nigeria field epidemiology and laboratory training programme risk factors of cervical cancer and...

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


2

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


3

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


4

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)


5

Lagos city


6

Geographical location of study area

Source: Health Mapper; WHO GIS unit

Lagos

Nigeria


7

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


8

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


9

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


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

10


11

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


12

Results


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


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


15

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


16






Multiparity 36 13.4




17






Multiparity 36 13.4




18







Multiparity 36 13.4



19






Multiparity 36 13.4




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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


21

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


22

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


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*


Factors associated with knowledge of cervical cancer of respondents, Lagos; Sept-Nov, 2012

Factors Good knowledge n (%)

Poorknowledge n(%)

Prevalence odd ratio (95% CI)*


33 (41.8)29(85.3)46(58.2)

0.24 (0.08-0.68)


21 (27.3)17 (43.6)

56 (72.3)22 (57.4)

0.40 (0.22-1.09)


30 (37.0) 8 (21.6)

51 (63.0)29 (67.9)

2.13 (0.86-5.26)



25

Factors associated with PCC among respondents, Lagos; Sept-Nov, 2012

Factors PCC Prevalence odd ratio ( 95% CI)*

P value

Yesn (%)

Non (%)

Multiple partners 25 (55.0) 20 (45.0) 18.7 (8.8- 39.8) <0.001

Early coitache 30 (44.8) 37 (55.2) 15.7(7.5-32.8) <0.001

Multiple risks 19(55.9) 15(44.1) 14.5 (6.5-32.0) <0.001

Grandmultiparity 12(33.3) 24 (66.6) 4.3 (2.0-9.4) 0.001

OCP use 22(16.2) 114 (83.8) 1.4 (0.7-2.6) 0.461

Previous STI 8(11.8) 60(88.2) 0.8 (0.3-1.8) 0.686



26



P value

Yesn (%)

Non (%)


Early coitache 30 (44.8) 37 (55.2) 15.72 (7.52-32.83) <0.001

Multiple risks 19(55.9) 15(44.1) 14.46 (6.53-32.03) <0.001


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



27



P value

Yesn (%)

Non (%)


Early coitache 30 (44.8) 37 (55.2) 15.72 (7.52-32.83) <0.001

Multiple risks 19(55.9) 15(44.1) 14.46 (6.53-32.03) <0.001


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



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P value

Yesn (%)

Non (%)


Early coitache 30 (44.8) 37 (55.2) 15.72 (7.52-32.83) <0.001

Multiple risks 19(55.9) 15(44.1) 14.46 (6.53-32.03) <0.001


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



29



P value

Yesn (%)

Non (%)


Early coitache 30 (44.8) 37 (55.2) 15.72 (7.52-32.83) <0.001

Multiple risks 19(55.9) 15(44.1) 14.46 (6.53-32.03) <0.001


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



30

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


31

Predictors of PCC on logistic regressionin respondents, Lagos; Sept-Nov, 2012



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


32

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)


33

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


34

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%)


35

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


36

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


37

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


38

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


39

THANK YOU !!!!


40

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)


41

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


42

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


43

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


44

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


45

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)


46

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%)


47

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


48

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


49

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


50


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%)


94 (66.7)94 (78.3)47 (33.3)

0.14 (0.08-0.24)


84 (50.6)48 (32.0)

82 (49.4)102 (68.0)

2.18 (1.38-3.44)


93 (42.3)38 (41.3)

127 (57.7) 54 (58.7)

1.04 (0.64-1.71)



52



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


53

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

nigeria field epidemiology and laboratory training programme risk factors of cervical cancer and...

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