DOI: https://doi.org/10.21203/rs.3.rs-1277059/v1
Background: The weak participation of women to cervical cancer screening is a major obstacle to the fight against that disease. This work had as objective to determine associated factors to the lack of cervical cancer screening in women in Cameroon, a middle-income country of Central Africa.
Methods: We conducted a cross-sectional analytic study both quantitative and qualitative on 1000 sexually active women aged 25 years old and above coming to the gynecology department of the Centre hospitalier de recherche et d’application en chirurgie endoscopique et reproduction humaine from March to December 2017.
Results: The mean age of the studied women was 37.1 ±10.1 years old, among them 733 (73.3%) had never been screened. Associated factors to the absence of previous screening were : age lower than 35 years old (OR=5.0 ; 95% CI : 3.6 – 6.9), Islam (OR=3.3 ; 95% CI :1.6 – 6.7), unemployment (OR=2 ; 95% CI : 1.5-2.7) and bachelorhood (OR=1.5 ; 95% CI: 1.1 – 2.1). The main evoked barriers to screening were: fear of cancer, inadequate sensitization, the lack of screening prescription by the medical staff and ignorance about the usefulness of screening.
Conclusion: It is important to diversify the means of communication on cervical cancer while focusing specifically on groups associated with the greatest lack of screening participation. Increased screening prescriptions by healthcare workers could also increase screening participation of women.
Cervical cancer is a major health problem. It is the 4th most frequent cancer in women and the 2nd most frequent gynecological cancer. Its incidence is about 570 000 new cases with 311 000 deaths worldwide in 2018. It is the 2nd mostly diagnosed cancer in 28 countries and the first cause of death in 42 countries, mainly in Sub-Saharan Africa and in South East Asia. In Central Africa its incidence is 26.8 new cases per 100 000 inhabitants [1]. According to the national register of Cameroon, 158 new cases had been diagnosed in 2011, representing 13.8% of all cancers [2, 3].
Screening is a fundamental strategy in the fight against cervical cancer. Indeed, it is estimated that between 2017 and 2040, screening could contribute to lower the incidence of the disease of about 50% in Central and East European countries [4]. Over the last decades, it was associated to a reduction of 105 000 – 492 000 cases of cancer in USA [5]. Meanwhile, screening coverage rate remains low in developing countries such as in Nigeria were it was 7,1%[6]. In Cameroon as in many others countries from Sub Saharan Africa, there is not yet a national systematic screening policy. Screening is done during sporadic campaigns or through medical prescriptions. Few studies found a screening rate between 31-32,5% in Cameroon [7, 8].
Many efforts are done for secondary prevention to popularize cervical cancer in Cameroon. Different screening methods are effective such as Visual Inspection of Cervix with Acetic Acid (VIA) and/or Lugol’s Iodine (VILI), Papanicolaou smear and more recently the Human Papilloma Virus High Risk (HPVHR). Meanwhile, effective screening rate is low. The goal of this study is therefore to evaluate the frequency of cervical cancer screening and to determine the associated factors to its uncommon practice.
We conducted a cross-sectional analytic study both quantitative and qualitative from March to December 2017 at the Centre Hospitalier de Recherche et d’Application en Chirurgie Endoscopie et Reproduction Humaine (CHRACERH).
CHRACERH is a reference center in gynecological and obstetrical cares in Cameroon with a specialized service in medically assisted procreation (MAP). Administrative authorizations to recruit sexually active women of 25 years old and above, attending gynecologic consultations at this center were granted to us. Those who could not speak French nor English were excluded from the study.
At the end of the consultation, we included patients who had never done a screening or who had an obsolete result and with their consent, we collected quantitative data with a form. For the qualitative part of the study, we did semi-directed interviews with 12 participants selected via a reasoned choice sampling within the sample. The selection was based on associated factors to the absence of screening that were found in the literature. It was an individual interview done using an interview guide and registered with a Dictaphone. At the end of it, a cervical cancer screening was proposed to participants who had never done it before.
Quantitative data were: socio-demographic characteristics such as age, marital status, profession and religion; Knowledge on cervical cancer and preventive means; previous screening and if none the reasons why. Dependent variable was the absence of screening and the others were the independent variables.
The interview guide covered the perception of participants on cervical cancer, the means of communication used to sensitize on the disease and proposals to improve those means.
Ethical clearance was granted by the Ethics Committee of CHRACERH and each participant gave her consent before enrolment. Our study was in compliance with the Helsinki Declaration [9].
Quantitative variables are presented using frequency (percentage) while qualitative variables are summarized with their median (interquartile range, IQR). Associated factors to the absence of screening were determined with the bilateral Chi-Square test. A multivariate analysis with logistic regression was performed to identify independent associated factors after the bivariate analyzes. Statistical significance was set at a p-value lower than 0.05. Statistical analysis was performed using SPSS version 23 (SPSS Inc. Chicago, IL). The required sample size was 708 participants considering an alpha error of 5%, a precision of 3% and an estimated prevalence of failure to perform cervical cancer screening obtained from Ezechi et al. in Mali [10].
Qualitative data were registered and processed by content analysis. For every aspect of the interview guide, frequent topics were identified and interpreted.
Among 1000 participants included, half of them had less than 35 years old and median age was 35 (29 – 42.8). About two-thirds (67.6%) were not single and 53.7% had a paid job. Christian women were the most represented (87.6%) and Muslims accounted for 8.5%. Risk factors for cervical cancer identified in this study were : multiplicity (more than 3) of sexual partners : 55.5% (555/1000); a history of sexually transmitted infection (STI) : 21.1% (211/1000), with Chlamydia infection been the most frequently encountered: 69.2% (149/211), followed by Syphilis : 10.4% (22/211) and Gonorrhea 4.3% (9/211); Other risk factors were HIV infection and multiparity accounting respectively for 5.4% (50/920) and 61% (610/1000) of the study population. Table 1 describes other characteristics of the study population.
| Variables | Frequency | Percentages |
|---|---|---|
| Age | ||
| [25 – 35[ | 485 | 48.5 |
| [35 – 45[ | 301 | 30.1 |
| [45 – 55[ | 141 | 14.1 |
| [55 – 65[ | 62 | 6.2 |
| ≥ 65 | 11 | 1.1 |
| Marital Status | ||
| In partnership | 676 | 67.6 |
| Single | 262 | 26.2 |
| Widow | 62 | 6.2 |
| Professional Status | ||
| Unemployed | 460 | 46 |
| Employed | 540 | 54 |
| Religion | ||
| Christian | 876 | 87.6 |
| Muslim | 85 | 8.5 |
| Other | 39 | 3.9 |
| History of STI | ||
| Yes | 211 | 21.1 |
| No | 789 | 78.9 |
| Type if STI (n = 211) | ||
| Chlamydia | 146 | 69.2 |
| Syphilis | 22 | 10.4 |
| Gonorrhea | 9 | 4.3 |
| Other | 33 | 15.6 |
| HIV serology (n = 920) | ||
| Positive | 50 | 5.4 |
| Negative | 870 | 94.6 |
| Gravidity | ||
| 0 | 101 | 10.1 |
| [1 – 2] | 289 | 28.9 |
| [3 – 5] | 405 | 40.5 |
| > 5 | 205 | 20.5 |
| Parity | ||
| 0 | 242 | 24.2 |
| [1 – 2] | 339 | 33.9 |
| [3 – 5] | 320 | 32 |
| > 5 | 99 | 9.9 |
| STI: Sexually Transmitted Infections; HIV: Human Immunodeficiency Virus | ||
Prevalence of women who never perform a screening was 73.3% (733/1000). 733 women (82.7%) had already heard about cervical cancer and 52.3% knew a screening center. At the end of the study, 92.6% (679/733) of the participants accepted to perform a screening after we explain to them the usefulness of cervical cancer prevention.
The main reasons evoked by those who never did a screening were: negligence (41.5%), absence of prescription by a healthcare professional (18.1%) and lack of information (17.3%). Table 2 shows all the reasons mentioned by participants.
| Reason | Frequency | Percentages |
|---|---|---|
| Negligence | 304 | 41.5 |
| Never prescribed | 133 | 18.1 |
| Never heard about | 127 | 17.3 |
| Do not think to have cancer | 37 | 5 |
| Not interested | 32 | 4.4 |
| Lack of money to pay | 28 | 3.8 |
| Fear to have cancer | 27 | 3.7 |
| Far away from screening centers | 11 | 1.5 |
| Prohibited by the religion | 1 | 0.1 |
| Other | 33 | 4.5 |
Associated factors to the absence of screening were : age less than 35 years old (OR : 5.0; 95% CI : 3.6 – 6.9), bachelorhood (OR : 1.5; 95% CI : 1.1 – 2.1), unemployment (OR : 2.0; 95% CI : 1.5 – 2.7), Islam (OR : 3.3; 95% CI : 1.6 – 6.7) and being a housewife (OR :1.5; 95% CI :1.1-2.2). After a multivariate analysis, independent factors retained were: age less than 35 years old, Islam and unemployment (Table 3).
| Variables | No screening | Screening | OR (95% CI) | Adjusted OR # (95% CI) |
|---|---|---|---|---|
| Age (years) | ||||
| < 35 | 427 (88) | 58 (12) | 5.03 (3.6 – 6.9)*** | 4.8 (3.3 – 6.8)*** |
| ≥ 35 | 306 (59.4) | 209 (40.6) | Ref | Ref |
| Single | ||||
| Yes | 206 (78.6) | 56 (21.4) | 1.5 (1.1 – 2.1)* | 1.1 (0.8 – 1.6) |
| No | 527 (71.4) | 211 (28.6) | Ref | Ref |
| Religion | ||||
| Christian | 629 (71.8) | 247 (28.2) | Ref | Ref |
| Muslim | 76 (89.4) | 9 (10.6) | 3.3 (1.6 – 6.7)** | 2.2 (1.1 – 4.6)* |
| Other | 28 (71.8) | 11 (28.2) | 1 (0.5 – 2.04) | 1.1 (0.5 – 2.2) |
| Unemployed | ||||
| Yes | 370 (80.4) | 90 (19.6) | 2 (1.5 – 2.7)*** | 1.6 (1.2 – 2.3)** |
| No | 363 (67.2) | 177 (32.8) | Ref | Ref |
| History of STI | ||||
| Yes | 137 (64.9) | 74 (35.1) | 1.6 (1.2 – 2.3)** | 1.3 (0.9 – 1.9) |
| No | 596 (75.5) | 193 (24.5) | Ref | Ref |
| HIV serology | ||||
| Positive | 33 (67.3) | 16 (32.7) | 0.8 (0.4 – 1.4) | |
| Negative | 636 (73) | 235 (27) | Ref | |
| Gravidity | ||||
| 0 | 80 (79.2) | 21 (20.8) | Ref | Ref |
| [1 – 2] | 224 (77.5) | 65 (22.5) | 0.9 (0.5 – 1.6) | 0.9 (0.5 – 1.8) |
| [3 – 5] | 290 (71.6) | 115 (28.4) | 0.7 (0.4 – 1.1) | 1.1 (0.6 – 1.9) |
| > 5 | 139 (67.8) | 66 (32.2) | 0.6 (0.3 – 0.9)* | 1.2 (0.6 – 2.2) |
| Parity | ||||
| 0 | 181 (74.8) | 61 (25.2) | Ref | |
| [1 – 2] | 266 (78.5) | 73 (21.5) | 1.2 (0.8 – 1.8) | |
| [3 – 5] | 222 (69.4) | 98 (30.6) | 0.8 (0.5 – 1.1) | |
| > 5 | 64 (64.6) | 35 (35.4) | 0.6 (0.3 – 1.02) | |
| *p value < 0.05 ; **p Value < 0.01 ; ***p value < 0.001 ; #Factors were adjusted to whole set of variables which have a significant association with the dependent variable; CI : Confidence Interval ; STI : Sexually Transmitted Infections ; OR : Odd ratio ; Ref : reference modality ; HIV : Human Immunodeficiency Virus. | ||||
The majority of women in our study population perceived cervical cancer as a scary serious illness without existing treatment. Some of them perceived it as a « private genitals » sickness or a disease for « the woman who gave birth a lot ». A 25 years old participant declared that: «It is a dangerous sickness which destroy and which has no reliable treatment ». Some women had few or wrong information on cervical cancer. They considered it as a hereditary incurable disease, which did not exist in previous generations and which is link to lifestyle and environmental changes.
Many among those women thought that means of communication on cervical cancer were inadequate because only a part of the population was covered by those means. They estimated that sensitization was focused on big cities and was done essentially by public Medias. A 65 years old woman declared that: « I find that we do not do a good sensitization, we focus on public radios and televisions ».
Women’s proposals on ways to fight cervical cancer can be group into three: use of private Medias for sensitization, training and use of community health workers to sensitize and promotion of screening centers as is the case with HIV. « There is a need to put up posters in crossroads, to screen everywhere, to put up sensitization posts in crossroads, markets, schools», said a 50 years old trader.
Participation of women in cervical cancer screening is a key to fight against this disease because screening helps in the early detection of precancerous lesions which can be treated. In order to contribute to the promotion of this secondary prevention method, we established as goal to determine the frequency and associated factors to the absence of cervical cancer screening in a women population attending gynecological consultation.
We found a low rate of cervical cancer screening i.e. 26.7% (267/1000) among the participants. The same result was obtained in two studies done in Kenya and in Nigeria with a respective screening rate of 21% and 9.7% [10, 11]. Reason for this low rate in our study was mainly negligence. Indeed, participants although being informed would not give great importance to screening. Some on the other hand were not aware of the existence of cervical cancer screening or were waiting for a healthcare worker prescription.
Better screening rates (72%) were obtained in a study in Botswana. The study population had a high HIV prevalence and therefore a high risk of precancerous lesions [12]. This would incite the healthcare workers to pay more attention to cervical cancer screening in that population.
Age lower than 35 years old was associated to the absence of cervical cancer screening. This result corroborates those from other studies where patients aged 30-40 years old and above were the most adherent to the screening [11, 13]. The poor adhesion of young women would be due to social perceptions on cervical cancer. In fact, we found among barriers to screening: ignorance; some women thought that « It is a disease for women who gave birth a lot», and so who are older. Sensitization must be therefore reoriented towards this young population.
Islam was significantly associated with the absence of performing cervical cancer screening. A similar result was found in a study in Uganda [14]. Some researchers have shown that for socio-cultural and religious reasons, husbands play a preponderant role in making decisions concerning access to health care [15]. Some Muslim participant in our study were waiting for the authorization of their husbands to access health services. Adaptation of communication strategies to focus also on men could therefore contribute to improve women participation to screening.
Employed women had a greater chance to be screened for cervical cancer. This could be explained by the fact that they are more exposed to get the information and they have more financial resources to access screening even without campaigns. This result is similar to other African studies [12, 13].
This study was done in an urban area and in a reference hospital. Therefore, the results obtained could not be applicable to the general population. Another limit of this cross-sectional study is that a causality link cannot be established between identified associated factors and the absence of cervical cancer screening.
Frequency of absence of cervical cancer screening remains high in our context. Improvement of sensitization and its contents to target young, Muslim or unemployed women could improve the participation of women to cervical cancer screening.
CHRACERH: centre hospitalier de recherche et d’application en chirurgie endoscopie et reproduction humaine
HIV: human immunodeficiency virus
HPVHR: human papilloma virus high risk
MAP: medically assisted procreation
STI: sexually transmitted infection
USA: united states of America
VIA: visual inspection of cervix with acetic acid
VILI: visual inspection of cervix with Lugol’s iodine
Ethics approval and consent to participate
Ethical clearance was granted by the Ethics Committee of CHRACERH prior the beginning of the study and each participant gave her consent before enrolment. all methods were carried out in accordance with the Helsinki Declaration [9].
Consent for publication
Not applicable
Availability of data and materials
The datasets generated and/or analyzed during the current study are available in the DRYAD repository, https://datadryad.org/stash/share/4Zb23eZ3IhDw-8LIaztOFuv_bdsgya9t6LwiqulwK4w
Competing interests
The authors declare that they have no competing interests
Funding
None
Authors’ contributions
AN, JDK and ENUM conceived the study and drafted the protocol. AN, JDK, GSW and ENUM implemented the research through patient recruitment, data collection and data analysis. AN, JDK, GSW, JFT drafted the first manuscript. JMK participated at all stages as supervisor. All the authors revised the first draft, read and approved the final manuscript.
Acknowledgements
Not applicable