based Cytology, respectively. The table also shows that 138 (69.7%) of the participants believe that cervical screening can be performed during pregnancy.{Table 2}

[Table 3] shows that 56 (28.3%) of the respondents are discouraged from screening for cervical cancer by partners or others, while 75 (37.9%) reported that it is painful to have a pap smear. While 77 (38.9%) of the participants believed that having a pap smear is embarrassing, 75 (37.9%) admitted that it is difficult to get a pap smear done.{Table 3}

The proportion of people who had a pap smear (Uptake of Pap’s smear) in the last 3 years was 37.9%, while 80 (40.4%) have undergone HPV vaccination. However, the majority of the respondents (77.3%) are willing to allow their children to be vaccinated. Fear that something wrong will be detected at screening, a pap smear is noninvasive, and screening is expensive were reported by 95 (48%), 97 (49%) and 85 (42.9%) of pregnant women; while 91 (46%) of them believe that a woman should not have sex 24 hours before having a pap smear.

[Table 4] shows that occupation was the only sociodemographic factor significantly associated with knowledge of cervical cancer screening among pregnant women (P = 0.027, OR = 9.957, 95% CI = 1.301 – 76.191). Respondents with higher social status (Civil/Public servants) were 10 times more likely to know about cervical cancer screening than those with lower social status (Trader/farmer/artisan). Factors such as age, marital status, number of deliveries, educational level, partner’s educational status, and employment status were not significant predictors of knowledge of cervical cancer detection among pregnant women (P > 0.05){Table 4}

[Table 5] shows that after including the sociodemographic factors into a multivariate model, occupation alone remained a significant predictor of knowledge of cervical cancer screening amongst pregnant women (P = 0.048, OR = 8.499, 95% C.I = 1.021 – 70.723). Respondents with higher social status (Civil/Public servants) were 8 times more likely to know about cervical cancer screening than those with lower social status (Trader/farmer/artisan).{Table 5}

 Discussions



This study has shown that only 48% of the respondents have heard about cervical cancer screening, which is comparable to a study conducted in Oshogbo Nigeria where 44.5% of their women are aware of cervical cancer screening,[12] but is higher than 30% obtained from a study in Ife.[13] These show that many people in the two study population have never heard about cervical cancer screening and are representative of the global scenario in developing countries such as Nigeria. Most of the participants heard about cervical screening methods through their doctors (gynaecologists). The rest heard it through family planning clinics and nurses, respectively. The finding is like the finding of the study done in Kenya[14] where most people heard about cervical cancer screening through their gynaecologists. Media houses have a role to play in disseminating information about cervical cancer screening since the study showed that none of the study population has ever heard about it through media which is one of the ways of spreading information to a large audience.

Most of the participants knew about the pap smear screening method alone as the only method of cervical screening method, while the minority knew about colposcopy, visual inspection with acetic acid, visual inspection with Lugol iodine and liquid-based cytology. This contrasts with the findings of a study conducted in Sokoto state, Nigeria, where 90.5% of the respondents have good knowledge of the methods of cervical cancer screening.[15] The disparity in the level of knowledge of the methods of cervical cancer screening between the two study could be as a result of the study participants. Whereas the Sokoto study population were health care workers, our study population were antenatal pregnant women. This calls for more awareness campaigns on cervical cancer screening modalities in our environment. The gynaecologist should provide more information on other cervical screening methods, so that the populace will be well informed about other screening modalities and how to easily access them. The information could be given during screening exercises in the community by primary health care centres, or by non-governmental organizations during outreaches or seminars.

Sixty-nine-point seven per cent believe that cervical cancer screening could be performed during pregnancy, which is like the study done in Kenya, where 63.4% of the respondents believe that cervical screening could be done during pregnancy.[16]

The level of uptake of cervical cancer screening was poor due to several factors including discouragement by partners, fear of pain, embarrassment, the uncertainty of result outcome and financial implications. This was slightly different from the study in Nnewi,[17] where most had no reason to not test (29.5%), 25% were afraid of the outcome of the results, 4.5% did not want to be embarrassed, and 25% felt that the test was unnecessary as they were not at risk. Although the uptake in our study was poor, it was still higher than the uptake in a study conducted in Abakaliki by Urom et al. where only 32 of the 385 participants (8.3%) had ever performed the Pap smear.[18] These reasons for the poor uptake of cervical cancer screening generally are a wake-up call that proper health education, government policies, seminars, organizing symposiums on cervical cancer screening methods, and its prevention strategy in developing countries such as Nigeria are of paramount importance.

Occupation is the only sociodemographic factor found to be a significant predictor of knowledge of cervical cancer screening amongst antenatal women even after multivariate logistic regression analysis. Respondents with higher social status (civil /public servants) were 10 times and 8 times respectively more likely to know about cervical cancer than those with lower social status (trader/farmer/artisan). Low socioeconomic status is one of the risk factors for cervical cancer,[15] respondents with higher social status had more knowledge about cervical cancer screening than those with lower social status.

The study was a hospital-based cross-sectional, non-interventional study, and the findings may not be generalized to the population. The wide confidence interval in the occupation could be the result of the ‘not too large’ sample size of the study. Future studies will address these limitations.

 Conclusions



The study shows that the knowledge about cervical cancer screening is quite low, the antenatal period should be seen as an opportunity to offer cervical cancer screening, and media and health workers should make efforts to spread accurate information on screening modalities for the prevention of cervical cancer. Occupation was the only sociodemographic factor found to be a significant predictor of knowledge of cervical cancer screening. Programs such as World Cancer Day should be used by government and non-governmental organizations to disseminate accurate information and offer free screening for cervical cancer. Community-based screenings should be offered to people with lower social status in their various communities. Information on the various modalities of screening should also be disseminated accurately and extensively. National screening programmes should be designed, funded, and implemented by the federal government.

Acknowledgement

Special thanks go to the antenatal clinic nurses of the two study centres for their support and assistance, especially as regards the randomization of the study participants throughout the study.

Financial support and sponsorship

The study was self-sponsored.

Conflicts of interest

No Conflict of Interest Declared

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