Knowledge and attitudinal study of Kenyan women in relation to cervical carcinoma

Znt. J. Gynecol. Obstet., 1990,34: 55-59 International Federation of Gynecology and Obstetrics

55

Knowledge and attitudinal study of Kenyan women in relation to cervical carcinoma J.M.N.

Machoki” and K.O. Rogob

“Deoarttnent of Obstetrics and Gynaecolom College of Health Sciences, University of Nairobi (Kenya) and bDepartment of Gynecologic Omology, University Hospital, Umeam(Sieden) (Received August 17th, 1989) (Accepted October 18th, 1989)

Abstract

Knowledge and attitude in relation to cervical carcinoma was studied in 8.5 cervical cancer patients and 177 matched controls. The mean age of the cases was 44.2 years and mean parity 6.5. The majority were illiterate. Statistically significant differences were seen in both mean age at marriage and at first coitus, being lower for cases than controls (P < 0.001). Basic knowledge of abnormalities of vaginal bleeding or discharge was characteristically poor in both groups. Over 90% had never attended any routine gynecological check up and did not deem it necessary. The few on regular check up were FP clinic attenders. Pap smear was totally unknown to most cases and controls. Against this background the vital role of public education in the control of cervical carcinoma is emphasized. Keywords:

Cervical carcinoma; Kenyan women.

Knowledge;

Introduction

Cervical carcinoma is now the leading female malignancy in developing countries [l]. Despite pausity of accurate data this tumor is estimated to account for up to 80% of all gynecological cancer admissions in sev0020-7292/90/$03.50 0 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland

eral African countries [2,3]. In Nairobi cervical carcinoma accounted for 71.5% of all gynecologic cancer admissions in 1974- 198 1 [4]. The picture is, however, rather different in developed countries where cervical cancer ranks fourth behind breast, ovary and corpus uteri malignancies [5]. A popular explanation for this difference has been the success of screening programs in industralized countries that had led to a progressive decline in the incidence of invasive disease and preponderence of pre-invasive or early invasive lesions 161. While the effectiveness of well-organized cytologic screening programs in reducing cervical cancer mortality is now well confirmed, controversy still continues on its viability and value in less developed countries. Although such efforts in developing countries have been few and mostly short-term, there is accumulating evidence that mounting successful screening programs may not be possible within existing socioeconomic frameworks [7]. To date, despite several promising pilot projects, no single developing country has been able to design a national screening program that could work despite social, administrative and infrastructural impediments. According to WHO, cervical cancer control is possible through primary prevention by promotion of genital hygiene, or by secondary prevention - through cytological Clinical and Clinical Research

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Machoki and Rogo

screening [8]. In both instances the cooperation of the client/patient cannot be ignored. Indeed, in most recent reports public education has been underlined as an important factor to be kept in mind when planning any screening services. The aim of this study was to determine the level of awareness of Kenyan women of cervical carcinoma as part of an ongoing effort to establish a national cytologic screening program.

12 --

a --

20-24

25-29

30-34

35-39

Materials and methods Fig. 1.

The study was carried out at Kenyatta National Hospital, Nairobi. Study subjects were 85 consecutive patients newly referred to the Radiotherapy Unit or the Gynecologic Oncology Ward with histologically confirmed invasive cervical carcinoma, over a 6-month period. There were all interviewed before admission into the wards. Non-Kenyan patients were excluded. For every case, two matched controls were selected from nongynecologic wards (general surgical, ophthalmology, medical and ENT). Selection was done by picking every second patient in every cubicle in the wards, moving in a clockwise fashion. Only if age, parity and level of education matched was the control further interviewed and examined to rule out cervical malignancy. Recruitment was done only after malignancy was ruled out. All the interviews were conducted by one person (JNM) through a pretested questionnaire. The data was entered into a computer for ease of analysis.

40-44 Age hard

45-49

SO-54

55-59

Age distribution of cases.

figures for the control group were 67.4% and 9.3%. Most cases were either married or divorced. Clinical stage and histopathologic types are shown in Fig. 3 and Table I, respectively. Only 15.3% had stage I disease. Presenting symptoms are shown in Table II. Abnormal vaginal discharge or bleeding were the commonest complaints and one patient presented with hemoptysis. Lung metastasis was confirmed radiologically. Most symptoms had lasted less than 1 year and the mean duration was 8.2 months (Table III). Both the age at marriage and at first coitus were lower in cases compared to controls (Tables IV and V). The differences were statistically significant (P< 0.001). Tables VI and VII show both case and control responses to the various questions asked. Knowledge and extremely poor in both groups. This was particularly interesting in

Results The mean age of cervical cancer patients was 44.2 years and the mode 45 years (Fig. 1). The mean age and mode for the control group was 44.4 and 45 years, respectively. Most cancer patients had high parity, only 9.4% being para 2 or less. The mean parity was 6.5 for cancer patients and 6.6 for the control group (Fig. 2); 67.1% of the cases had received no formal education and only 9.4% had post-primary education. The respective Int J Gynecol Obstet 34

LO-64

5-6

7-8 PARITY

Fig. 2.

Parity distribution of cases.

9-10

II-12

Kenyon women and cervical carcinoma Table II.

10

0

I

II

III

57

Distribution of symptomatology.

Symptom

Frequency

Percemtage

Abnormal vaginal bleeding Vaginal discharge Pain Postcoital bleeding Effort bleeding Hemoptysis Chest pain Lower abdominal swelling

67

78.8

41 39 29 7 1 1 1

48.2 45.9 34.1 8.2 1.2 1.2 1.2

IV

STAGE

Fig. 3.

Distribution of clinical stages (FIGO).

the case of cervical cancer patients who had by the time of the study been seen by several doctors before eventual referral for definitive treatment in this unit. It would appear that their prolonged contact with medical personnel had not appreciable ‘improved their knowledge of the disease and related symptomatology. Interesting causes for various abnormalities given by respondents included: ?? irregular vaginal bleeding - curse by mother or co-wives, eating of eggs and husband crossing over the wife in bed; ?? postcoital bleeding - eating of eggs and breast feeding; ?? vaginal discharge excessive sexual intercourse, husband crossing over wife in bed;

Table III.

Duration of symptoms.

Duration (months)

Cases (n = 85) Numbers

Percentage

6-10 11-15 16-20 21-25 26-30 31-35 36-40

13 (l-2 months) 9 (3-5 months) 27 10 7 11 6 1 1

25.8 31.7 11.7 8.4 12.9 7.1 1.2 1.2

Totals

85

100

l-5

Table 1. Histological classification. Histology Moderately differentiated squamous cells Poorly differentiated squamous cells Well differentiated squamous cells Adenocarcinoma Total

Percent 9.4

Table IV.

Age of marriage for cases and controls. The controls are on average 1.1 years older at marriage than cases (t = 3.323, P< 0.001).

64.7 18.8 7.1 100

No. of patients Range (age in years) Mean Standard deviation (A S.D.)

Cases

Controls

83 13-24 18.35 2.49

161 15-26 19.45 2.42

Clinical and Clinical Research

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Machoki and Rogo

Most felt that checkups were unecessary unless one was overtly ill. The few on regular checkups were family planning clinic attenders.

Table V.

Age at first coitus for cases and controls. The cases are on average 1.4 years younger at first intercourse as compared to controls (r = 6.203, P< 0.001).

No. of patients Range (age in years) Mean (age in years) Standard deviation (* S.D.)

Cases

Controls

83 13-20 16.29 1.65

170 13-20 17.68 1.69

Discussion Patient and disease characteristics with regard to age, parity and stage distribution found in this study are similar to previous reports [9]. It is generally agreed that cervical cancer is a disease of the lower socioeconomic groups and illiteracy and poor genital hygiene have been mentioned as related cofactors [8]. The finding of significantly lower age at marriage and first coitus in cases fits in with the present knowledge of the etiology of this disease [8]. In a Nigerian study, Emembolu and Ekwempu [lo] reported early age at marriage

postmenopausal bleeding - coitus with age mates of one’s children or relatives, co-wife’s curse or husband having sex with daughter. More than 90% of both cases and controls were not on regular gynecological checkup and did not know what a Pap smear was. ??

Table VI.

Responses to questions on vaginal bleeding and discharge,

Question

Cases

1. Frequency of menses per month?

2. 3. 4. 5.

Is irregular vaginal bleeding normal? Is post-coital bleeding normal? Is vaginal discharge normal? Do menses stop completely at a certain age? 6. Is post-menopausal bleeding normal?

Table VII.

Controls

Know

Don’t know

Know

Don’t know

88.2 91.8 89.4 83.5 88.2

11.8 8.2 10.6 16.5 11.8

92.4 91.2 94.1 84.1 92.9

7.6 8.8 5.9 15.9 7.1

85.9

14.1

89.4

10.6

Enquiry on causes of vaginal bleeding and discharge.

Question causes of

Group

Response (o/o) Don’t know

Know Infection

Cancer

Abortion

Injury

1.2 -

2.4 1.2 -

-

Irregular vaginal bleeding Post-coital

Cases Controls Cases

95.3 95.3 91.8

3.5 4.1 5.8

bleeding Vaginal discharge Post-menopausal bleeding

Controls Cases Controls Cases Controls

92.9 96.5 95.4 98.8 98.8

5.3 3.5 4.1 1.2

Int J Gynecol Obstet 34

1.2 1.2 -

-

1.2 2.8 -

Kenyon women and cervical carcinoma

and first coitus to be common among cervical cancer patients. They found the disease to be common in both low as well as high parity patients. Previous Kenyan studies have documented the condition mostly in women of high parity [9]. Symptom distribution in the study was also similar to previous African reports [ 111. Cervical carcinoma is a preventable and curable disease. While cytological screening has proved effective in several western countries, its successful implementation in developing countries has been hampared by: (a) competing health priorities; (b) shortage of trained cytologists/cytotechnicians; (c) poor backup facilities; (d) negative sociocultural practises and beliefs. As stated by Luthra et al. [7] the concept of health checkup, so much part of “western lifestyle” has not yet found a place in most sociocultural mileau in rural areas. The responses to some of the questions testify to the possible impeding roles of sociocultural beliefs. Most recent reports on cervical cancer control in developing countries have not failed to identify the key role of public education. This is an essential aspect of any health program and has particular importance in instances where individual participation is necessary even though there may be no obvious “illness” as is the case with periodic cervical cytology. Irrespective of how well organized the laboratories and other health service delivery systems are, unless women themselves are convinced of the need and value of Pap smear any attempts at control of cervical malignancy is likely to fail. It would appear that in Kenya, education must also be directed towards health personnel. The finding that cervical cancer patients still remained ignorant of the symptomatology of the disease even after they had been in reasonably long contact with health workers indicated an obvious lack of communication. As Kenya and indeed other developing coun-

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tries strive to design appropriate cancer prethe role of public vention programs, education and creation of community awareness needs special emphasis. Mass media, women’s groups, schools, church gatherings and other innovative forums should be fully utilized in a programmatic fashion to enhance community awareness and voluntary participation. References 1

Waterhouse I, Muir CS, Shamnugaratnan K, Power J @Is.), Cancer Incidence in Five Continents, Vol. IV. IARC Scientific Publications No. 42. International Agency for Research on Cancer, Lyon, 1982. 2 Mgaya HN, Massawe SN: The pattern of cervical cytology among gynaecology and family planning clinic attenders in Dar es Salaam. J. Obstet Gynecol E Centr Afr 3: 13, 1984. 3 Mmiiro EA: Gynaecologic Oncology in Africa. Guest lecture delivered at the 12th Annual Scientific Conference of the Kenya Obstetrical and Gynecological Society, Nairobi, February 1987. 4 Kaguta TK: A ten year review of carcinoma of the vulva seen at Kenyatta national Hospital, Nairobi. M Med Thesis, University of Nairobi, 1984. 5 Anderson MC: The pathology of cervical cancer. Clin. Obstet Gynecol 12: 87, 1985. 6 Kjellgren 0: Mass screening in Sweden for cancer of the uterine cervix. Effect on incidence and mortality. Gynecol Obstet Invest 22: 57, 1977. 7 Luthra UK, Rengachari R: Organisation of screening pregnancies in developing countries with reference to screening for cancer of the uterine cervix in India. In: Screening for Cancer of the Uterine Cervix (eds. M Hakama, AB Muller, NE Day) IARC Scientific Publications No. 76. International Agency for Research on Cancer, Lyon, 1986. 8 Control of Cancer of the Cervix. Bull WHO 64: 607, 1986. 9 Rogo KO, Omany J, Ojwang SBO, Onyango JN, Stendahl U: Carcinoma of the cervix in the African setting. Int J Gynecol Obstet 33: 249, 1990. 10 Emembolu JO, Ekwempu CC: Carcinoma of the cervix in Zaria; etiologic factors. Int J Gynecol Obstet 26: 265, 1988. 11 Ojwang SBO, Mati JKG: Carcinoma of the cervix in Kenya. East Afr Med J 55: 194, 1978. Address for reprints. K.O. Rogo Department of Gynecologic Oncology University Hospital S-901 85 Umea Sweden Clinical and Clinical Research