Olawunmi O. Adeoye ¹ , O. Fawole ² , I. Ajayi ², O. Biya ¹ , P. Nguku ¹

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 Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria Department of Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria

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

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

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)

Lagos city

Geographical location of study area Lagos Nigeria Source: Health Mapper; WHO GIS unit

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

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

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

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 Confidentialitywas maintained Beneficence: All services were provided free

Results

Age distribution of respondents, Lagos; September-November 2012

Prevalence of risk factors of cervical cancer in respondents, Lagos; Sept-Nov 2012

Prevalence of precancerous cervical changes in respondents, Lagos; Sept-Nov 2012 Finding on VIA/VILI

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 95% Confidence interval*

Factors associated with PCC among respondents, Lagos; Sept-Nov, 2012 95% Confidence interval*

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

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)

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

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 lowcervical cancer screening uptake • Ayinde and Omigbodun, Nigeria, 2002 (6.8%) • Adanu in Ghana, 2002 (8.3%) • Wellensiek and Moodley, South Africa, 2002 (36.7%)

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

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

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

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

THANK YOU !!!!

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)

Sample size calculation n = 253 n = z²pq d² Z= 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%

Recoding schema for study variables

Distribution of respondents by types of preventive measures known

Reported reasons for never being screened for cervical cancer

Respondents’ sources of information on cervical cancer, Lagos; Sept-Nov, 2012

Association between knowledge and having ever screened for CC, Lagos; Sept-Nov, 2013

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

Sampling technique Multistage 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

Association between non- modifiable factors and PCC

Olawunmi O. Adeoye ¹ , O. Fawole ² , I. Ajayi ², O. Biya ¹ , P. Nguku ¹