Prevalence of cervical intraepithelial neoplasia in relation to knowledge, attitudes/beliefs, and practices among university students in North-Eastern Nigeria

Background: The involvement of communities in control of cervical cancer cannot be overemphasized, but this must take cognizance of their current knowledge, attitudes/beliefs, and practices (KABP) of the people if it will be sustainable. This study assessed the prevalence of cervical intraepithelial neoplasia (CIN) among university students and their level of KABP concerning cervical screening in Maiduguri North-Eastern, Nigeria. Materials and Methods: Two hundred and fifty-two subjects (age range: 18-69 years) were screened using pap smear screening method and acetowhite method. A structured questionnaire was administered on each subject to elicit information on KABP that could predispose them to the disease. Results: CIN was recorded in 12.8% of subjects with low-grade squamous intraepithelial lesion in 10.8% and high-grade squamous intraepithelial lesion 2.0% of the women, respectively. The average general level of knowledge of various aspect of was 43.3% average positive attitudes/beliefs about the disease was recorded in 17.1% of subject, while positive practices that could lead to prevention of the disease was obtained in 30.0%. Conclusion: The level of knowledge of the disease and screening is very low and together with high levels of negative attitudes and practices, will adversely affect control measures and therefore have to be addressed.

Keywords: Cervical cancer, knowledge, attitudes/beliefs, practices

Cervical cancer is the second most common cancer in women, with an estimated 500,000 new cases and 231,000 deaths annually worldwide. ^[1] In most countries with an established national screening program, the incidence of invasive cervical cancer has decreased, ^[2] but increasing numbers of preinvasive cervical intraepithelial neoplasias (CINs) have been registered in UK ^[3] and the USA, ^[4] particularly in young women. It is unlikely that this increase in the number of abnormal cervical smear results can be accounted for either by the increase in number of women participating in the screening program ^[5] or by changes in diagnostic procedures or terminology. ^[6]

Cervical cancer is yet to be recognized as an important public health problem in sub-Saharan Africa. Several studies have shown poor knowledge and awareness of the disease in Africa, which even cuts across different literacy levels. ^[7],[8] Among 500 attendees of a maternal and child health clinic in Lagos, Nigeria only 4.3% were found to be aware of cervical cancer. ^[9] Similar studies in Kenya and Tanzania also reported very poor knowledge of the disease in patients. ^[10] Poor knowledge is not limited to patients alone; however; health care workers who are supposed to be better informed do not have knowledge of the disease either. In Lagos, delay by primary health care providers in referring cases of cervical cancer was found to be an important cause of women presenting with late-stage disease. It took a mean of 9.35±12.9 months for primary health care providers to diagnose and refer women with cervical cancer to a tertiary hospital for management. ^[11]

The study of CIN in Maiduguri, Nigeria showed an overall prevalence rate of 104 per thousand (10.4%), with CIN I, II, and III accounting for 56.9%, 33.4%, and 9.7%, respectively, while carcinoma in situ was found in five women. Cancer of the cervix accounts for 70.5% of the female genital tract in North-Eastern Nigeria. ^[12] This high incidence could be attributed to early marriage and high number of live birth by women in the region. This study, therefore, seeks to find out the relationship between the prevalence of CIN and knowledge, attitudes/beliefs, and practices (KABP) in North-Eastern Nigeria.

Two hundred and fifty-two female students aged between 18 and 69 years comprising one hundred and fifty-three married and ninety-nine unmarried but sexually active subjects from Maiduguri, Nigeria; were recruited for this study. A questionnaire to determine their KABP as regards CIN was designed and administered to the subjects. This was then followed by visual inspection of the cervix with 5% acetic acid and collection of  Pap smear ^{More Details} with Ayre’s spatula and cytobrush. The smeared slides were then fixed in 95% ethanol and stained by Papanicolaou’s method. Each slide was examined carefully for nonspecific, premalignant, and malignant changes.

The cervical smear collected from 252 female students of University of Maiduguri revealed nonspecific inflammatory changes in 176 subjects representing 69.8% [Table 1]; low-grade squamous intraepithelial lesion in 27 subjects representing 10.7% and high-grade squamous intraepithelial lesion in five subjects representing 2% [Table 2]. Peak age for specific squamous intraepithelial lesion prevalence rate of 40.6% was recorded in 20-29 years age group; while the lowest age-specific prevalence rate of 3.1% was recorded in 50-59 years age group.

Results from the questionnaire revealed that only 64 subject representing 25.4% claimed knowledge of the cause of CIN, while 188 subjects (74.6%) claimed not to have knowledge of the cause of the disease. The questionnaire further revealed that 24.2% and 80.2% of the women had correct knowledge of the symptoms and treatment respectively as against 75.8% and 9.8% who are not knowledgeable [Table 2].

The study on attitude and belief revealed that 133 (44.8%) had positive attitude on early marriage and 139 (55.2%) had negative attitude on early marriage. A greater number of the women 241 (95.6%) and 247 (98.0) had negative attitude toward participation in organized cervical screening and sex of health personnel collecting the smear respectively as against 11 (4.4%) and 5 (2.0%) with positive attitudes [Table 3].

On practices that may predispose them to CIN 120 (47.6%), 214 (84.9%), and 174 (69.0%) had negative attitude about age at first sexual exposure, number of sexual partners, and practice toward number of children, respectively, while 132 (52.4%), 38 (15.1%), and 78 (31.0%) had positive attitude respectively about the practice. In contrast, 75 (29.8%) of the female students are from polygamous families which is a positive practice that promote development of CIN [Table 4].

Comparing the results of aceto-white and pap smear diagnosis revealed that 9 (3.6%) out of the study population were positive for acetowhite and pap smear. While 188 (71.2%) were negative for acetowhite and positive for nonspecific inflammatory changes and 44 (16.7%) were negative for acetowhite and negative for pap smear [Table 5].

The objective of this study was to find out the level of KABP regarding CIN among female students of University of Maiduguri through the use of systematic sampling and questionnaires administered to 252 students. The general knowledge on the cause and symptoms of CIN was 64 (25.4%) and 61 (24.2%), which explains why the prevalence of CIN is up to 12.8% in the study area. The level of knowledge is comparable to that of Maiduguri, Borno state, where only (44.8%) of the women who responded to similar questionnaire had adequate knowledge of CIN. ^[13] Among 500 attendees of a maternal and child health clinic in Lagos, Nigeria only 4.3% were found to be aware of cervical cancer. In 2004, also in Lagos, 81.7% of 139 patients with advanced cervical cancer had never heard of cervical cancer before. ^[9] This result highlights the need for better public education on the cause, symptoms, and treatment of CIN/cervical cancer as an important component of control of the disease. The level of ignorance of the people apparently sustains the current prevalence level of this condition. The 44.8% of the subjects accepting early marriage is abnormal. This is worrisome because it is a major predisposing factor to CIN and other social problems. The response of the subjects to participation in organized cervical screening was quite negative [Table 3] and so was the issue of the sex of health personnel collecting the smear in the same table. This is expected since these have to do with their privacy and the sociocultural and religious factors that are prevalent in the area. Purdah is the way of life and that means that a woman is to be kept away from the view of other men as much as possible, so a healthcare facility that would respond appropriately to reproductive health needs of the women must take these factors into consideration.

A practice that may likely predispose to CIN from this study is age at first sexual exposure and age at which women get married. This is because those who have sex at an early age with more than one partner or have been married to more than one husband have increased risk of exposure to human papillomavirus (HPV) infection. In this culture, very young girls, usually virgins are given out in marriage to much older men, some with several more wives already. ^[14] This may increase the likelihood of such girls being infected with HPV at intercourse. Polygamy is reported to increase the risk of cervical cancer by twofolds and the risk increases with increasing number of wives. Also from [Table 4], (31.0%) of subjects would like to have as many children as possible. This practice also promotes development of CIN.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.127780

[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]