ABSTRACT

Cervical cancer is a major reproductive health concern among women and a preventable disease that poses a significant public health challenge, particularly in developing countries. It ranks as the third most common cancer globally and the second most common cancer among women in developing countries, where it is also a leading cause of cancer-related deaths. This study was conducted to determine the prevalence of premalignant cervical lesions, assess women's knowledge of cervical cancer and its associated risk factors, and establish the level of screening uptake among women of reproductive age attending the Gynaecology Clinic of General Hospital, Owerri. A descriptive cross-sectional study was carried out between January and March 30, 2013.

Data were analysed using Epi Info version 3.5.3 at a 95% confidence interval and a 5% level of significance. Univariate analysis involved the use of frequencies, means, and proportions, while bivariate analysis included the calculation of prevalence odds ratios, assessment of associations between cervical abnormalities and selected exposure factors, and Fisher's exact test to determine statistical significance. A total of 108 Pap smear samples were collected, and questionnaires were administered to all participants.

The findings showed that 14 participants (13.9%), with a reported 95% confidence interval of 0.8–21.9, had abnormal Pap smear results. Among the abnormal cytological findings, low-grade squamous intraepithelial lesions (LSIL) accounted for 12 cases (11.11%), while two cases (1.9%) showed human papillomavirus (HPV)-related changes. In addition, 17 participants (16%) had inflammatory findings. Most respondents, 72 (66%), reported that they had heard about cervical cancer, while 77 (71%) indicated awareness of cervical cancer screening. A total of 74 respondents (68%) identified the Pap smear test as the only available screening method, whereas 67 women (62%) lacked knowledge of the risk factors associated with cervical cancer. Screening uptake was considerably low, as only five women (4.6%) had undergone cervical cancer screening before the study.

The study identified an abnormal cervical smear prevalence of 14 (13.9%), with a reported 95% confidence interval of 0.8–21.9. This finding was consistent with previous reports on abnormal cervical smear prevalence among women in sub-Saharan Africa. Age was also an important factor, as the highest prevalence was observed among women aged 49 years and above. The study recommended regular and sustained public health campaigns to educate women about cervical cancer, with particular attention to its causes, risk factors, and preventive measures. It also recommended the introduction of policies that would encourage or, where appropriate, require women attending antenatal services to be offered Pap smear screening.

CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Cervical cancer is a significant reproductive health challenge among women. Although it is a preventable disease, it remains a major public health concern, particularly in developing countries. Globally, it is ranked as the third most common cancer, while in developing countries, it is the second most common cancer among women and one of the leading causes of cancer-related deaths.¹ In 2018, approximately 529,000 new cases and 274,000 deaths resulting from cervical cancer were recorded worldwide. Estimates also indicate that more than one million women across the world are currently living with cervical cancer, with many remaining undiagnosed and unable to access treatment that could cure the disease or extend their lives.²

The regions with the highest cervical cancer burden include Eastern and Western Africa, where the age-standardised rate (ASR) exceeds 30 cases per 100,000 women. Southern Africa records 26.8 cases per 100,000 women, while South-Central Asia has 24.6 cases per 100,000. South America and Middle Africa also record high rates of 23.9 and 23.0 cases per 100,000 women, respectively. In contrast, the lowest rates are found in Western and Northern America, as well as Australia and New Zealand, where the ASR is below six cases per 100,000 women.⁴ More than 85% of deaths associated with cervical cancer occur in developing countries, where the disease accounts for approximately 13% of all cancers affecting women.

Cervical cancer was previously the leading cause of cancer-related deaths among women in the United States. However, over the last four decades, both the incidence of the disease and the number of related deaths have declined considerably.² This improvement has largely been attributed to the introduction of regular screening programmes using Pap tests, which help identify precancerous changes in cervical cells before they develop into invasive cancer.³ In 2018, approximately 11 out of every 100,000 women in the United States were diagnosed with cervical cancer, while three out of every 100,000 women died from the disease.⁴ In comparison, the incidence in less developed countries was reported as 453 per 100,000 women, with 242 deaths per 100,000 women.

In sub-Saharan Africa, the high prevalence and mortality associated with cervical cancer are largely linked to inadequate screening and treatment policies, strategies, and programmes. Many women lack access to effective preventive and diagnostic services and therefore seek medical attention only when the disease has progressed to an advanced stage. This situation is reflected in the age-standardised incidence rates of 35.7 cases per 100,000 women in Bamako, Mali, and 41.7 cases per 100,000 women in Kyadondo, Uganda.

Nigeria is the most populous country in sub-Saharan Africa, with an estimated population of approximately 167 million inhabitants, according to the population figure cited in the original study. The country has a reported life expectancy at birth of 50.6 years for males and 52.6 years for females. Child mortality rates were reported as 159 per 1,000 among males and 152 per 1,000 among females. Furthermore, annual per capita health expenditure was estimated at US$8. The female population aged 15 years and above was estimated at 36.59 million, representing the population considered to be at risk of developing cervical cancer.

Available estimates indicate that approximately 9,922 Nigerian women are diagnosed with cervical cancer annually, while about 8,030 die from the disease. In Nigeria, cervical cancer is the second most common cancer among women and also ranks second among cancers affecting women aged 15–44 years.⁵˒⁶ Research conducted in Ibadan reported an annual age-standardised cervical cancer incidence rate of 19.9 per 100,000 women between 1998 and 2019.⁷

Although vaccination offers considerable potential for preventing cervical cancer, regular screening remains necessary. Vaccination programmes cannot completely eliminate the need for screening because currently available vaccines protect against HPV types responsible for approximately 70% of cervical cancer cases.⁸ Combining vaccination with effective screening services and public education could therefore improve the chances of preventing cervical cancer among young women.⁸

Human papillomavirus (HPV) is the primary cause of cervical cancer, which remains one of the most common cancers affecting women worldwide. HPV infections are widespread, and many individuals with genital HPV infections do not experience noticeable symptoms. However, persistent infection can lead to cervical cancer in women and may also result in transmission of the virus to other individuals.⁹

Globally, HPV has been identified in approximately 95–99.7% of cervical carcinoma cases.¹⁰ Almost all cervical cancer cases, estimated at 99%, are associated with genital HPV infection, which is the most common viral infection of the reproductive tract. Apart from cervical cancer, HPV can also cause other forms of cancer, including anogenital and head and neck cancers, as well as genital warts in both males and females. Transmission of the virus occurs mainly through sexual contact.¹¹

Cervical HPV infection is a common sexually transmitted infection, affecting an estimated 50–80% of sexually active women at least once during their lifetime.¹² High-risk HPV types 16 and 18 are responsible for more than 65% of cervical cancer cases.¹³˒¹⁰˒¹² However, detailed information on the prevalence of cervical HPV infection has only become available in recent years.⁷˒¹⁴˒¹⁵˒¹⁶˒¹⁷

Other factors that may increase the risk of cervical cancer include early sexual activity, having multiple sexual partners, low socioeconomic status, smoking, nutritional factors, and prolonged use of contraceptives.⁷ Cervical cancer develops when abnormal cells grow uncontrollably in the cervix, which is the lower part of the uterus that connects to the vagina. The disease commonly originates in the cervical transformation zone, an area where the squamous epithelium of the ectocervix gradually replaces the columnar epithelium of the endocervix.¹⁸

Globally, approximately 400,000 new cases of cervical cancer occur annually, with about 80% of these cases recorded in developing countries. It has also been reported that a woman dies from cervical cancer every two minutes worldwide.¹⁹˒²⁰˒²¹

The development of cervical cancer involves several stages. These include HPV infection of the metaplastic epithelium within the cervical transformation zone, persistence of the viral infection, progression of the infected cervical cells into precancerous lesions, and eventual invasion through the epithelial basement membrane. Cervical cancer may not produce noticeable symptoms during its early stages. However, as the disease progresses, affected women may experience unusual vaginal bleeding or discharge, bowel and bladder difficulties, and pain.²²

The transformation of normal cervical cells into cancerous cells usually occurs over several years. Cervical cancer can be prevented through regular screening, particularly the Papanicolaou (Pap) test, which involves examining cervical cells under a microscope to identify abnormalities. Regular Pap testing helps detect changes in cervical cells early enough for appropriate treatment before they develop into cancer. Women who do not participate in routine cervical screening face a greater risk of developing advanced disease because potentially precancerous abnormalities may remain undetected and untreated.²³

1.2 Statement of the Problem

Cervical cancer is the second most common cancer affecting women worldwide.²⁴ It represents a serious public health challenge in low-income countries, including Nigeria, which has access to only about 5% of global resources allocated to cancer control.²⁵˒²⁶˒²⁷ Approximately 300,000 deaths from cervical cancer occur annually in low-income countries, where many patients are diagnosed at advanced stages and access to appropriate treatment facilities is limited.²⁸

A large proportion of women in developing countries do not have access to effective cervical cancer screening programmes. In Nigeria, cervical cancer is regarded as the most common cancer of the female genital tract and one of the leading cancers affecting women.²⁴˒²⁹ In the local environment, an increase in the occurrence of the disease has been observed, with many patients presenting at health facilities when the condition has already progressed and produced different complications.³⁰

There is also limited documentation on the extent of the cervical cancer problem in Nigeria, particularly in Northern Nigeria.³¹˒³²˒³³ Differences in cervical cancer prevalence across geographical regions may be influenced by hereditary factors, healthcare practices, lifestyle changes, and environmental exposures, including dietary patterns, tobacco use, and pesticides.

The availability of affordable and effective treatment for precancerous cervical lesions makes early detection particularly important. Cervical cancer screening has been shown to reduce the occurrence of invasive cervical cancer and related deaths. The level of reduction achieved is directly influenced by the proportion of women in the population who participate in screening programmes.

To improve access to cervical screening, many developed countries have established organised and effective screening programmes. However, this approach is not widely implemented in many developing countries, where screening is largely opportunistic. In Nigeria, participation in opportunistic screening also appears to be limited. Consequently, Nigerian gynaecologists have been encouraged to increase the provision of opportunistic screening services, while the inclusion of cervical cancer screening in pre-employment medical examinations has also been suggested.

As part of efforts to improve cervical cancer screening coverage, the Medical Women's Association of Nigeria in Enugu, South-Eastern Nigeria, established a highly subsidised screening centre in the late 1980s.

The present study is a time-bound cross-sectional investigation involving a limited number of participants, with each participant undergoing a single Papanicolaou smear test at the point of recruitment. Although repeated Pap smear examinations over an extended period would have provided additional information, this was beyond the scope of the present study. Further investigations are therefore necessary to address these limitations. Nevertheless, the findings are expected to provide useful information on cervical cancer screening and the prevalence of abnormal cervical smears among women.

1.3 Aim and Objectives of the Study

The aim of this study is to determine the prevalence of abnormal cervical smears and assess knowledge of cervical cancer screening among women attending the Gynaecology Clinic of General Hospital, Owerri, Nigeria.

The specific objectives of the study are to:

1. Determine the number of women of reproductive age diagnosed with cervical cancer.

2. Identify the age distribution of women diagnosed with cervical cancer.

3. Determine the parity of women diagnosed with cervical cancer.

4. Establish the number of women who have undergone cervical screening using the Pap smear test.

1.4 Research Questions

The following research questions were formulated to guide the study:

1. What is the number of women of reproductive age diagnosed with cervical cancer?

2. What is the age distribution of women diagnosed with cervical cancer?

3. What is the parity distribution of women diagnosed with cervical cancer?

4. How many women have undergone cervical screening using the Pap smear test?

1.5 Significance of the Study

The findings of this study will provide information on the prevalence of cervical cancer among women of childbearing age. They will also offer insight into the extent to which women in Uyo participate in cervical cancer screening programmes and help identify existing gaps in their knowledge and screening practices.

The findings may be useful to professional nurses, midwives, healthcare planners, and other stakeholders in the health sector. They can provide relevant information for planning and implementing health education programmes and public awareness campaigns that will improve women's understanding of the different methods of cervical cancer screening.

When properly applied, the findings may encourage more women to participate in cervical cancer screening, thereby reducing delays in seeking medical attention, diagnosis, and treatment. This could contribute to lowering the incidence and mortality associated with cervical cancer among women in the state.

Furthermore, the study will contribute to existing literature on the prevalence of cervical cancer among women of childbearing age and provide information that may be useful in assessing the effectiveness of cervical cancer screening programmes in the state. It will also serve as a reference resource for other researchers undertaking studies on related subjects.

1.6 Scope of the Study

This study focuses on determining the prevalence of cervical cancer among women of childbearing age. It was conducted among women attending the Gynaecology Clinic of General Hospital, Owerri, Nigeria. The study was restricted to women aged between 18 and 45 years who were available at the study location during the period of data collection.

1.7 Operational Definition of Terms

Cervical Cancer: This refers to a malignant growth that develops in the cervix, which is the lower portion of the uterus.

Childbearing Woman: In this study, a childbearing woman refers to a female within the age range of 18–45 years who is still capable of becoming pregnant and giving birth.

Prevalence: This refers to the proportion of individuals within a specified population who have a particular disease or medical condition at a given point or during a defined period.