Knowledge, attitude and practice of cervical cancer prevention, among women residing
in an urban slum in Lagos, South West, Nigeria
Tope Olubodun1,&, Oluwakemi Ololade Odukoya2, Mobolanle Rasheedat Balogun2
1Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria, 2Department
of Community Health and Primary Care, College of Medicine of the University of
Lagos, Idi-Araba, Lagos, Nigeria
Tope Olubodun, Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria
cervical cancer is the most common genital tract malignancy among women in Nigeria. Cancer of the cervix is preceded by a curable premalignant stage which can be detected by screening. The disease can also be prevented by Human papillomavirus (HPV) immunization. Women living in slums usually have poor reproductive health knowledge and poor health behaviours. Mostly of low socioeconomic status, these women are at higher risk of cervical cancer. This study assessed the knowledge, attitude and preventive practices towards cervical cancer among women living in an urban slum in Lagos, Nigeria.
this descriptive cross-sectional study was carried out among 305 women of
reproductive age in Idi-Araba, Lagos, Nigeria. Multistage sampling method
was used to select respondents. Data was collected using interviewer administered
questionnaires. Analysis was done with SPSS 20 software.
only 39 (12.8%) had heard about cervical cancer. Knowledge of cervical cancer, screening and Human papilloma virus (HPV) immunization was poor. Most respondents (64.3%) did not consider themselves at risk for cervical cancer. However, majority (88.9%) were willing to undergo screening and 93.8% were willing to take HPV immunization or recommend the vaccine to a friend/relative. Only 2(0.7%) had done a cervical cancer screening test and none had taken HPV vaccine or immunized their eligible daughters.
there is thus the need for increased awareness creation and health education
programs on cervical cancer prevention among such population of women.
Cervical cancer is one of the most common cancers in the women 
and 80% of cases occur in the developing world. It is the leading
cause of mortality from cancers among women living in developing
In 2012, new cases of cervical cancer were estimated at 528,000 globally
and deaths estimated at 266,000 . In sub-Saharan Africa,
34.8 new cases of cervical cancer are diagnosed per 100,000 women
annually and 22.5 per 100,000 women die from the disease. In comparison,
in North America
the figures are much lower: 6.6 per 100,000 women new cases and
2.5 per 100,000 women deaths . According to the Cervical
Cancer Global Crisis Card, Nigeria ranks 5th among countries with
regards to death count from cervical cancer, after India, China,
Brazil and Bangladesh
. Figures from the Ibadan Population Based Cancer Registry
(IBCR) covering a 2 year period 2009-2010 show that cervical cancer
age standardized mortality rate (ASR) was 36.0 per 100,000 
which is higher than in most developed countries. Cervical cancer
can have very high
human, social and economic costs. It has devastating effects and
commonly affects women in their prime . Fortunately,
there are measures that offer prevention for this cancer that devastates
include screening approaches and vaccines that are efficacious in
preventing the infections and precancerous changes that can lead
to cervical cancer .
Cervical cancer screening tests for precancerous lesions and cancer
in women at risk, most of whom have no symptoms . This
includes the conventional Papanicolau (Pap) test, liquid based cytology,
with acetic acid or lugols iodine (VIA or VILI) and Human papiloma
virus (HPV) testing for high risk HPV types . Three
types of vaccines against HPV infection are currently available on
the market - gardasil, gardasil
9 and cervarix. They protect against high risk HPV types .
Women living in urban slums are mostly of low socioeconomic status
and this has been shown to be associated with a higher risk of cervical
health knowledge and poor access to health services .
This study was thus carried out to determine knowledge, attitude
and practice of cervical cancer prevention among women living in
Idi-Araba, a slum in Lagos
Idi-Araba is one of the political wards in Mushin Local government area of Lagos, Nigeria. It is a densely populated slum with residential houses and shops, many of which are substandard and overcrowded. The area is known as a settlement for the Hausa people although the commonest tribe is the Yoruba tribe. There is a tertiary government hospital located in Idi-Araba, which offers cervical cancer screening services and HPV immunization. The approximate population of Idi-Araba is 48,944 and the predominant occupation is trading.
The study was a descriptive cross-sectional study carried out among women living in Idi-Araba community. Eligibility criteria was women of reproductive age (15 - 49 years) who had resided in the community for at least 2 years prior to the study.
The sample size of 305 was determined using the Cochran formula for descriptive studies. A multistage sampling method was used to select respondents. The first stage involved selection of twenty streets out of the total number of streets (fifty streets) using simple random sampling. The second stage involved use of systematic sampling to select houses on each of these twenty streets until the desired number of houses was met. Where there was more than one eligible female in a house, the respondent was selected by balloting. Data was collected using pretested, interviewer administered questionnaires. The questionnaires were administered by three trained female research assistants with a minimum of post-secondary school qualification. Data analysis was done with SPSS 20 software. Frequency tables were made for categorical variables.
Approval was obtained from the ethics and research committee of the Lagos University Teaching Hospital prior to commencement of the study.
Three hundred and five women were interviewed. The mean age was 33.5± 9.0 years. Most of the respondents were married (73.1%). Of those married, 29.6% were in a polygamous relationship. Majority of the respondents were of the Yoruba tribe (54.4%). A higher proportion of respondents had attained secondary education as their highest level of education (54.1%). Only 8.5% had attained tertiary education. Majority of the respondents were semi-skilled (70.8%) and most of the respondents were of the Islamic religion (Table 1).
Knowledge of cervical cancer
Most of the respondents (98.7%) had heard about cancer but only 39 (12.8%) had heard of cervical cancer. About 90% did not know any risk factors of cervical cancer. Some of the risk factors mentioned by respondents were early age at first sex (3.6%), multiple sexual partners (2.0%), infection with HPV (2.0%) and use of tobacco (0.7%). Some of the symptoms of cervical cancer mentioned by respondents include: foul smelling vaginal discharge (5.6%), heavy vaginal bleeding (1.7%) and vaginal bleeding after intercourse (0.7%). Majority of respondents did not know of the symptoms of cervical cancer (90.8%), cervical cancer screening (92.1%) and HPV immunization (98.4%). Most of the respondents’ knowledge of cervical cancer came from the media and the hospital (Table 2
Respondents’ attitude towards cervical cancer
Majority (64.3%) considered themselves not susceptible to cervical cancer and the commonest reason was believe in spiritual protection (60.7%). However, most respondents (88.9%) were willing to undergo cervical cancer screening when asked but about seventy percent would require the consent of their spouses. Majority (93.8%) were also willing to be immunized or recommend HPV immunization to a friend or relative. Reasons given for not wanting to be immunized were: the vaccine may cause sexually transmitted infections, could have adverse health effects and could encourage promiscuity among young people (Table 3
Cervical cancer prevention among respondents
Only 2(0.7%) of the women that took part in the study had done a cervical cancer
screening test at some time. One did a pap smear in a tertiary institution and
the other, visual inspection with acetic acid (VIA) at an outreach. Reasons given
for undertaking screening were: health worker request and test was subsidized.
Some reasons given for not undertaking screening include: not being aware of
screening (91.4%), lack of symptoms (15.9%), not requested by health worker (2.6%).
None of the respondents had taken HPV immunization and none who had female children
of 9 years or older, had immunized them (Table 4
This study reported low awareness of cervical cancer. Only 12.8%
had heard of cervical cancer. Those aware of cervical cancer screening
and HPV immunization comprised 7.9% and 1.6% respectively. Knowledge
issues, cervical cancer prevention inclusive, is commonly poor
among women of low resource, which may explain the level of knowledge
reported in this
study. A study carried out among women in two urban slums: Makoko
waterside and Abete in Lagos, found that only 4.2% were aware of cervical
cancer . Similarly, another study among women residing
at the urban slums of Old Hubli Karnataka, India, showed that only
about 7.5% of the respondents had heard about cervical cancer .
A study conducted in two urban slums of Mumbai India, reported
37.7 percent were aware of cervical cancer whereas only 3.6 percent of women
of pap smear test .
A much larger proportion had heard about cervical cancer in a study among mothers
in Shomolu local government area of Lagos State Nigeria [13
Respondents in the Shomolu study were more educated and that could explain the
wide disparity in awareness of cervical cancer (79.6%) [13
as compared with this study (12.8%). Higher level of education is known to be
associated with better access to health information. A study in Owerri, capital
of Imo state, south west of Nigeria, also reported higher awareness of cervical
cancer screening of 52.8% [14
]. About three – quarter of
the respondents (74.5%) in the Owerri study, had attained tertiary education
as compared with 8.5%, less than a-tenth, in this study.
A community based study in Bugiri and Mayuge districts, eastern Uganda, reported that 88.2% of the respondents were aware of cervical cancer, the majority having received information from radio (70.2%) and from health facilities (15.1%) [15
]. Living in peri-urban areas, urban areas, having a higher monthly income were associated with better knowledge about cervical cancer prevention [15
Belief in personal susceptibility was low in this study. Only 17.7% considered themselves susceptible to cervical cancer. A similar finding was observed in a hospital based study in Abakaliki, where only 11.1% felt they were at risk for cervical cancer [16
]. The commonest reason given for not being susceptible to cervical cancer in this study was believe in spiritual protection (60.7%). Though most women considered themselves not susceptible to cervical cancer, majority (88.9%) were willing to undergo cervical screening and 93.8% were willing to take HPV immunization or recommend the vaccine to a friend or relative. However, majority said they will require the consent of their spouse to be screened. A finding similar to a study in Ile-Ife where 72.1% were willing to be screened but 66.8% required their partners consent [17
Although uptake of screening is reported to be low in Nigeria, studies from rural
areas and slums have reported lower uptake of cervical cancer screening. Only
two (0.7%) respondents in this study had done a cervical cancer screening test
at some time. Among women interviewed in two slums, in Lagos, also none had been
screened or was aware of a screening test for cervical cancer [10
In a study at rural Okada a community in Edo state, Southern Nigeria, none had
been screened for cervical cancer [18
]. A low uptake of
cervical cancer screening was however, also observed in a study in Olusosun,
a commercial and residential area of Lagos where only 5% of the female respondents
had undertaken a pap smear [19
]. Similarly, in a study in
Onitsha, a metropolitan city in Anambra, Southeast Nigeria, only 1.8% of respondents
had done a cervical screening test [20
A survey in Britain reported 91% of women have had a cervical cancer screening test at least once [21
]. Uptake of cervical cancer screening varies globally, being higher in developed countries compared with less developed. Studies carried out in some other developing countries also showed low uptake of cervical cancer screening. In a Kenyan study, uptake was 6% [22
] and 0.8% in a community based study in Elmina, Ghana [23
None of the respondents had taken HPV immunization and none with daughters eligible for HPV vaccination, had immunized their daughters. In contrast, in a study among female health care workers in Enugu, about half of the respondents with adolescent daughters had immunized their daughters [24
]. This may be as a result of better knowledge of the vaccine as well as access to the services.
The women in this study had poor knowledge of cervical cancer and majority felt not susceptible to the disease. Uptake of cervical cancer screening and HPV immunization was low. Most however, expressed willingness to undergo screening and be immunized. There is thus, need for increased cervical cancer awareness and promotion campaigns. Women’s partners should also be targeted for health education. Improving access to cervical cancer prevention services is also crucial among this underserved population.
What is known about this topic
- Cervical cancer is one of the most common cancers in women;
- It is a leading cause of mortality from cancers among women living in developing countries.
What this study adds
- Low awareness of cervical cancer was reported among the slum dwelling women in this study;
- Belief in personal susceptibility was low but most participants were willing to be screened or vaccinated. However, the majority will require the consent of their spouses;
- This highlights the need for health education campaigns on cervical cancer prevention with involvement of males, as well as increasing access to cervical cancer preventive services among low resource women.
The authors declare no competing interests.
All authors have contributed to this work. All the authors have read and agreed to the final manuscript.
Table 1: sociodemographic characteristics of respondents
Table 2: respondents’ knowledge of cervical cancer
Table 3: respondents’ attitude towards cervical cancer
Table 4: practice of cervical cancer prevention
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