NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME Risk Factors of Cervical Cancer and Prevalence of Precancerous Cervical Changes among Sexually Active Women in Lagos, Nigeria Olawunmi O. Adeoye¹, O. Fawole², I. Ajayi², O. Biya¹, P. Nguku¹ 1. Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria 2. Department of Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria
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NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Risk Factors of Cervical Cancer and Prevalence of Precancerous Cervical Changes among Sexually Active
Women in Lagos, Nigeria
Olawunmi O. Adeoye¹, O. Fawole², I. Ajayi², O. Biya¹, P. Nguku¹
1. Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria
2. Department of Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria
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Introduction
• Cervical cancer (CC) is a major public health problem • The second most common cancer in women globally • About 500 000 new cases and 250 000 deaths yearly• Characterized by precancerous cervical changes (PCC) • Women who develop CC have one or more identifiable
factors that increase their risk • Most studies are facility-based, need for population
based studies
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Specific objectives• To determine the prevalence of cervical cancer risk
factors
• To determine the prevalence of precancerous
cervical changes
• To assess the knowledge of cervical cancer
• To identify the predictors of precancerous cervical
changes
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Methods
• Study was in Lagos State in south-western Nigeria
• Consists of 3 Senatorial Districts and 20 LGAs
• Multi-ethnic city and commercial capital of Nigeria
• Estimated population-10 million (2006 census)
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Lagos city
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Geographical location of study area
Source: Health Mapper; WHO GIS unit
Lagos
Nigeria
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Methods• Study design: population based cross-sectional
study • Study period: September-November 2012• Sampling technique: five stage sampling • Sample size: 332 participants• Eligibility criteria: sexually active, non pregnant,
> 15 years with no previous diagnoses of cervical cancer
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Data collection tool• Interviewer administered semi structured questionnaire
– socio-demographic characteristics – respondents’ knowledge of cervical cancer – preventive practices against cervical cancer – risk factors for cervical cancer in respondents
• Clinical assessment– visual inspection with acetic acid (VIA) and visual inspection
with lugol’s iodine (VILI) of the cervix done for PCC
• PCC defined as both acetowhitening on VIA and Yellowish changes on VILI
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Operational definitions of CC risk factors• Early coitache: first sexual intercourse before 18 years
• Grandmultiparity: parity > 5
• Multiple sexual partner: lifetime partners > 4
• Sexually transmitted Infection: foul smelling and/or copious vaginal discharge or a genital lesion
• Oral Contraceptive Pills (OCP) use: OCP use for at least 1 year
• Sexually active: at least one episode of sexual intercourse
• Multiple risks: 3 or more defined risk factors
. . . . Based on standard definitions, the National Demography and Health Survey (NDHS) and literatures
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Grading of respondents’ knowledge on cervical cancer
• Knowledge of respondents graded on a scale• Eight items used for grading• For each item
– Zero scored for wrong response – One point for ‘’I don’t know ‘’response– Two points for right response
• Maximum score was 16, minimum 0– 12 to 16 points: Good knowledge– 0 to 11 points: Poor knowledge
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Ethical considerations• Ethical approval obtained from Nigeria Institute of
Medical Research (IRB/12/196)• Informed consent obtained from respondents• Respondents informed that positivity of VIA/VILI may not
imply a cervical cancer diagnoses, all with positive results were referred for confirmation (colposcopy and biopsy) and treatment
• Confidentiality was maintained
• Beneficence: All services were provided free
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Results
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Age distribution of respondents, Lagos; September-November 2012
Age (in years) Frequency Proportion (%)
≤ 19 5 1.5
20-29 49 14.8
30-39 115 34.6
40-49 101 30.1
50-59 42 12.7
≥ 60 14 4.2
Missing 6 1.8
Total 332 10013
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Age distribution of respondents, Lagos; September-November 2012
Age (in years) Frequency Proportion (%)
≤ 19 5 1.5
20-29 49 14.8
30-39 115 34.6
40-49 101 30.1
50-59 42 12.7
≥ 60 14 4.2
Missing 6 1.8
Total 332 10014
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Variable Frequency percentage
Oral contraceptive use 140 44.3
Previous STI 76 24.1
Early coitache 67 20.2
Multiple sexual partners 45 14.6
Multiparity 36 13.4
Smoking 4 1.3Multiple risks 34 10.2
Prevalence of risk factors of cervical cancer in respondents, Lagos; Sept-Nov 2012
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Variable Frequency percentage
Oral contraceptive use 140 44.3
Previous STI 76 24.1
Early coitache 67 20.2
Multiple sexual partners 45 14.6
Multiparity 36 13.4
Smoking 4 1.3Multiple risks 34 10.2
Prevalence of risk factors of cervical cancer in respondents, Lagos; Sept-Nov 2012
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Variable Frequency percentage
Oral contraceptive use 140 44.3
Previous STI 76 24.1
Early coitache 67 20.2
Multiple sexual partners 45 14.6
Multiparity 36 13.4
Smoking 4 1.3Multiple risks 34 10.2
Prevalence of risk factors of cervical cancer in respondents, Lagos; Sept-Nov 2012
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Prevalence of risk factors of cervical cancer in respondents, Lagos; Sept-Nov 2012
Variable Frequency percentage
Oral contraceptive use 140 44.3
Previous STI 76 24.1
Early coitache 67 20.2
Multiple sexual partners 45 14.6
Multiparity 36 13.4
Smoking 4 1.3Multiple risks 34 10.2
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Variable Frequency percentage
Oral contraceptive use 140 44.3
Previous STI 76 24.1
Early coitache 67 20.2
Multiple sexual partners 45 14.6
Multiparity 36 13.4
Smoking 4 1.3Multiple risks 34 10.2
Prevalence of risk factors of cervical cancer in respondents, Lagos; Sept-Nov 2012
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Prevalence of precancerous cervical changes in respondents, Lagos; Sept-Nov 2012
Precancerous cervical changes
Normal0
10
20
30
40
50
60
70
80
90
100
Perc
enta
ge
Finding on VIA/VILI
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Prevalence of precancerous cervical changes in respondents, Lagos; Sept-Nov 2012
Precancerous cervical changes
Normal0
10
20
30
40
50
60
70
80
90
100
13%
87%
Perc
enta
ge
Finding on VIA/VILI
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Awareness, screening utilization and knowledge of CC; Sept-Nov, 2012
• Of 332 respondents– 135 (41.9%) are aware of CC
– 11 (3.3%) had ever been screened for CC
• Of 135 respondents who are aware of CC– 38 (28%) possess good knowledge on CC
– 49 (36.5%) have access to CC screening facility
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Factors associated with knowledge of cervical cancer of respondents, Lagos; Sept-Nov, 2012
Factors Good knowledge n (%)
Poorknowledge n(%)
Prevalence odd ratio (95% CI)*
Educational level No/LowHigh 5 (14.7)
33 (41.8)29(85.3)46(58.2)
0.24 (0.08-0.68)
Age group< 40 years≥ 40 years
21 (27.3)17 (43.6)
56 (72.3)22 (57.4)
0.40 (0.22-1.09)
Marital status Currently marriedNot currently married
30 (37.0) 8 (21.6)
51 (63.0)29 (67.9)
2.13 (0.86-5.26)
2395% Confidence interval*
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Factors associated with knowledge of cervical cancer of respondents, Lagos; Sept-Nov, 2012
Factors Good knowledge n (%)
Poorknowledge n(%)
Prevalence odd ratio (95% CI)*
Educational level No/LowHigh 5 (14.7)
33 (41.8)29(85.3)46(58.2)
0.24 (0.08-0.68)
Age group< 40 years≥ 40 years
21 (27.3)17 (43.6)
56 (72.3)22 (57.4)
0.40 (0.22-1.09)
Marital status Currently marriedNot currently married
30 (37.0) 8 (21.6)
51 (63.0)29 (67.9)
2.13 (0.86-5.26)
2495% Confidence interval*
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Factors associated with PCC among respondents, Lagos; Sept-Nov, 2012
OCP use 22(16.2) 114 (83.8) 1.35 (0.70-2.59) 0.461
Previous STI 8(11.8) 60(88.2) 0.77 (0.34-1.77) 0.686
95% Confidence interval*
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Predictors of PCC on logistic regressionin respondents, Lagos; Sept-Nov, 2012
Variables Adjusted Odds ratio
95% Confidence interval
p value
Multiple sexual partners 9.69 3.29-28.50 <0.001
Early coitache 7.93 3.20-19.6 <0.001
Multiparity 1.67 0.57-4.85 0.35
Multiple risk factors 0.67 0.18-2.54 0.55
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Predictors of PCC on logistic regressionin respondents, Lagos; Sept-Nov, 2012
Variables Adjusted Odds ratio
95% Confidence interval
p value
Multiple sexual partners 9.69 3.29-28.50 <0.001
Early coitache 7.93 3.20-19.6 <0.001
Multiparity 1.67 0.57-4.85 0.35
Multiple risk factors 0.67 0.18-2.54 0.55
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Discussion• Most prevalent risk factors were modifiable factors
– oral contraceptive use– previous STI– early coitache – multiparity
(Durowade et al, 2012, Oguntayo et al 2011 , Kahesa et al, 2012)
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Discussion
• High prevalence of PCC(Daniel et al, 2013 (7%), Adekunle & Samaila, 2010
(4.8%)
• Factors independently associated with PCC – multiple sexual partnering– early coitache
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Discussion• Knowledge significantly associated with educational
status– Lindau et al in 2002 found literacy to be the only factor
independently associated with CC knowledge
• Very low cervical cancer screening uptake‒ Ayinde and Omigbodun, Nigeria, 2002 (6.8%)‒ Adanu in Ghana, 2002 (8.3%)– Wellensiek and Moodley, South Africa, 2002 (36.7%)
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Limitations
• Social desirability bias- issues explored were sensitive
• Recall- issues majored on the long term memory of
respondents
• Inability to assess for Human papilloma virus infection
• Ascertainment bias- risk factors were self reported
• Sensitivity and specificity of VIA/VILI
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Conclusion• High prevalence of
– risk factors of cervical cancer – precancerous cervical changes
• Knowledge of cervical cancer was poor
• Cervical cancer screening utilization was low
• Predictors of PCC are modifiable factors
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Recommendations
• Efforts to boost cervical cancer screening through improved understanding should be particularly directed toward women with low education levels
• Health education on CC targeting women with early coitache and multiple sexual partners was initiated and needs to be sustained
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Acknowledgement
• This study was made possible by support from the PEPFAR through cooperative agreement [#5U2GGH000431] from CDC, Global AIDS Program
• The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the CDC
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THANK YOU !!!!
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Introduction• Women who develop CC have one or more identifiable factors
(modifiable or non modifiable) that increase their risk• Non modifiable factors
‒ Family history‒ Age ‒ Race/ethnicity
• Modifiable factors-sexual activity at an early age -Multiple sexual partners-Oral contraceptive use-Cigarette smoking-Multiparity-Sexually transmitted infections (including Human Papilloma Virus
infection)
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Sample size calculation
n = z²pq
d²Z= standard normal deviate corresponding to a 2 sided level of
significance=1.96
p= prevalence of CIN (Cervical Intraepithelial Neoplasia) in Nigerian women (Audu et al, 1999) =18.3%= 0.183
d= level of precision=5%
q= 1-p=1-0.183=0.817 Adjusting for a non response rate of 10%
n = 253
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Recoding schema for study variablesVariable Recoded variable
Age in years (Q 1)< 20 years, 20-29 years, 30-39 years, 40-49 years, 50-59 years and >59 years
Highest level of education(Q5) No education – No formal education
Low Education – Primary education
High Education– Secondary education & tertiary education
Marital status (Q3) Not currently married- single, cohabiting, separated, divorced and widowed
currently married- married
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Distribution of respondents by types of preventive measures known
Preventive measure Frequency
Percentage (%)
Pap smear 41 66.1
VIA/VILI 21 33.9
HPV DNA 0 0
HPV vaccine 0 0
Total 62 100
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Reported reasons for never being screened for cervical cancer
Reasons Frequency Percentage
‘‘I don’t think it’s important’’ 15 31.3 ‘‘No screening facility is available’’ 15 31.3 ‘‘I am not a likely candidate for cervical cancer’’ 6 12.5
‘‘Screening is expensive ‘’ 6 12.5 ‘‘I am afraid it will hurt’’ 3 6.3 ‘‘I am afraid of the outcome’’ 3 6.3
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Respondents’ sources of information on cervical cancer, Lagos; Sept-Nov, 2012
Mass media(radio)
Health workers Church/Mosque Neighbour/friend
Those with the disease
0
20
40
60
80
10089
3329
20
4
Sources of information
Pe
rce
nta
ge
(n=135 for each source)
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Association between knowledge and having ever screened for CC, Lagos; Sept-Nov, 2013
Knowledge grade
Ever screened Prevalence odd ratio (95% CI)
Fishers exact
Yes No
Good 9 (40.9%) 12 (59.1% 29.08 ( 3.4-35.5) < 0.001
Poor 2 (2.3%) 39 (97.7%)
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Data Processing and Analysis• Double data entry undertaken
• Consistency checks performed to clean data
• Data analyzed with Epi-info software (version 3.5.1) and
SPSS
Univariate analysis
– Frequencies and proportions
Bivariate analysis
– Identify associated factors
– Prevalence odd ratio used to determine statistical significance
Unconditional logistic regression
– Control for effect modification and confounding
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Sampling techniqueMultistage sampling • Stages 1: 2 out of the 3 Senatorial Districts selected by
balloting.• Stage 2: 2 LGAs also selected in each of the 2 selected
Senatorial Districts by balloting• Stage 3: 1 ward was then selected in each of the 4 LGAs
from the 2 senatorial districts by balloting• Stage 4: Systematic random sampling was used to
select houses from the 4 selected wards. • Stage 5: Sampling of one eligible female in all the
households in each selected house
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Association between non- modifiable factors and PCC
PCC present
n (%)
PCC absent
n(%) P value
Age group< 40 years
≥ 40years
23 (13.6)
19 (12.1)
145 (86.4)
138 (87.9)
0.81
TribeYoruba
Others
24 (12.4)
19 (14.2)
169 ( 87.6)
115 ( 85.8)
0.87
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NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Factors associated with awareness of cervical cancer among respondents, Lagos; Sept-Nov, 2012
Factors Aware of cervical cancer Prevalence odd ratio (95% CI)*
Yes (n%) No (n%)
Educational level No/LowHigh 26 (21.7)
94 (66.7)94 (78.3)47 (33.3)
0.14 (0.08-0.24)
Age group< 40 years≥ 40 years
84 (50.6)48 (32.0)
82 (49.4)102 (68.0)
2.18 (1.38-3.44)
Marital status Currently marriedNot currently married
93 (42.3)38 (41.3)
127 (57.7) 54 (58.7)
1.04 (0.64-1.71)
5195% Confidence interval*
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Variables Adjusted Odds ratio
95% Confidence interval
p value
No/Low education 0.15 0.09-0.26 <0.001
> 40 years 1.59 0.91-2.77 0.1038
Predictors of cervical cancer awareness among respondents, Lagos; Sept-Nov, 2012
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Discussion• Factors independently associated with PCC
– multiple sexual partnering– early coitache
• Less than half of the study population were aware of cervical cancer – Ogunbode and Ayinde, Nigeria, 2005 (40.8%)– Adanu, Ghana, 2002 (93%)
• Media was the main source of information • Knowledge of the disease was poor