Cervical Cancer: Community Perception and Preventive Practices in an Urban Neighborhood of Lagos (Nigeria)

Background. Cervical cancer prevention in developing countries is suboptimal compared with the developed world where there are fewer deaths and improved survival rates. This study describes the perception and preventive practices on cervical cancer by residents of an urban neighborhood of Lagos, Nigeria. Methods. A descriptive cross-sectional study was conducted on 317 consecutively recruited consenting participants at a medical outreach using a pretested, interviewer-administered, semistructured questionnaire. Data analysis was done using statistical package for social sciences version 19. Tests of significance were performed using 95% confidence interval with level of significance set at P < 0.05. Results. The majority of respondents were within 30–49 years of age (46.7%) and female (62.1%) and 70.3% had secondary level education and above. About 37.2% of respondents had heard about cervical cancer with 84.5% of the participants willing to attend a cervical cancer health education program. Among the female respondents, 4.1% had received the HPV vaccine, while 5.1% had undergone a Pap test. Awareness about cervical cancer was significantly higher with increasing age in the total population (P < 0.05). Conclusion. There is a need to improve awareness of at-risk groups and the menfolk about cervical cancer based on the immense benefit of male involvement in reproductive health matters.


Introduction
Invasive cervical cancer (ICC) is the leading cause of cancerrelated deaths among women in developing countries [1]. It is the second most common cancer among women worldwide with an estimate of over 500,000 new cases and about 275,000 deaths in 2008. About 86% of these cases occur in developing countries representing approximately 15% of female cancers [2,3].
The incidence of cervical carcinoma in Africa is on the rise. However, the true incidence in many African countries is unknown as there is gross underreporting [1]. Few countries have functioning cancer registries but record keeping is suboptimal. Many of the figures in literature are hospital-based, and these represent a small fraction of women dying from cervical cancer, as most women cannot access hospital care and oftentimes die at home [4]. Mortality rates in developed countries with successful screening programs hardly exceed 5 per 100,000 women. In sub-Saharan Africa in 2002, survival rate was 21% compared with 70% and 66% in USA and Western Europe, respectively [2]. In Nigeria, 80% of the 10,000 women who develop cervical cancer annually die from it [5].
The known primary underlying cause is the humanpapillomavirus (HPV), which is the most common sexually transmitted infection worldwide, and it is estimated that 50% to 80% of sexually active women are infected at least once in their lifetime [6]. Prevention of cancer of the cervix is achievable by preventing HPV infection and ensuring early detection and treatment which significantly reduces its morbidity and mortality. Pap smear test is one of the most reliable and effective cancer screening tests available. About 75% of women in industrialized countries have been screened for cervical cancer in the previous five years, compared to less than 5% in developing countries [7]. In sub-Saharan Africa, few women are ever screened for cervical cancer. Screening coverage in developing countries is low ranging from 2.0% to 20.2% in urban areas and 0.4% to 14.0% in rural areas [8]. Low 2 ISRN Preventive Medicine levels of awareness and poor knowledge of cervical cancer coupled with unavailability and inaccessibility of cervical cancer screening services are responsible for the very small number of women being screened in developing countries [9].
Lagos State has two tertiary and about 22 government owned secondary health care facilities where follow-up and treatment may be accessed for cases of positive Pap smear results. This survey was undertaken to assess community perception and preventive practices on cervical cancer amongst residents of an urban neighborhood of Lagos, Nigeria.

Location of the Study.
Lagos State is located in southwestern Nigeria and lies on longitude 3 ∘ 24 E and latitude 6 ∘ 27 N. Lagos State has an estimated population of 15 million people [10]. It is made up of 20 local government areas, and 37 local council development areas (LCDA). Olusosun is located in Onigbongbo LCDA of Lagos and is an area known widely on account of the presence of the largest landfill in Lagos State [11]. The area is presently a commercial and residential area.

Study Design.
A descriptive cross-sectional study design was used and the study population was selected among the residents of Olusosun area.

Sample Size Determination.
Sample size was established such that an accuracy of 5% could be reached around an observed probability of 25%.
The required sample size was calculated using the formula 2 / 2 [12]. Therefore minimum sample size calculated was 288. A nonresponse rate of 10% (+29) was anticipated; therefore, a total sample size of 317 was obtained.

Sampling Method.
A medical outreach (consisting of free medical consultation and basic services) was conducted in June 2013 at Olusosun community by resident doctors undergoing medical specialist (postgraduate) training at a tertiary health institution in Lagos as part of the activities for the annual general week of the resident doctors involving elections, medical mission, and other programs. Residents of the community had been sensitized about the program prior to the Outreach to promote community participation in the event. Consecutive recruitment was done for consenting residents until the sample size was obtained. The inclusion criterion is the condition that the respondents must be 18 years of age or above.

Survey Instruments.
A structured interviewer-administered questionnaire developed by the researchers (based on literature search) was used for data collection. This instrument was pretested in a different community close to the tertiary health institution to exclude ambiguities and administered by research assistants who had a day training to ensure lexical coherence as well as efficient and effective discharge of duties.
The questionnaire sought information on sociodemographic details, perception, and preventive practices on cervical cancer.
2.6. Data Analysis. Analysis was done using Statistical Package for social sciences (SPSS) version 19. Tests of significance were performed using a 95% confidence interval, and the level of significance was set at < 0.05. Bivariate analysis was done to determine associations between variables. Outcome measures include perception of cervical cancer, knowledge of preventive practices, and proportion of respondents who had engaged in preventive practices.
Ethical clearance was obtained from the research and ethics committee and informed consent was obtained from each participant at the point of data collection.

Study Limitation. Lagos State is divided into 20 local government areas (LGAs) with a breakdown of 16 urban and 4 rural
LGAs. The study was conducted in one of the LGAs. The findings might not be representative of the entire state (rural and urban combined), but it is fairly representative of the urban communities of Lagos.

Discussion
The results from this study show that just over a third of respondents (37.2%) had heard about cervical cancer, with television (39%) being the commonest source of the information. This is quite low when compared to a cross-sectional survey of 650 women conducted in London, which showed that 76.2% of the participants perceived cervical cancer to be a common disease and were also aware of the risk factors for the disease [13]. Similarly, a Yemeni study revealed that most respondents (80.6%) had heard about cervical cancer with a quarter of the respondents (26.4%) accessing this information from television [14]. In Africa, a study in Kenya, to assess knowledge and practices about cervical cancer and Pap smear testing among cervical cancer and noncancer patients, found that 51% of the respondents were aware of cervical cancer which is also higher than that obtained in the present study [15].
Sub-Saharan Africa which appears to be one of the most affected regions also has the lowest awareness rates about cervical cancer, as even lower rates were reported in Cameroon where a study to assess the knowledge of cervical cancer showed that only 28% had prior knowledge of cervical cancer and another study in Ibadan among women aged 20 to 65 years attending the general outpatient unit of a department in a tertiary hospital found that only 15% of the respondents had heard of cervical cancer [4,16]. Among rural women in a study conducted in Osun State of Nigeria, about 39.2% of the women had heard about cervical cancer which is also very similar to the findings in the present study [17]. Suboptimal awareness of cervical cancer is further demonstrated in the present study by the fact that only 5.1% of respondents who had heard of cervical cancer understood that HPV infection has been strongly implicated in its causality. Correspondingly, none of the respondents in a study conducted in Malaysia had heard of the HPV [18]. The low awareness in these countries that have a greater share of cervical cancer deaths than high income countries is worrisome.
In the midst of this, however, a favorable finding is that 84.5% of respondents are willing to attend a cervical cancer heath education program. This gives an indication that the population is willing to learn about cervical cancer and its prevention in at-risk groups.
Based on the minimal proportion of cervical cancer, informed respondents, it is not surprising that over 90% of the study participants were uninformed on ways of preventing cervical cancer with only 6% of all respondents having heard of the HPV vaccine. These are similar to the finding in a cross-sectional survey among college women in a university in Ghana which showed that only 7.9% were aware of the link between humanpapillomavirus and cervical cancer [19]. Findings from the present study are also similar to those reported from an intervention study conducted among market women in Lagos to evaluate the effect of health education on awareness and uptake of cervical cancer screening where only 6.9% and 12.0% of respondents in the study and control groups had heard about Pap smears at baseline [20]. These figures are quite low when compared with findings from the study conducted in Yemen where a great majority (70%) of respondents were correctly informed that cervical cancer is preventable. Proportions of 59% and 18% of participants in that study knew that routine screening by Pap smear and vaccination against HPV infection are some methods for the prevention and control of cervical cancer [14]. Knowledge generally does not necessarily translate to practice in numerous cases as has been observed on certain occasions. For instance, despite the better awareness observed about cervical cancer prevention in the Yemen study, preventive practices were low with only 19 (7%) of all those knowledgeable about cervical cancer reported having received cervical cytology testing (Pap smear test) [14]. This is comparable to findings in the present study where among the respondents, who had heard of cervical cancer, only 8.5% had undergone a Pap smear test and 6.8% had received the HPV vaccine. Some limiting factors may include cost, availability of vaccines, and screening services as well as accessibility. Contrarily, findings in developed countries such as UK showed that 80.5% of women in a study in London had undergone at least one Pap smear test with 71.5% reporting regular smear tests (every 3-5 years) [13]. Furthermore, screening practices were reported to be poor in a South African survey where in spite of good knowledge on cervical screening and readily accessible facilities with available screening services, the majority of women (87%) from higher social and educational backgrounds did not undergo cervical screening [21]. In Nnewi, Nigeria it is interesting to observe that, among female health care workers who are expected to uptake innovative promotive and preventive health practices, only 5% had ever had a Pap smear done [22].

Conclusion
The findings in the present study indicate that although awareness of cervical cancer and its prevention appear poor, there was a willingness to learn about this preventable cancer by all respondents. This can form the basis for improving awareness of at-risk groups and other stakeholders including the menfolk particularly in the light of the immense benefit of male involvement in reproductive health matters in Lagos, Nigeria, and Africa as a whole. It is therefore very important to develop ways of ensuring that the message about cervical cancer and its prevention spreads to the grassroots across Nigeria and sub-Saharan Africa to reduce the avoidable morbidity and mortality. In addition, primary and secondary prevention need to be emphasized in terms of health education, HPV vaccination, and cervical screening services which should also be made readily available and accessible in both rural and urban areas.

A. Cervical Cancer: Community Perception and Preventive Practices in an Urban Neighborhood of Lagos (Nigeria)
Dear Respondent, Cervical cancer is a common female condition throughout the world. This questionnaire is aimed at assessing your understanding and preventive practices regarding cervical cancer. Please be assured that all your responses will be kept strictly confidential. This is an anonymous questionnaire which does not require your name or identity.
Participation in this study is voluntary, and a refusal to participate will not attract any sanctions.
Please answer the entire questions to the best of your ability and as truthfully as possible.
Your responses will assist the researchers in the prevention and control of this condition.
A research assistant is available to help you in filling the questionnaire.
◻ By checking this box I agree that I have read the above and agree to participate in this study.
Thank you for participating.

A.1. Sociodemographic Details
(1) Age: (in years) (2) Marital status:   Awareness about cervical cancer was significantly higher with increasing age ( < 0.05) in female and total population.