ASSESSING KNOWLEDGE AND PRACTICE OF CERVICAL CANCER PREVENTION AMONG WOMEN OF CHILDBEARING AGE

Abstract

Cervical cancer (CC) is an extremely preventable and curable disease with early detection and treatment. Unfortunately, the practice of cervical cancer prevention (CCP) remains poor in resource constrained countries.

This study aimed to assess knowledge and practice of cervical cancer prevention amongst women of childbearing age in the Great Soppo Community, Buea, South West Region Cameroon. This was a descriptive cross-sectional study of 350 women on childbearing age using a self-administered structured questionnaire to assess their knowledge of cervical cancer, preventive practices and challenges face toward the prevention of cervical cancer.

Data was analyzed using tables, bar and pie charts. Half (50.60%) of the women had knowledge of cervical cancer while 75.71%% had heard about cervical cancer. Majority (84%) said cervical cancer can be prevented and (50.34%) knew the preventive practices of cervical cancer.

Most of the women had challenges as far as cervical cancer prevention is concern. In Cameroon the burden of cervical cancer can be reduced if women are educated and health care providers challenged to recommend cervical cancer screening and HPV vaccination.

CHAPTER ONE
INTRODUCTION
1.1 Background

Cervical cancer is a malignant proliferation of the cells of the uterine cervix and can be treated if diagnosed earlier (Nkfusai et al 2019). In the modern era, the world is heading towards the rising of non-communicable diseases (NCD). Out of these non-communicable diseases, cancer is the second leading cause of death globally (Nigussie et al. 2020). Among all the cancers, cervical cancer is the fourth most frequent cancer among women worldwide.

Every year, around 500,000 new cases of cervical cancer are diagnosed out of which 270,000 women die, mostly (85%) in developing countries (Ganju et al. 2017). According the World Health Organization (WHO) in 2018, around 570,000 women were diagnosed with cervical cancer worldwide and about 311,000 women died from the disease. Almost 99% cases of the cervical cancer are associated to infection with human papillomaviruses (HPV).

It is a common virus which is transmitted through sexual contact (WHO. 2018). Cancer of the cervix is the major reproductive health problem in women, especially in emergent nations (Eke No et al, 2010). It is the major cause of morbidity and mortality in women globally and an issue of significant public health concern (Nigussie et al. 2020).

It is a slow growing cancerous disease that generally takes several years to undergo malignant transformation for primary infection by the oncogenic human papillomavirus (HPV) to the various precancerous histological lesions accompanying the persistence of the infection (Bosch et al. 1995). Cervical cancer takes about 10 to 15years to develop (Louie et al. 2009).

Cervical cancer is a deadly disease once it reaches the invasive stages, but out of all the female genital tract cancers, it is the only preventable cancer if detected at its early stages (Simms Kate et al. 2020). Population-based screening with Pap smear is an important secondary preventive measure for cervical cancer that leads to a high-cure rate among cervical cancer patients (Sah et al. 2012). Screening of cervical cancer offers a protective benefits and is associated with a reduction. Every woman must undergo screening of cervical cancer once in three years as advised by the World Health Organization (WHO) (Moyer et al. 2012).

Cancer of the cervix is the second most common cancer among women aged 15 to 44years in India with an annual estimated incidence of 122, 844 cases and mortality of 67,477 women (Bruni et al. 2017). Developing countries contribute to about 85% and India alone accounts for ¼ of the world’s cervical cancer burden (Bray et al. 2018). This is probably due to unavailability of nationwide regular cancer screening programs, lack of awareness and unwillingness of rural India women towards screening procedure for cancer of the cervix (Sankaranarayanan et al. 2009).

Cervical cancer is the fourth most common cancer and also the fourth leading cause of cancer-related death in women globally (Bray et al. 2018). The progression from HPV infection to cancer occurs in four steps, as follows: HPV transmission, acute HPV infection, precancerous changes and finally, invasive cervical cancer. HPV type 16 and HPV type 18 are responsible for almost 70% of the cervical neoplasia cases (Whitlock et al. 2011). Whereas HPV infection and abnormal findings of the cytology are normal among young women, invasive cervical cancer is rare in young females (Raluca et al. 2021).

In Saudi Arabia, cervical cancer is the eight most common cancer amongst women in the 45 to 59-year of age group and accounts to 2.2% of all cancers (Kingdom of Saudi Arabia Saudi Health Council Saudi Cancer Registry. 2014). According to the fact sheet of human papillomavirus (HPV) information center (2018), it is estimated that every year 316 women are diagnosed with cervical cancer and 158 die as a result of the disease in Saudi Arabia.

Several common risk factors recognized to be associated with cervical cancer worldwide include sexually transmitted diseases (mainly human papillomavirus and other human immunodeficiency virus, herpes simplex virus), reproductive and sexual factors (multiple sexual partners, early age at first sexual partner, early age at first delivery, parity and oral contraceptive pills), behavioral factors (smoking and obesity), and host factors (genetic sensitivity) (Patti Olusola et al. 2019).

Abnormal vaginal bleeding, foul-smelling vaginal discharge and contact bleeding are recognized as the major signs of cervical cancer and in many cases, women with cervical cancer report no symptoms. Almost all cervical cancers are caused by HPV and therefore, are largely preventable (Braaten and Laufer, 2008).

The World Health Organization (WHO) has stated that ‘regardless of the test used, the key to an effective program is to reach the largest proportion of women at risk with quality screening and treatment. The primary barrier to decrease the morbidity and mortality of this disease remains lack of awareness of the risk factors, causes, signs, and symptoms of cervical cancer’ (Chinn et al. 2019). Previous Global Cancer Observatory (GLOBOCAN) estimates for 2008 indicates that approximately 530,000 cancer cases and 2755,000 deaths had occurred worldwide, with 85% of cases occurring in less developed countries.

In 2010, Bruni et al reporte a 4-fold higher prevalence of cervical cancer in low-to middle-income countries compared with that in developed countries. In countries ranked in the Human Development Index, cervical cancer is ranked as the second most common type of cancer and the second highest cause of cancer-related mortality amongst women after breast cancer. In Sub-Saharan Africa, the highest incidence of cervical cancer since 2012 was observed in women aged between 15 to 44yearss (Ginindza et al. 2018).

Also, cervical cancer, with an estimated 570,000 new cases and 311,000 deaths in 2018 globally, is the fourth most common cancer and the fourth leading cause of cancer death among women worldwide; however, it is the most commonly diagnosed cancer in 28 countries and the leading cause of death in 42 countries, the majority of which are in Sub-Saharan Africa (Bray et al, 2018).

Tanzania exhibits the sixth highest rate of cervical cancer in the world, with age-standardized incidence reached 51.1 per 100000 women and age-standardized mortality reached 42.7 per 100000 women per year. Cervical cancer was responsible for 39% of all newly developed cancers in women and among them around 80% presented with advanced-stage and thus was the leading cause of cancer-related deaths among Tanzanian women (Bray et al. 2018).

Cervical cancer is a malignant tumor of the cervix that can be divided into two histological types, adenocarcinoma (AC) and squamous cell carcinoma (SCC) (Torre et al, 2012). Squamous cell carcinoma is more common and has an occurrence rate of 70% (Herrero et al. 2015). Adenocarcinoma originates from glandular cells that line the cervical canal (the endocervix), whereas squamous cell carcinoma originates from squamous cells lining the outer part of the cervix that opens to the cervix.

The most common cause for the occurrence of cervical cancer is a persisting infection with the sexually transmitted human papillomavirus (HPV) (Golfetto et al. 2018). Human papillomavirus is accountable for 90 to 100% of cervical cancer cases amongst women, especially those less than 35years old (Bruni et al. 2010).

According to Global Initiative Against HPV and Cervical Cancer (GIAHC) in 2015. Cervical cancer is the only cancer that is almost completely preventable by safe, simple and inexpensive methods, and yet every two minutes one woman dies an unnecessary death from this cancer in the world. Unlike other cancers that occur in older age, cervical cancer peaks between the ages of 35 to 65years and not only takes the life of young women, but devastates families with young children along the way.

In 2012, 528,000 new cases and 266,000 cases of death from cervical cancer were reported (Ferlay et al. 2015). Cervical cancer is a dynamic condition that has the highest incidence rate in young adults (Bruni et al, 2010). There has been a significant reduction in mortality associated with cervical cancer in the developed countries as many cases are detected in a timely manner (Vaccarella et al, 2017).

The disproportionate burden of cervical cancer in developing countries and elsewhere in medically underserved populations is mainly due to lack of effective screening program (Hristova and Hakama, 1997; Duguid, Duncan and Currie, 1985). The results of several studies suggest that socioeconomic differences play an important role in the incidence, mortality and survival rate of cervical cancer (Akinyemiju et al, 2016 Ibfelt et al,2013 Kim and Kang, 2016 Ueda et al, 2006).

This is associated with a variety of factors such as low access to screening (Leinonen et al, 2017), non-implementation of prevention programs (Chidyaonga Maseko et al, 2015), ineffective and inadequate treatment and poor sanitary conditions (Benard et al, 2008 Ganesan et al, 2015 Chiantera et al, 2014). Several epidemiological studies have revealed the role of varous genetic factors in the incidence of cervical cancer (La Vecchia and Bocci. 2014).

Cervical cancer is preventable and curable if early diagnosed. The causative agent of the disease is the Human Papilloma Virus (HPV) which is transmitted through sexual intercourse causing cervical cancer through a slow growth over a period of 10-20 years (Daniel A et al, 2020). There are over 150 different types of HPV; more than 40 can infect the cervix and are sexually transmitted, causing 99.4% of cervical cancer cases and 100% of genital warts cases (WHO, 2013). It has been proven that, at least 50% of women who are sexually active have suffered an infection with at least one strain of HPV (Gregorio GA et al, 2016).

The global incidence of cervical cancer is greater than 530 000 annually, with death approaching 275 000 per year (Kafuruki L et al, 2013). The prevalence of cervical cancer worldwide is estimated by (Saslow D et al, 2012) to be 12%. One of the most important reasons for the incidence of cervical cancer in developing countries is the lack of early detection of pre-cancerous lesions and treatment of the lesions before they progress (Torre LA et al, 2015).

In Africa which has a population of 267.9million women aged 15years and older are at risk of developing cervical cancer, approximately 80,000 women were diagnosed with cervical cancer per year, and just more than 60,000 women die from the disease (Lynette Denny and Rose Anorlu, 2012). However, cervical cancer incidence in Africa also varies considerably by region. The highest rates in Africa (Age Standardized Incidence Rate (ASIR) greater than 40/100,000) are found in Eastern and Southern Africa (Lynette Denny and Rose Anorlu, 2012).

Most women in developing countries present with advanced disease, often untreatable or suitable only for palliation. For instance, in Sudan where 197 women were diagnosed with cervical cancer in 2007, 141 (71%) had advanced stage disease (Ibrahim et al, 2011). Cervical cancer is a significant cause of cancer-related mortality for women living in sub-Saharan Africa (SSA).

In 2013, 39 out of 48 countries, classified as part of SSA region, identified cervical cancer as the most common cause of cancer-related death for women, followed by breast cancer (Fitzmaurice C et al 2013). Collectively, the 236,000 women who died from cervical cancer in 2013, 90% of them in developing nations, represent a failure of the health system to implement a functional cervical cancer control strategy (Ferlay J et al, 2015).

Sub-Saharan Africa (SSA) consist of 46 countries almost all of which have the lowest ranked Human Development Index (HDI) and highest Human Poverty Indices (HPI) (Independent Evaluation Group Studies, 2009) with a total population estimated in 2008 of 812 million (404million men and 408million women), only 7.2% were covered by medically certified causes of death and 8.3% by population-based registries.

It was estimated in 2008 that there were 667,000 incident cancer diagnosed and 518,000 cancer death recorded that is 78% of those diagnosed with cancer died from the disease, however reliable data on cancer are difficult to find in the African context (American Association for Cancer, 2012).

Also, Eswatini had the highest incidence rate of cervical cancer followed by Malawi (WHO, 2018 Arbyn et al. 2020). Cervical cancer is a preventable disease. Yet it is the most common cause of cancer in the African Region where it accounts for 22% of all female cancers and 12% of newly diagnosed cancer in women every year (WHO, 2015). In Africa, 34 out of every 100,000 women are diagnosed with cervical cancer and 23 out of every 100,000 women die from cervical cancer every year (WHO, 2015).

In Cameroon, Cervical cancer (CC) is the second most encountered cancer in women after breast cancer with 7.1million women with ages 15 years and above who are at risk of developing the diseases (Donatus et al. 2019). Cervical cancer is the 2nd leading cause of cancer deaths in women aged 15 to 44 years in Cameroon (Donatus et al. 2019) According to the National Committee for the Fight against Cancers, Cervical Cancer accounts for 24% of female cancers (Ekane et al. 2015). In Cameroon, about 1,993 new cervical cancer cases are documented with 1,120 cervical cancer deaths (Nkfusaiet al. 2019).

In 2010, 30% of deaths among women were attributed to cervical cancer. The cervical cancer registry in Yaoundé estimates incidence at 107 cases for 100,000 inhabitants (Abongwa et al. 2015). The epidemiology rightfully points out the dire situation of the morbidity and mortality from cervical cancer beginning from global, to regional and country with the need for primary prevention interventions (screening and treatment of precancerous lesions) (Donatus et al. 2019).

There are 1993 new cases of cervical cancer yearly of which 1120 die of the disease (Nkfusaiet al. 2019, Institute of Medicine, Department of Public Health and Community Medicine EPSO). In poor countries, awareness as well as uptake of cervical cancer screening services has remained poor over the years. Several studies done in communities and among women in Sub-Saharan Africa revealed that knowledge was generally poor (Nakibuule C, 2014).

Mogtomo et al, 2009 have demonstrated a high incidence of sexually transmissible infections, multiple sex partners, low use of condoms and other risk factors of cervical cancer among students in the University of Douala. This therefore, calls for relevant measures to reduce this trend of progression.

The level of knowledge of the general population is very important in determining the right strategy in planning an effective intervention against cervical cancer (Ngwayu Claude Nkfusai et al, 2019).

WHO report that cervical cancer screening coupled with immediate management leads to early detection of pre-cancerous and cancerous lesions, thus preventing serous morbidity and mortality due to the disease (Cameroon Baptist Conventional Health Service CBCHS,).

In a study carried out by Abongwa et al, 2015, they showed that the level of awareness of Human papillomavirus infection and prevention of cervical cancer is moderately low in Cameroon. Risk factors of cervical cancers have also been highly demonstrated among Cameroonian women, especially the rural women (Tufon et al, 2013).

1.2 Statement of the problem
Cancer of the cervix is the second most common cancers among women worldwide after breast cancer, with an estimated 494,000 new cases annually out of which about 80% (376,000) occur in developing countries. About 49.5% (233,000) die every year (Abel et al. 2020).

Though cervical cancer is a preventable no communicable diseases of the female genital organ through early cervical cancer screening, HPV vaccine, and lifestyle modification as well, it still remains the major cause of death in Cameroon, Africa and the World at large.

Despite all the preventive measures put in place, a greater population of women in Cameroon (that is more than 6million Cameroonian females who are aged 15years and above) are at risk of developing cervical cancer (Tufon et a., 2011). There are 1993 new cases of cervical cancer yearly in Cameroon of which 1120 die of the disease (Nkfusai et al. 2019).

After reading the above articles on cervical cancer and after the several cervical cancer cases seen in hospital during the internship, the investigator chose to write on the topic ” Knowledge and Practice of Cervical Cancer Prevention among women of childbearing age in the Great Soppo community, Buea, South West Region of Cameroon”.

1.3 Research objectives
1.3.1 General objectives
To assess the knowledge, and practice of cervical cancer prevention amongst women of child bearing age in the Great Soppo community.

1.3.2 Specific objectives
To evaluate respondents’ knowledge of cervical cancer.
To assess the practices taken toward the prevention of cervical cancer
To find out the challenges faced by respondents toward cervical cancer prevention