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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 41-46

Perception of cervical cancer and its cytological screening among medical students


1 Department of Histopathology, National Hospital, Abuja, Nigeria
2 Department of Morbid Anatomy and Forensic Medicine, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
3 Department of Human Anatomy, Bayero University, Kano, Nigeria
4 Department of Obstetrics and Gynecology, National Hospital, Abuja, Nigeria

Date of Submission20-May-2018
Date of Decision27-Jun-2018
Date of Acceptance01-Sep-2018
Date of Web Publication18-Mar-2020

Correspondence Address:
Dr. Said Mohammed Amin
Department of Histopathology, National Hospital, Abuja
Nigeria
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DOI: 10.4103/smj.smj_26_18

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  Abstract 


Introduction: In Nigeria, cancer of the cervix is known to be the second commonest malignancy among females. In developed countries, there has been a paradigm shift attributed to effective cervical cancer screening predominantly using the Papanicolaou (Pap) smear. This screening tool is highly sensitive and specific; having a commendable positive predictive value as well as relatively cheap and effective means of screening cervical cancer for early detection. Objectives: The aim of this study is to assess the perception of Pap smear among medical students in College of Health Sciences, Usmanu Danfodiyo University, Sokoto (CHS-UDUS) in order to be able to recommend ways for improving acceptability, usage, and dissemination of information of the screening tool (Pap smear). Materials and Methods: The study utilized a cross-sectional study design. Preclinical students of CHS-UDUS were selected using random sampling technique. Pretested semi-structured, self-administered questionnaires were administered on the students. Quantitative variables were analyzed and presented using measures of central tendency [mean and median] and measures of dispersion (standard deviation), while Chi-square test was used in bivariate analyses, to determine the statistical association between the categorical groups, with a P < 0.05 considered as statistically significant. Results: Preclinical medical students in UDUS were found to have high awareness of cervical cancer-screening (82%) which made them positively disposed toward the screening tool. Most of them (75.6%) believe that Pap smear is effective in detecting cervical cancer. Majority of respondents obtained their information from routine lectures (81%) as against mass media (7%) and other extraneous source. However 42.8% were unaware of Pap smear screening services availability in their institution. Conclusion: The level of awareness about cervical cancer screening is high among the study population. Future studies should concentrate on utilization of this service in later life of young students.

Keywords: Cervical cancer screening, medical students, perception


How to cite this article:
Amin SM, Abdullahi K, Muhammad M, Mohammed LI, Mahmoud RA, Muhammad RB. Perception of cervical cancer and its cytological screening among medical students. Sahel Med J 2020;23:41-6

How to cite this URL:
Amin SM, Abdullahi K, Muhammad M, Mohammed LI, Mahmoud RA, Muhammad RB. Perception of cervical cancer and its cytological screening among medical students. Sahel Med J [serial online] 2020 [cited 2020 Jul 4];23:41-6. Available from: http://www.smjonline.org/text.asp?2020/23/1/41/280940




  Introduction Top


Cervical cancer is known to be second only to breast cancer as the commonest malignant neoplasm among females in Nigeria.[1],[2],[3] This trend contrasts sharply with the observed trend in developed countries where cervical malignancy has been drastically reduced to the barest minimum.[4],[5] The paradigm shift observed in developed countries has been attributed to effective cervical screening using predominantly, the Papanicolaou (Pap) cervical smear.[6],[7],[8]

The Pap cervical cytology smear is a relatively cheap, effective cervical cancer screening program for the detection of carcinoma of the uterine cervix at the precursor stage. It consists of taking a sample from the transformation zone of the cervix, smearing on a glass slide and reviewing for atypical cells after staining. The role of Pap cervical screening in reducing cervical cancer incidence and mortality has been attested to by numerous studies.[9] Three distinct periods of testing (annual, biennial, and triennial) are recommended for routine  Pap smear More Details depending on confounding varying factors including the age of the woman and her risk factor profile.[10]

The Pap smear is acknowledged to have commendable sensitivity and specificity as well as positive predictive value[11] and is adjudged to compare favorably with most of the other screening methods such as visual inspection with acetic acid (VIA),[12] cervicogram,[13] colposcopy,[14] and human papillomavirus (HPV) screening.[15] Most studies now advocate for combination of the methods for effective screening.[16],[17]

Various factors have been implicated in the causation and/or exacerbation of cervical cancer. These risk factors include human papilloma virus infection, use of intrauterine contraceptive devices, smoking, early sexual debut, high parity, multiple sexual partners, human immunodeficiency virus type 2 co-infection and immunosuppressants.

There is no national screening program for cervical cancer in Nigeria and detection of cervical intraepithelial lesions by Pap smear screening has remained virtually the only surrogate end point for the detection and eradication of cervical cancer. However in developing countries, even those with national cancer screening programmes like Cameroun, the result has not shown optimal success due to erroneous perception and limited knowledge of the screening in the population.[18] Uptake of cervical cancer screening in developing countries are believed to average about 5.3% in most studies[19] as compared to 75% in developed countries.[20] Indeed uptake in Sokoto is reported to be an abysmal 1.29% annually.[21]

There is no gainsaying the fact that perception of women in developing countries about Pap smear is still infantile and serves as a hindrance to the effectiveness of this screening test in these countries.[22] Different workers have investigated perception of cervical cancer screening among various categories of people. Groups assessed include market women,[23] university students,[24] secondary school teachers,[25] gynecology clinics' patients,[26] female primary school teachers[27] nurses,[28] and other female health workers[29] among others. Interestingly, even among health workers, especially in developing countries, the perception of Pap smear screening is deemed less than desirable.[30],[31] The College of Health Sciences (CHS) is a faculty of Usmanu Danfodiyo University (UDUS) graduating average of 70 medical doctors annually. It is located in the heart of Sokoto, an ancient city in the Sahelian northern part of Nigeria with a population of about 2.5 million people. The University has an average of 24,000 students with about 1.8% (n = 432) been preclinical medical students. The preclinical students are composed of about 260 students in laboratory medicine and the rest in basic medical subjects.

This study aims at assessing the perception of cervical cancer and Pap smear screening method among undergraduate preclinical medical students in laboratory medicine in CHS-UDUS. To our knowledge no such study has been carried out in this center in the past.

Specific objectives

  • To assess the study respondents' perception of Pap smear
  • To recommend ways for improving the perception or acceptability of Pap smear.



  Materials and Method Top


Study type

This is a descriptive, cross-sectional study.

Sample size determination

The study population is composed of all preclinical students of CHS-UDUS in laboratory medicine (Histopathology, Microbiology, Chemical Pathology, and Hematology) posting. These number about 260 students.

Inclusion criteria

All third and fourth year (preclinical) medical students of College of Health Sciences UDUS in 2018 are eligible.

Exclusion criteria

Inadequately filled questionnaire was excluded from the study.

Research modality

The structured, self-administered, 30-item, questionnaire sought to assess the knowledge of and attitude to Pap smear screening as well as perception of barriers to uptake of cervical cancer screening. The questionnaire was pretested in a smaller group of medical students in the school who were excluded from the study.

Data Analysis

A simple study questionnaire was self-administered to consenting participants. Data analysis was done analysis using simple statistical methods including SPSS. Categorical variables are presented as percentages while continuous variables are presented as means ± standard deviation.

Ethical Consideration

Ethical clearance was obtained from Research and Ethics committee of Ahmadu Bello University Teaching Hospital on 11th April 2015 (Protocol no: ABUTHZ/HREC/S2/2015. NHREC/10/12/2015). We complied with relevant guidelines of 2013 Helsinki's declaration.


  Results Top


Total number of questionnaires administered numbered 180 out of which 162 satisfied the criteria for the study giving a response rate of 91%. The students' ages ranged from 20 to 49 years with a mean of 24.1 and standard deviation of 3.0. The gender ratio is 2.8:1 in favor of males. Five percent of the respondents are married as depicted in [Table 1].
Table 1: Sociodemographics of respondents

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Nearly 96% of the students have heard of cervical cancer (n = 156) and 75% (n = 122) of these from routine lectures [Table 2] and [Table 3]. Furthermore 82% (n = 133) of the participants have heard of Pap smear screening and an overwhelming majority (n = 131, 81%) were informed by a medical doctor [Table 3 and [Figure 1] as against mass media (7%) and Internet (4%). Most of the students (n = 129, 78.7%) knew Pap smear as a procedure for detecting cancer of the cervix whereas a few (n = 21, 12.8%) students are completely oblivious of its purpose. Additionally, majority of the students are familiar with symptoms of cervical cancer such as irregular menstruation (n = 132, 81%), postcoital bleeding (n = 120, 74%), and dyspareunia (n = 88, 54%).
Table 2: Respondents' awareness of cervical cancer and pap smear

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Table 3: Source of knowledge of cervical cancer among respondents

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Figure 1: Sources of information about Papanicolaou smear for participants. NGO: Nongovernmental organization

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A large proportion of the students (n = 37, 22.6%) are ignorant of the age at which Pap smear should commence. Analysis showed that 19.5% of the study respondents (n = 32) erroneously believe it should commence at 15–20 years age. A large percentage (n = 75, 46.3%) of the students have no idea of the frequency of Pap smear. This is shown in [Table 4]. However a noteworthy number of the study participants (n = 67, 41%) correctly indicated Pap smear screening should commence at 21 years of age. This is indicated in [Table 5].
Table 4: The knowledge of frequency of screening

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Table 5: Respondents' perceptions on age of commencement of pap smear test

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About 46.3% (n = 76) of the students are uninformed about the frequency of screening though 26.8% (n = 44) indicated it should be at least once every 3 years.

Regarding the predominant age of manifestation of cervical cancer, 4% (n = 7) of the students believe cervical cancer can manifest below 20 years age, while 15% (n = 24) have no idea about the age at risk. 36% (n = 59) indicate 20–40 years as the at-risk group, while 44% (n = 72) however indicated women above 40 years as the commonly affected age.

About 7% (n = 11) of the respondents consider Pap smear as unimportant for women of reproductive age. Conversely majority of the students (n = 118, 72%) acknowledge Pap smear is an important investigation for all women above 40 years age.

Up to 76.6% (n = 124) of the students believe Pap smear is capable of detecting cancer cells before symptoms appear whilst 49% (n = 76) consider cervical cancer curable.

Majority of the students recognize HPV infection (84%), positive family history (83%), smoking (77%), and multiple sexual partners (71%) as risk factors for cervical cancer. However, only about 25% agree that having more than 5 children is a risk factor [Table 6].
Table 6: Knowledge of risk factors for cervical cancer among participants

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Knowledge of other cervical cancer screening tests consisted mostly of HPV screening (65%) colposcopy (27%) and least of all, VIA (8%) as depicted in [Figure 2].
Figure 2: Chart showing knowledge of cervical cancer screening methods among undergraduate medical students in UDUS. HPV: Human papillomavirus; VIA: Visual inspection with acetic acid

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Interestingly a significant number (n = 70, 42.8%) of the students are unaware there is cervical screening service in their center (UDUTH).

Overall, no statistically significant difference was detected between gender, age group, marital status, stage of medical education, and knowledge of cervical cancer and pap smear (P > 0.05). However, there is an association between the ethnicity of the participating students and knowledge of Pap smear test (P = 0.02).


  Discussion Top


Awareness of cervical cancer and Pap smear screening tests among medical students in our study is above average which tallies with similar studies – among secondary school teachers in Nnewi,[26] health workers in Sokoto,[31] female health professionals in Umuahia,[32] and female students in Botswana.[33] Paradoxically, however, this high level of awareness did not translate to higher uptake in most studies. Indeed, Adanu[34] in Ghana reported from a study that, of 93% of women aware of Pap smear only 37% have adequate knowledge, and of the latter only 8.5% go for screening. On the other hand, this high level of awareness contrasts sharply with findings from South Africa among undergraduate students,[35] in Tanzania among nurses[36] metropolitan women in Makurdi,[37] women in Ogun state[38] and urban women in Anambra[28] where the awareness is quite low. The contribution of low awareness in all these cities and centers to the resulting low uptake may not be controverted.

A 3-year study of Pap smears in a tertiary hospital in Sokoto[22] reported 20% abnormal smears among randomly screened women – an incidence higher than obtained in most other centers in Nigeria and beyond. It is highly suggestive that the higher number of abnormal smears may be a consequence of poor uptake of screening programs.

The main source of information about cervical cancer and Pap screening, in our study, is the medical doctor and/or routine classroom lectures. This is in contrast with findings from similar studies in Lagos,[39] where the predominant source of information was the electronic media. It is pertinent to note that the internet, mass media and nongovernmental organization programs which seem to play salutary roles in improving knowledge of Pap smear tests and cervical cancer in other spheres do not impact significantly on knowledge among our study group. This is an area that should be explored.

The controversy about the frequency of Pap smear screening is raging on in various societies and is subtly expressed in our studies by the distribution of opinion along the three primary recommended periods – annual (n = 24, 15%), biennial (n = 8, 5%), and triennial (n = 43, 27%). Moreover, a significant proportion of the participants (n = 76, 47%) admit complete ignorance of the recommended frequency of screening. Studies from other centers produced similar findings. Indeed, a report from the US[10] involving 11,739 women reported the following; 55% – annual, 17% – biannual, and 16% – triennial screening frequency amongst respondents. Mitigating factors such as risk profile, age of the woman, and outcome of last screening are important considerations in determining the frequency of screening. It is noteworthy that most authorizing bodies are now recommending lesser frequency in their guidelines. A systematic review and meta-analytic survey[9] opined that there is no conclusive evidence to determine optimal age for initiating or terminating screening and no definitive frequency of screening.

One crucial consideration that features prominently in all cervical cancer discussions is the risk factors and their assessment. Awareness and perception of risk factors immensely affect uptake and frequency of screening in most studies. Knowledge of the risk factors among participants in our study is considered average-similar to other studies involving health workers.

A significant number of students (n = 97, 60%) recognize HPV screening as an alternative method for cervical screening but only a few knew other methods such as colposcopy (n = 40, 25%) and VIA (n = 13, 8%). The need to improve on this knowledge base is quite essential. The practice of cervical cancer screening among students aged 40 and above was not investigated. This is a limitation of this study.


  Conclusion Top


Preclinical medical students in UDUS have high awareness of cervical cancer screening but sub optimal knowledge of risk factors.

Source of information on cervical cancer and screening methods among medical students is mainly their routine lectures. Considering that medical undergraduate students are potential priority groups for dissemination of information on cervical cancer screening in the society, appropriate and adequate training might impact positively on uptake of screening tests. A focused lecture curriculum on cancer screening might help fill the knowledge gap for these students.

Acknowledgment

Our special appreciation to the Department of Morbid Anatomy and Forensic Medicine, UDUS, especially to Alhaji Bello Kaura for his untiring support in administration of the questionnaire.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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