title: Awareness and attitude towards cervical cancer risk, screening, and HPV vaccination in West Africa
Creators: name: Olajide, Nike Abiodun
Publisher: name: University of Glasgow
Year: 2024

description: Background: Cancer is a major global public health problem. Cervical cancer is the fourth most diagnosed cancer and the fourth leading cause of death in women. Cervical cancer incidence and mortality is higher in sub–Saharan Africa (SSA) compared to the rest of the world. There is a paucity of research on the burden of cervical cancer in West Africa. To contribute towards reducing the burden of cervical cancer in West Africa, understanding the various factors contributing to higher risk burden of cervical cancer in West Africa is pertinent. This thesis focused on two main aims: (1) Review evidence on the knowledge, attitudes, and barriers of HPV vaccination and cervical cancer screening among healthcare professionals. (2) Examine the risk burden of cervical cancer, awareness and participation in cervical cancer screening and its determinants among women aged 15 – 49 years.

Methods: To address the research objectives, two approaches were taken: (1) A systematic review (study 1) of quantitative studies on evidence relating to the knowledge, attitudes, and barriers of healthcare professionals in West Africa toward HPV vaccination and cervical cancer screening, using a narrative synthesis. (2) empirical analyses (studies 2-4) was used to examine the risk burden of cervical cancer, awareness and participation of cervical cancer and screening and its determinants among women aged 15-49 years across eight West African countries. The study (studies 2-4) analysed a secondary data (N = 128,173), using the Demographic and Health Surveys (DHS) which included Benin, Cameroon, The Gambia, Guinea, Liberia, Mali, Nigeria, and Sierra Leone. Statistical analyses were conducted in R statistical software using Poisson and logistic regression. Total number of risk factors of common risk factors for cervical cancer were analysed and factors associated with increased or decreased total number of risks were discussed. Also, demographic and media factors associated with awareness and participation in cervical cancer and screening were established.

Results: In study 1, twenty-five (25) studies were identified from the systematic review, and they varied based on country of study, outcome of interest, and population of study. Only studies from five West African countries were represented in the analysis with most considering nurses or midwives than doctors. Awareness varied across the countries, willingness to recommend HPV vaccine and cervical screening were high among HCPs, but recommendation of HPV vaccine or cervical cancer screening were low. Participation in pap smear was low among HCPs. Barriers of HPV vaccination as reported by the HCPs included limited information, poor knowledge or awareness of the vaccine and doubt about the efficacy of the vaccine. Psychological barriers were commonly reported by the HCPs as reasons for not participating in cervical screening. This included fear or scared of the result, stigmatization, and beliefs (religious, cultural), among other reasons. Cost was a system barrier for both HPV vaccination and cervical screening while availability of the vaccine was also a system barrier for HPV vaccination. The media was the major source of information of HCPs about HPV vaccination and cervical screening.

Study 2 showed that the risk factors for cervical cancer with the highest prevalence across the eight West African countries included: age of first sexual intercourse (≤ 17 years), age of first birth (≤ 19 years), and parity greater than two children. Liberia had the highest prevalence of early age of first sexual intercourse ≤ 17 years (84.1%) and early age of first birth ≤ (67.2%) while Mali had the highest prevalence of parity greater than two children (54.1%). Women in the older age group in Nigeria, Benin, Cameroon, and Sierra Leone had an increased number of risk factors from 30 years, but in the other countries there were no clear pattern. Liberian women aged 30-34 years had the highest number of risk factors (adjusted incidence risk ratio aIRR: 1.30; 95% CI: 1.18-1.42) among all the countries and age groups. Increased educational level was associated with lower number of risk factors compared to women with no education. The risk was lowest in women with higher education in The Gambia (aIRR: 0.59; 95% CI: 0.51-0.69) and Nigeria (aIRR: 0.59; 95% CI: 0.56-0.63).

Study 3 found awareness of cervical cancer was very low in Benin (9.5%) compared to women in Cameroon (46.1%). Women aged 45+ were two and three times more aware of cervical cancer in Benin and Cameroon respectively. Awareness of cervical cancer was six times more in Benin and about nine times more in Cameroon among women with higher education, compared to women with no education. The odds of cervical screening awareness varied with age. Women aged 25-34 years in Benin and 45+ in Cameroon had almost twice the odds of cervical screening awareness. In women with higher education in Benin the odds of cervical screening awareness were four times and in Cameroon almost three times compared to women with no education. Study 4 found that the prevalence of cervical screening participation was extremely low (&lt;5%) in Benin and Cameroon. In Benin, the odds of women who were aware of cervical cancer and participating in cervical screening was six times higher, while women aware of both cervical cancer and screening had odds ratio of 39 times, compared to women not aware of cervical cancer or screening. In Cameroon, the odds were about 15 times in women aware of cervical cancer and screening. Also, in Cameroon older age, and having health insurance and reading the newspaper or magazine and using the internet were associated with increased odds of cervical screening participation while living in a rural area had a reduced odd.

Conclusions: The findings from this research observe that recommendations from HCPs are important in the implementation of HPV vaccination and cervical screening program in West Africa. Early age of first sexual intercourse (≤ 17 years), early age of first birth (≤ 19 years), and parity greater than two children are some of the risk factors for cervical cancer that might be of more importance than others in West Africa. In contrast to the high knowledge of cervical cancer and screening among HCPs, awareness was low among women. Lastly, while screening participation was low among HCPs, it was much lower among the women population in the study.