African Journal of Medical

A F R I C A N J O U R N A L O F M E D I C A L

ME C O N P U B L IC A T IO N S 2(1):42-58; 2019 AJMAS 00278.

Original Research Article

Determinants of Cervical Cancer Screening Uptake among Women in Orlu Local Government Area, Imo State, Nigeria.

Ejikunle SD1*, Anolue F1 , Ohamaeme MC2, Egwurugwu JN3, Dike EI1, Eberendu IG4.

1. Department of Obstetrics and Gynaecology, Imo State University Teaching Hospital, Orlu, Imo State, Nigeria. 2. Department of Community Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria 3. Department of Human Physiology, Imo State University, Owerri, Nigeria. 4. Department of Paediatrics, Imo State University Teaching Hospital, Orlu, Imo State Nigeria. *Correspondence author. Dr. Ejikunle Samson. Department of Obstetrics and Gynaecology, Imo State University Teaching Hospital, Orlu, Imo State, Nigeria. Email: [email protected] Article information:

DOI:10.33798/ajmas2019/vol-2-1-00278

Date received: March 30, 2019

Accepted: April 29, 2019

Published: April 30, 2019.

Abstract

Background: Cervical cancer is the 2nd commonest cancer among women worldwide and is the leading cause of cancer deaths among women in developing countries. Optimal cervical cancer screening uptake is one of the most cost effective control strategies for the disease. Objectives: To assess the determinants of cervical cancer screening uptake among women in Orlu Local Government Area, Imo State, Nigeria. Materials & Methods: A community based cross-sectional study with the use of 502 interviewer-administered questionnaires was conducted among women in Orlu Local Government Area of Imo State. All the women in the community attending the annual 2018 August meeting were recruited for this study. Results:The study showed that the mean age of the respondents was 42±2.8 years. Furthermore, 82.3% of respondents attained postsecondary school educational level. Also 80.5% of respondents have heard about cervical cancer screening but level of cervical cancer screening uptake was very low among the respondents (13.5%). Significant associations were found between embarrassment, lack of symptoms, lack of physician request, lack of counselling, cost, unavailability of services and cervical cancer screening uptake. Conclusion: Despite the high knowledge of cervical cancer screening among women in Orlu LGA, uptake of cervical cancer screening was low. Enhancing health education and provision of free and widely accessible health screening services may increase uptake among these women.

Key words: Cervical cancer, screening, Orlu women, uptake.

1. Introduction

Cervical cancer is the second commonest coitarche, multi-sexual partner,

[1] [7] cancer among females worldwide and the immunosuppression, smoking habit etc . commonest cancer of the female genital tract Cervical cancer is one of the most easily in Nigeria[2]. In 2008 alone, not less than preventable cancers, however, poor attitude, 530,000 new cases of the disease and access to prevention services and 275,000 deaths were recorded globally. affordability of the service can affect Surprisingly, 90% of these deaths were decision for uptake of cervical cancer recorded in the developing countries. In the [8] screening . In view of the increasing WHO African region, about 75,000 new burden of cervical cancer generally, the cases were recorded for the same year [3]. In World Health Assembly (WHA), in 2005, Nigeria, an estimated 10,000 new cases of adopted resolution 58.22 which urged cervical cancer and 8000 deaths due to the member states to intensity action against disease are recorded among women yearly cancer through creation of National cancer [4] . Moreover, Nigeria has an estimated five- [9] control programmes . In Nigeria, the year prevalence of 21.6% for cervical cancer National Cancer Control Programmes was [5]. Evidence has shown that virulent strains developed in 2008 with the view of reducing of the sexually transmitted human papilloma the morbidity and mortality associated with virus (HPV) particularly HPV 16 & 18 are [10] cancer and its socioeconomic impacts . [6] implicated in cervical cancer . The Major However, the level of implementation of this source of HPV infection and cancer of the plan is still debatable in Nigeria. cervix depends on factors like age of Cervical cancer screening is a known cost

effective strategy used in reducing the

burden of cervical cancer worldwide, its 2. Methodology uptake is still abysmal especially in 2.1 Study Area developing countries like Nigeria [11,12]. One Imo State is in South East geopolitical zone of the barriers to access is that most cervical of Nigeria. The state is densely populated cancer screening services in Nigeria had with a figure of about 3.93 million [16]. It is been sporadic and poorly coordinated. divided into three senatorial zones: Orlu, Services are not equitably distributed with Owerri and Okigwe. The study was most of them being available at the urban conducted in Orlu Local Government Area areas. (LGA) of Imo State. It is the second largest

Several studies have documented factors city in the State after Owerri, with an associated with uptake of cervical cancer estimated population of 142,792 according screening worldwide, these include age of to 2006 census and a 2016 projected the woman, marital status, parity, risk population of 196,600 [17]. The LGA has 16 perception, financial constraints and district areas which include Umuna, knowing someone who has cervical cancer Umutanze, Okporo, Owerre Ebeiri,

[13,14]. Umuzike and Amaifeke. Others are Eziachi,

Umudioka, Umuowa, Amike, Mgbe, The prevalence of cervical cancer is high in Ihioma, Orlu rural, Ogberuru, Obibi-Ochasi our domain [15] though preventable by and Ihitte- Owerre. cervical cancer screening. This study was designed to assess the determinant factors influencing uptake of cervical cancer screening among women in Orlu, Imo State.

2.2 Study Population

The study was conducted among women 2.5 Exclusion criteria attending the usual annual August meeting All attendees of August meeting within the in Orlu LGA of Imo State. These were age group who declined to participate in the women aged 20 years and above, who met at study. the community square and church premises 2.6 Sample size for the 2018 August meeting.

The sample size was calculated using the 2.3 Ethical approval [18] formula below . Based on documentation The ethical approval was sought and of previous study conducted in Nigeria by obtained from the Imo State University [19] Nwozor and Oragndosi , a population of Teaching Hospital Ethics and Research 36% was used as the percentage of Nigeria Committee. Consent to carry out the study women who were aware of cancer of the was obtained from each respondent after cervix. A precision of 5% was used and adequate explanation of the study to them. correction for non response was made. No participant was coerced to take part in n=Z2 x p(1-P) the study. d2

2.4 Inclusion criteria n = 1.962 x 0.36(1-0.36)

0.052 All women attending the central August n =354 meeting aged 20 years and above, who where n = minimum sample size consented to, were recruited for the study. z = Standard normal deviant

p = prevalence ie 36%

d= sampling error of 5%(0.05). 44

For the purpose of this study the sample size criteria were recruited for the study was increased to 502 to increase the power statistical analysis. of the study and better generalization. Data was cleaned, coded and entered into

2.7 Data collection IBM – SPSS version 21. Frequency and

percentage tables were generated. Fisher’s This was a community based descriptive exact test was done to implore relationships cross-sectional study. A structured between educational status and knowledge interviewer-administered questionnaire of cervical cancer screening, educational which included socio-demographics, status and practice of cervical cancer knowledge of cervical cancer and uptake of screening as well as reasons for not doing cervical cancer screening was used. The cervical cancer screening and uptake of questionnaires were administered by the cervical cancer screening among researchers to a total of 502 participants. All respondents. The level of statistical the respondents who met the inclusion significance was set at p < 0.05 at 95%

confidence interval.

3. Results

The results of the socio-demographic characteristics, determinants of cervical cancer uptake and other variables are displayed below.

Table 1: Frequency Distribution of socio-demographic characteristics of the respondents

Factor Frequency (percentage) Age range 20 – 29 54(10.8) 30 – 39 100 (19.9) 40 – 49 166(33.1) 50 – 59 97 (19.3) 760 85 (16.9) Total 502(100) Marital status Single 48(9.6) Married 349(69.5) Divorced 20 (4.0) Separated 28 (5.6) Widowed 57 (11.4) Total 502 (100)

Educational level None 9(1.8) Primary 16(3.2) Secondary 64(12.7) Post secondary 413 (82.3) Total 502(100) Parity None 86(17.1) 1-5 310 (61.8) >5 106 (21.1) Total 502(100)

The mean age of the respondents was 42±2.8years out of the 502 respondents, 166 (33.1%) were in the 40-49 year age range. Three hundred and forty nine (69.5%) were married, 20 (4.0%)

divorced, 28 (5.6%) separated and 48(9.6%) single. A total of 413 (82.3%) had post secondary level of education. Majority, 310(61.8%) had parity of 1-5, while 106(21.1%) were grandmultips as shown in table one above.

Table 2: Knowledge of cervical cancer

Variables Yes(%) No (%) Total (%)

Heard of cervical cancer 404(80.5) 98(19.5) 502(100)

Cervical cancer is preventable 243(48.4) 259(51.6) 502(100)

In table 2 above, Majority, 404(80.5%) have heard of cervical cancer, however, greater proportion 259(51.6%) were not aware that cervical cancer is preventable.

Table 3: Educational status and uptake of cervical cancer screening

Educational status Yes(%) No (%) Total (%) Fisher’s p-value

None 0 9 9 4.886 0.299 Primary 1 15 16 Secondary 5 59 64 Post secondary 62 351 413 Total 68(13.5) (134(86.5) 502(100)

Table 3 above shows cross tabulation results between educational status and the uptake of cervical cancer screening. Only 68(13.5%) have done one form of cervical screening or the other previously though not statistically significant (p= 0.29).

Table 4: Socio demographics and uptake of cervical cancer screening

Social demographics Yes(%) No (%) Total (%) x2 p-value

AGE 20-29 2 52 54 12.218 0.02 30-39 19 81 100 40-49 16 150 166 50-59 19 78 97 >60 12 73 85 Total 68 435 502 Marital Status Single 3 45 48 3.619 0.603 Married 49 300 349 Divorced 4 16 20 Separated 3 25 28 Widowed 9 48 57 Total 68 434 502

Educational Status None 0 9 9 4.885 0.30 Primary 1 15 16 Secondary 5 59 64 Post-secondary 62 351 413 Total 68 435 502 Family history of cancer Yes 11 8 19 33.165 0.01 No 57 426 483 Total 68 434 182 OCP use Yes 18 39 57 17.855 0.01 No 50 395 445 Total 68 434 502 Table 4 shows cross-tabulation results between age, marital status, and educational status, family history of cancer, oral contraceptive use and uptake of cervical cancer screening. Asides educational status that was not statistically signifance (p=0.30). Others were statistically significant.

Table 5: Reasons for not doing cervical cancer screening and uptake of cervical cancer screening Reasons Yes(%) No (%) Total (%) x2 p-value Embarrassment Yes 10 113 123 4.080 0.04 No 58 321 379 Total 68 454 502 Lack of symptoms Yes 13 217 230 22.585 0.001 No 55 217 272 Total 68 434 502 No encouragement from the partners Yes 10 45 55 1.278 0.5 No 59 389 447 Total 68 434 502 No physician request Yes 20 226 246 12.082 0.001 No 48 208 256 Total 68 434 502 Lack of counselling Yes 22 282 304 26.196 0.001 No 46 152 198 Total 68 434 502 Cost Yes 18 218 236 13.323 0.001 No 50 216 266 Total 68 434 502 Unavailability Yes 16 190 206 9.962 0.002 No 52 244 296 Total 68 434 502 Table 5 shows cross-tabulation results between reasons for not doing cervical cancer screening and uptake of cervical cancer screening among the respondents. All but lack of encouragement from the partner (p<0.5) were statistically significant.

Table 6: Educational status and knowledge of cervical cancer screening

Educational status Knowledge of Cervical Ca screening

Yes(%) No (%) Total(%) Fisher’s p-value

None 5 4 9 29.306 0.001 Primary 7 9 16 Secondary 45 19 64 Post secondary 347 66 413 Total 404(80.5%) 98(19.5%) 502(100%)

Table 6 shows cross tabulation results between educational status and knowledge of cervical cancer screening. It showed statistically significant relationship between knowledge of cervical cancer screening and educational status (p<0.01)

cervical cancer screening (80.5%), majority

(51.6%) were not aware that cervical cancer Discussion is preventable with very low uptake of Uptake of cervical cancer screening and cervical cancer screening (13.5%) among early treatment of cervical cancer if women in Orlu LGA of Imo State, South detected, remains the most effective way to Eastern Nigeria. This is relatively similar to reduce the morbidity and mortality findings in South Western [20] and South associated with the disease [8,15]. This study Eastern [21] Nigeria where the level of assessed the determinants of cervical cancer knowledge of cervical cancer was close to screening uptake among women in Orlu 100% among respondents but uptake of LGA, Imo State. cervical cancer screenings of 4.2%.

This study, demonstrated high level of knowledge of cervical cancer (80.5%) and

The uptake of cervical cancer screening of suggests that there may be more factors

13.5% in this study is comparable to that affecting the uptake of cervical cancer from the study [21] conducted in Enugu, screening than knowledge alone.

South Eastern Nigeria. The similarity in this The finding of low uptake of cervical cancer result with that of Enugu was screening in this study correlates with the understandable because of population findings in other studies [22,24,26] in Africa distribution of participants and geographical among women of diverse populations, locations of the two studies. occupation, age and educational level. The

Furthermore, poor uptake of the screening common determinants proposed for low services observed in our study affirms uptake in the above studies were similar to similar findings among nurses in Nnewi the findings of this present study which

[22] [23] (7.1%) , and Owerri (7.1%) , all in revolved around inadequate knowledge

South Eastern Nigeria. The knowledge of about cervical cancer and its prevention, cervical cancer screening increased with socio demographic factors, costs, absence of increasing educational status in this study, symptoms and poor knowledge/lack of

[24,25] similar to the findings in other studies . screening modalities.

However, this study showed a significant In this study, majority (80.5%) of the association between the educational status respondents were aware of cervical cancer and the knowledge of cervical cancer screening but only 13.5% of our respondents screening, which did not translate into had undergone the procedure. This may not uptake of cervical cancer be unconnected to the widely held view that screening(13.5%).This finding which has cervical cancer increases with age, as [22,26] also been supported by other studies , findings from this study showed a

statistically significant association between with uptake of cervical cancer screening. age of respondents and uptake of cervical However, lack of encouragement from the cancer screening (P<0.02). However, the partner was not statistically associated with marital status, and educational status did not uptake of screening (P<0.5) have any statistically significant association These findings were slightly different from with uptake of cervical cancer screening. the study in Nnewi, Nigeria [22] where This is similar to findings in Sokoto, majority gave no reason for not testing and [27] Nigeria . of those that had reasons, the commonest

However, family history of cancer and use were the fear of the result and not being of oral contraceptive pill showed a susceptible to cervical cancer. statistically significant association with the In a study done at Ilorin North central, uptake of cervical cancer screening. This Nigeria [28], it was shown that the low might suggest that people at risk of cervical uptake of cervical cancer screening was due cancer were more likely to undergo cervical to poor availability of screening services cancer screening. This window of within Ilorin, financial incapability to access opportunity should be utilized in counselling healthcare services, and cervical cancer patient for cervical cancer screening. screening services being only mostly

The common reason for the low uptake of available in tertiary health institution. This is cervical cancer screening in this study similar to findings in our study. Though our included cost, lack of symptoms, lack of study was in the SouthEastern geopolitical counselling, unavailability of screening zone of Nigeria, it seems the determinants of services, lack of physician request which uptake of cervical cancer screening are showed statistically significant association similar to other part of the country. The

similarities in the determinants of the uptake uptake of cervical cancer screenings. of cervical cancer screening across national Common reasons for this low uptake geopolitical zones of the country may be included cost, unavailability of screening useful in developing guideline and protocol services, lack of symptoms, lack of for national intervention by national cancer physician among others. Hence, enhancing control programme. health education and provision of free and

widely accessible health screening services Conclusion by government, non-governmental Majority of the women in Imo State organization and individuals may increase demonstrated high level of awareness of the uptake of cervical cancer screening cervical cancer and cervical cancer among these women. screening modalities but with very low

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Ejikunle SD, Anolue F, Ohamaeme MC, Egwurugwu JN, Dike EI, Eberendu IG. Determinants of Cervical Cancer Screening Uptake among Women in Orlu Local Government Area, Imo State, Nigeria. Afr J Med Allied Sci, 2019; 2(1):42-61.