Background: Cervical cancer is a cause of significant morbidity and mortality among Nigerian women. Early detection by screening has proved to be an effective preventive measure. Knowing the factors that determine and predict uptake helps to determine where more efforts need to be put to achieve better uptake of the screening test. Aim and Objective: To determine the predictors and factors related to the uptake of cervical cancer screening test among female secondary school teachers in Sagamu. Methods: A cross-sectional descriptive study was carried out among 256 secondary school teachers in Sagamu Local Government Area of Ogun State. Data were collected using semi-structured, self-administered questionnaires and analyzed using SPSS version 21. Chi-square test was used to determine factors related to the uptake of the screening test while logistic regression was done to predict which group was less likely to be screened. Results: Uptake of screening test was 17.6%. One hundred and sixty-nine (66%) respondents were willing to be screened. The most common reason for not willing to be screened was the belief of not been at risk of the disease. About 84% of the respondents had a positive attitude toward cervical cancer screening, with a mean score of 7.8 ± 1.5 while only 23.4% had good knowledge with a mean score of 7.6 ± 3.6. Teachers with lower knowledge and attitude scores who had one sexual partner were less likely to be screened. Conclusion: Adequate knowledge needs to be passed across to teachers to improve uptake of cervical cancer screening.
Keywords: Attitudes, cervical cancer, predictors, screening, teachers
Cancer of the cervix remains a public health problem in women worldwide. It is the second most common cancer in women globally., Cervical cancer accounts for 35% of adult female deaths worldwide. Cervical cancer screening can identify precancerous changes in cervical cells and tissue. Early recognition and treatment of these precancerous changes prevents transformation into invasive cancer.
Human papillomavirus (HPV) infection appears to be a necessary factor in the development of almost all cases (90%) of cervical cancer., Widespread comprehensive cervical cancer screening programs have resulted in a marked reduction in the incidence and mortality in most developed countries where precursor lesions which antedate the development of cervical cancer by several years are more often detected.,, The cervical cancer screening tests look for cell changes on the cervix that might become cervical cancer if they are not treated appropriately.
HPV is transmitted sexually and the probability of transmission is increased with first occurrence of sexual intercourse at an early age and multiple sexual partners. Cigarette smoking, low socioeconomic status, oral contraceptive use, and immunosuppression are also factors known to increase risk of cervical cancer ,,
Despite slightly high levels of awareness of cervical cancer in Nigeria, uptake is still very low. Studies in Osogbo, Southwest Nigeria showed 44.5% are aware cervical cancer was common and only 5.4% had been screened, in Ife about 37% are aware and only 3.2% had been screened  while also in Sokoto, Northwest Nigeria, 98.6% are aware of cervical cancer, 76.6% were aware of the screening test and where it could be done but only 1.4% had been screened. And in Nnewi, South-East Nigeria, awareness was 74.6% and uptake was 20.5%.
School teachers are considered very important in education and disseminating reproductive and other health-related information and so they play a role as health advocators to teenage children and their parents. They are in a better position to educate young girls in their domain and the society at large.
The study objectives were to examine the predictors and factors related to the uptake of cervical cancer screening test among female secondary school teachers in Sagamu, Ogun State.
The study was carried out in Sagamu, an Urban Local Government Area (LGA) in Ogun central senatorial zone of Ogun State, Southwest Nigeria. It is one of the 20 LGAs making up the state. It serves as a transit zone to many regions of the country particularly South-South, South-East, and the Northern regions.
A cross-sectional descriptive study was carried out among female secondary school teachers in public schools situated in Sagamu between May and June 2013. The sample size for the study was calculated using the formula for descriptive study N = Z2pq/d2. The calculated minimum sample size (n) was 256.
Respondents were selected via multistage sampling technique. The first stage involved selection of 3 wards out of the 15 existing wards in Sagamu LGA using simple random sampling technique. The second stage involved selection of 2 public secondary schools in each of the selected wards using simple random sampling technique, making a total of six schools. All female teachers who were willing to participate in the study were recruited into the study.
Data were collected with the aid of semi-structured, self-administered questionnaires, which had been pretested in Ikenne LGA of Ogun State. Participation was fully voluntary and participants’ written consent was obtained. Written permission was obtained from the office of the Zonal Education Officer for the study. Ethical approval was also obtained from the Health Research and Ethics Committee of Olabisi Onabanjo University Teaching Hospital Sagamu.
Knowledge and attitude related questions were scored. The maximum knowledge score was 16; scores from 0 to 5 were designated poor knowledge, scores from 6 to 10 were designated fair knowledge while scores from 11 to 16 were designated good knowledge. The maximum attitude score was 5, half (0.5) mark for each correct answer in response to a related question; scores from 0 to 2 was designated bad attitude while 3 to 5 was designated good attitude.
The Chi-square test was used to examine the relationships between uptake of cervical cancer screening and nonparametric variables, whereas independent t-test was used to test the relationships between uptake of cervical cancer screening and continuous variables. A paired t-test was used to compare the means of continuous variables.
Pearson’s correlation was performed to determine the relationships between knowledge and attitude scores and age, number of sexual partners, age at coitarchy and parity.
Logistic regression was used to predict the uptake of cervical cancer screening based on knowledge and attitude scores as well as some other demographic factors. The Hosmer and Lemeshow test of goodness of fit as well as the Omnibus tests of model coefficients was used to test the overall fit of the logistic model while the Cox and Snell R2 and Nagelkerke R2 tests were used to indicate the amount of variability in the dependent variable.
All data analysis was done using IBM Statistical Package for Social Sciences (SPSS) Version 21.0 (IBM Corporation) with 95% level of significance.
The total number of respondents was 256. The mean age of the respondents was 38.95 ± 6.9 years, and their ages ranged from 23 to 56 years. The sociodemographic characteristics of respondents are presented in [Table 1].
The mean knowledge score was 7.6 ± 3.7. Of the 256 respondents, 73 (28.5%) had poor knowledge, 123 (48%) had fair knowledge, and 60 (23.5%) had good knowledge.
Concerning their attitudes towards cervical cancer and its screening tests, 216 (84.4%) respondents had good attitude to cervical cancer screening while 40 (15.6%) had poor attitudes. The mean attitude score is 3.9 ± 1.5.
Of the 256 respondents, 45 (17.6%) have had the screening done while 211 (82.4%) have never been screened.
Two hundred and twenty-four (87.5%) respondents thought cervical cancer was of public health importance, while 32 (12.5%) thought it was not. Two hundred and nine (81.6%) felt it was important to go for screening while 47 (18.4%) felt it was not.
Concerning respondents’ awareness of and willingness to learn more about the cervical cancer and screening tests, 82.2% were aware of cervical cancer while 73% were aware of cervical cancer screening tests. Exactly, 214 respondents (83.6%) were willing to listen to information on cervical cancer and its screening tests while 42 (16.4%) were not. One hundred and ninety-one (74.6%) were willing to talk to their friends about it while 65 (25.4%) were not. The benefits of early detection were known to 201 (78.5%) while 55 (21.5%) believed there was no benefit.
One hundred and sixty-nine respondents (66.0%) were willing to have the screening test done while 87 (34%) were not willing.
Factors associated with cervical cancer screening and willingness to be screened are presented in [Table 2] and [Table 3], respectively, and reasons for unwillingness to be screened are presented in [Table 4].
There was a correlation between attitude score and parity (ρ =0.14; P = 0.40), number of sexual partners (ρ = −0.273; P = 0.00) and the knowledge score (ρ =0.38; P = 0.00). There was also a correlation between knowledge score and age (ρ =0.17; P = 0.14), number of sexual partners (ρ = −0.16; P = 0.26) and attitude score (ρ =0.38; P = 0.00).
The mean difference between the attitude score, knowledge score, age, age at coitarche and number of sexual partners among teachers who had been screened and those who had never been screened was calculated using the independent t-test [Table 5]. Uptake of cervical cancer screening was significantly associated with the mean knowledge and attitude scores. The mean values were higher for those that have been screened than those that are unscreened.
[Table 6] shows the predictors of cervical cancer screening and their odds ratios. The Cox and Snell R2 and Nagelkerke R2 tests showed that between 27.9% and 45.9% of the variability in the uptake of cervical cancer screening can be explained by the model. The Hosmer and Lemeshow test’s significance was 0.87 while the omnibus tests of model coefficients significance was 0.00, both indicating our model was well fitted.
Globally, cervical cancer screening reduces morbidity and mortality of cervical cancer. The screening exercise gives an opportunity for early detection and prompt treatment. Awareness of the existence of the disease is the first step to challenging it. It is however discouraging to find out that even though this disease has been discovered for over 40 years, many developing countries still do not have 100% awareness even among their educated individuals.
Considering that this study was done among secondary school teachers, 82% awareness of the existence of disease and 73% awareness of its screening is still low even though it was higher than that found among female secondary school teachers in Osogbo South West Nigeria  and similar to that of Nnewi school teachers.
In this study, 66% of the respondents were willing to have cervical screening test done, which is similar findings from Ile Ife, South-West Nigeria, and Malaysia  but only 19.6% were willing in Ilorin, Nigeria.
The most common reason for unwillingness to be screened was the belief that they were not at risk of having the disease/they cannot have cancer (29.3%). This is the “God forbid” belief and such deters from going for screening. This was also a common reason in Sokoto, North-West Nigeria, among rural nurses in India, among teachers in Nnewi, South-East Nigeria, and among health workers in Ilorin. This shows that knowledge of the risk factors of this disease and the disease entity as a whole is poorly understood and it is reflected as only 23.5% had good knowledge and the mean knowledge score of 7.6 ± 3.7. Those who had been screened had a mean score of 9.7 ± 3.2 while those who had never been screened had a mean score of 7.1 ± 3.5 (t = 4.74, P = 0.000). This is higher than that found among school teachers in Osogbo. However, more health workers in Ilorin  had good knowledge about cervical cancer which was attributed to their profession. A study in Ghana  showed low levels of knowledge among university students. This goes to show that even within the educated cohort, the correct knowledge about cervical cancer and its screening is still low.
Very few respondents (2.7%) chose not to do the test for the fear of its outcome. This value is higher than that obtained among staff nurses in India (0.4%) and much lower than findings among health workers in Sokoto.
About 79% of the respondents believed that there was benefit to early detection of the disease. A similar proportion was found in Ghana. These values were however lower than that found in the United Kingdom, and this is attributed to the level of awareness and knowledge available in a developed country as opposed to that in developing countries.
In this study, over 80% of the respondents had a good attitude toward cervical cancer screening while in India and Mexico, only 14% and 29.5%, respectively, had positive attitude toward it., While rural women in Nigeria with good perception were <10%.
This further buttresses the importance of awareness campaigns as those that had heard had a better attitude and were willing to do the test.
From our study, we also observed some factors associated with wiliness to be screened and these included attitude, educational level, and age at coitarche (P values are 0.000, 0.006, and 0.050, respectively). All except one of the respondents with poor attitude were not willing to be screened while 77.8% of those with good attitude were willing to be screened. More than two third of the respondents whose age at coitarche was <20 were willing to be screened. The knowledge of being predisposed is responsible for this willingness.
The factors significantly associated with uptake of cervical cancer screening test include educational level, knowledge, and attitude. None of the respondents with bad attitude and only 5.5% of the respondents with poor knowledge had been screened.
Knowledge, attitude, and number of sexual partners predicted the uptake of cervical cancer screening. This was similar to a study among women in Nigeria,, and Malaysia.
The odds for a female secondary school teacher with just one sexual partner not to be screened was 13.7 times higher than that for those with multiple sexual partners. Also, teachers with higher knowledge and attitude scores were less likely to have not been screened.
When discussing cervical cancer and its screening, the aim is to achieve 100% uptake among women so as to greatly reduce the incidence of the disease.
Secondary school teachers have direct contact with the age group who should be educated about cervical cancer, its screening and vaccination against HPV infection. Arming female secondary school teachers with enough information would transform to better knowledge and attitude which are the factors associated with and predictors of uptake of the screening test. This would eventually lead to reduction in the incidence of cervical cancer as the younger generation would begin to receive vaccination against HPV and do screening tests as scheduled when they become sexually active.
This study revealed that depth of knowledge, the attitude and the number of sexual partners predicts the uptake of cervical cancer screening.
Awareness campaigns which propagate knowledge and make their attitudes toward the screening better should be targeted towards them due to its potential to predict uptake and cause a widespread propagation of factual information about cervical cancer prevention and early detection.
The authors acknowledge Dr. A.D Alabi and Dr. Adewale Oluwatosin for their immense contributions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]