Assessing the uptake of cervical cancer screening among women aged 25-65 years in Kumbo West Health District, Cameroon

Introduction Cervical cancer remains one of the leading health hazards affecting a majority women across the globe. The situation is even more, preoccupying particularly in areas where screening programmes and services are absent. The World Health Organization (WHO) says “cervical cancer is the fourth most frequent cancer in women, with an estimated 570,000 new cases diagnosed in 2018 which represents 6.6% of all female cancers. Approximately 90% of deaths from cervical cancer occurred in low- and middle-income countries”. Despite the high mortality rate from cervical cancer globally, the trend could be reduced through a comprehensive approach that includes prevention, early diagnosis, effective screening and treatment programmes. In Cameroon, the prevalence of cervical cancer is 24% among women of reproductive age. An estimated 1,993 new cases are recorded annually in Cameroon with 1676 deaths. Despite this precarious situation, the uptake in cervical cancer screening service remains poor and stands at 19.6% in Cameroon. It is against this background that this paper evaluates the uptake of cervical cancer among women aged 25-65 years in the Kumbo West Health District (KWHD). Specifically, this study assesses the knowledge of women in this health district on cervical cancer and determines factors that affect the uptake of cervical cancer screening services. Methods This study is a cross-sectional study in the KWHD involving 253 consented women between the ages 25 to 65 years. The principal research instrument was a three-part questionnaire designed to collect information on socio-demographic profile, cervical cancer knowledge and associated factors for uptake in cervical cancer screening. Data was entered in MS Excel and analysed using Excel. Results were presented in tables and figures. Results Our study reveals that a majority of the participants (74.70%) had heard of cervical cancer and 43.48% had undergone cervical cancer screening. Again, 24.51% and 29.25% of the participants respectively could not identify any risk factor and symptom of cervical cancer. Conclusion The study revealed that the uptake of cervical cancer screening in KWHD is higher than the national uptake. The level of awareness on the risk factors and symptoms of cervical cancer is low, posing a need to put more emphasis on educating and creating awareness of cervical cancer among communities on risk factors, prevention measures and signs and symptoms in all the health areas of the KWHD.

annually [2]. In Africa, there are 99,038 new cases with 60,098 deaths annually. It is the second leading cause of death from cancers among women aged between 14-44 years. Cervical cancer is a major problem in South Africa and it is the second most common cancer and affects one out of every 41 women. In 2009, estimates revealed that 43 000 women were diagnosed with cervical cancer and 274 000 died from the disease in South Africa [3]. On her part, in 2014 Ethiopia had about 27.19 million women above the age of 15years projected to be at risk of developing cervical cancer. Current assessments indicate that, an estimated 7,095 cases of cervical cancer and 4,732 deaths resulting from it occur every year [4]. In Kenya, the estimated annual number of cervical cancer cases stands at 2,454 cases, while the annual number of deaths from cervical cancer sums up to 1,676 and accounts for 70-80% of all cancers of the genital tract. Cervical cancer screening coverage in Kenya for all women within the ages 18 to 69 years is only 3.2% [5].
In Cameroon, Cervical cancer (CC) is the second most encountered cancer in women after breast cancer with 7.1million women with ages 15 years and above who are at risk of developing the diseases.
Cervical cancer is the 2 nd leading cause of cancer deaths in women aged 15 to 44 years in Cameroon [5]. According to the National Committee for the Fight against Cancers, Cervical Cancer accounts for 24% of female cancers [6]. In Cameroon, about 1,993 new cervical cancer cases are documented with 1,120 cervical cancer deaths [7]. In 2010, 30% of deaths among women were attributed to cervical cancer. The cervical cancer registry in Yaoundé estimates incidence at 107 cases for 100,000 inhabitants [8]. The epidemiology rightfully points out the dire situation of the morbidity and mortality from cervical cancer beginning from global, to regional and country with the need for primary prevention interventions (screening and treatment of precancerous lesions

Methods
Study design and research type: this study is an observational and cross-sectional study.
Study population and target population: the target population for this study are women between the ages 25-65 years which is Cameroon's recommended age group for cervical cancer screening.

Selection criteria
Inclusion criteria: women with ages between 25-65 years and who have been residing in the Kumbo Health District for at least two years.
Those who met the above criteria and were willing to participate.
Exclusion criteria: women who did not give consent to participate; women who wanted to be motivated before they responded to the questionnaire and women that had undergone complete hysterectomy were not included.
Sample size: to determine the sample size of this study, the sample size was calculated using the formula: N=required sample size, t=level of confidence at 95% (1.96), p= prevalence of studied variable, in this case prevalence of cervical cancer screening in Cameroon 19.6% [6], e: error margin at 5% Sampling method: a stratified random sampling method was used wherein each Health Area represented a stratum. In each Health Area, quarters were selected by simple random sampling, that is, we sampled the second quarter in each Health Area. In each quarter and with the help of the quarter head, houses were selected randomly (every third house) to get the sample size in that quarter. To be able to get a good representative of the community, a member was recruited from each household with priority given to the most elderly Data collection and analysis: all participants who consented were interviewed using a structured questionnaire adapted from a questionnaire formulated by Mohammed [9]. Prior to its use in this study, a total of 20 respondents from Kumbo East, an area with similar characteristics as KWHD were solicited with the aim of revising poorly structured questions. This was to be done by estimating the average time required to fill the questionnaire, and eventually validating the use of the questionnaire in the context of this study. A total of 253 questionnaires were administered to participants under study for a period of 2 months to assess their uptake of cervical cancer screening among women in the KWHD. Knowledge on uptake of cervical cancer screening consisted 12 questions and each correct response was scored as 1 and 0 for a wrong response. The knowledge scores for an individual was calculated and summed up to give a total knowledge score on 12. A score between 0-4 was classified as poor, 5-8 as good and 9-12 as excellent as adapted from Abongwa's [10] study. The quantitative data was analysed using Microsoft Excel and the results were presented in terms of numbers and percentages in the form of charts and tables. The main questions to access the knowledge of the uptake of cervical were the following.  whereas 24.51% of the respondents were unable to identify a single risk factor. In assessing the symptoms of cervical cancer, abdominal pain was identified as being the highest symptom of cervical cancer by the respondents with a 44.66% response, followed by provoked vaginal bleeding with 37.94% response rate, whereas 20.25% could not identify any symptom of cervical cancer. As a means of preventing cervical cancer, the respondents pointed out that avoiding multiple sexual partners was essential 25.6% (n=114), followed by avoiding early sexual intercourse with 36.76%, screening with 31.62%, where as 13.04% could not identify a preventive method (Figure 1, Table   2).
Awareness of procedures to detect cervical cancer, uptake of cervical cancer among respondents and duration of last screening: a majority of the respondents 86.96% (n=220) believed there were procedures to detect cervical cancer while 13.04% (n=33) did not believe there were screening procedures to detect cervical cancer. Cervical cancer screening uptake among the respondents was found to be 43.48% (n=110). Majority of the respondents had never been screened for cervical cancer 56.52%. Among those who had been screened, 48.18% had done it more than three years ago (Table   3).
Determining factors to cervical cancer screening uptake: a total of 77.47% of the respondents knew a health care unit to seek screening while 22.53% had no idea of where to get screened. A greater percentage of the respondents 59.68% (n=151) had no idea on the cost of screening while 17.39% respondents said it was more than 5000fcfa and 22.92% responded that it was less than 5000fcfa.
In assessing the distance to a screening unit, a majority 42% of the participants had to cover a distance more than 5km to assess a screening unit while 24% had no idea on the distance covered and a slightly higher portion of the respondents 35% covered a distance less than 5km (Table 4).

Reasons for not screening for cervical cancer: in evaluating
reasons for not haven done cervical cancer screening among those who have never screened, a majority of the respondents 25.30% (n=64) responded that they were not informed. This was followed by 9.49% made up of those who said they haven't decided yet and 6.32% made up of those who claimed the screening is expensive.
While, 5.53% opined that they were healthy and saw no need for screening, 4.35% thought it could be painful, 3.16% were shy to expose their private body parts and 2.37% feared the CCS would reveal cervical cancer (Table 5).

Ways to encourage uptake: when respondents were asked about
what could be done to increase the uptake of cervical cancer screening services, a 43.87% (n=111) majority suggested that education about the disease, followed by free screening 34.78% (n=88), counselling 14.62% (n=37), provision of centers 5.53% (n=14) and SMS sensitization 6.72% (n=17) were ways to encourage uptake ( Figure 2).

Discussion
The mean age of the respondents was 40 years with majority of the respondents 33.99% (n=86) with ages between 25-34 years. There was no relationship between age and uptake of cervical cancer screening. This is higher than the 28.4%; based on a study carried out by Enow and colleagues Yaounde, Cameroon [11]. This is in contrast with other studies that have found lower rates of screening among women aged 20-29 years [12]. Another study done in Kenya on risks and barriers to cervical cancer screening among 219 women attending MNCH-FP clinic at the Moi teaching and referral hospital (MTRH), found that women over 30 years were more likely to have screened for cervical cancer than younger women [12]. A majority of those who had been screened 69.7% (n=54) were married but there was no significant relationship between marital status and uptake of screening. Other studies also revealed that unmarried and widowed women are less likely than the married to obtain screening [12].
These findings are in contrast with other two studies that revealed that single women are more likely than married women to have been screened [13]. There was no relationship observed between level of education and uptake of cervical cancer screening. This contrasts with studies that revealed that women with high screening rates have a higher level of education [12]. A relationship was not observed between employment status and uptake of cervical cancer screening.
This contrasts studies carried out in India [14] and at Kenyatta National Hospital (KNH) in Kenya where there was a significant association between employment and CCS uptake. This may explain why 34.78% of those who had not attended screening services recommended free screening as a strategy to increase uptake as these women lack the means to finance their health care needs. A 75% (189) of the women had heard of cervical cancer. This level of awareness is in keeping with a study done in Kenya which found cervical cancer awareness to be at 73.2 % [14] but higher than a study done in India where only 44.5% of respondents were aware of CC [15]. The source of information on cervical cancer screening among most of the respondents were informed by a health care worker (HCW 32% (80)) which ties with a study in Ethiopia where 33% of the respondents got information on cervical cancer from HCW [16].
Women's awareness on cervical cancer screening was significantly associated with uptake of screening or screening status. This means that women who are aware of cervical cancer and screening are more likely to undergo screening for the disease. This ties with of the outcome of a study carried out in North Central Nigeria were 88.9% of women were aware of CCS with a screening rate of 8.0%. The proportion of those who had screened were from those who were aware [3]. This was contrary to a study carried out in South Western Nigeria where 41.9% were aware of cervical cancer but only 3.3% had undergone a screening. This indicates that the more people are aware of CCS, the more the screening uptake will increase. This study was similar to [17] in Buea Cameroon, where up to 42.2% of participants had poor knowledge on cervical cancer. The awareness on cervical cancer risk factors was also found to be inadequate. Only  [18]. A majority of the respondents were aware of a health unit where they could seek screening as 77.47% knew where to screen and only 22.53% did not know where to get screened. These results are greater than those of a study in India carried out to assess women's knowledge on Cervical Cancer. In this study, only 22% of women knew a center where they could seek screening [19].
A greater proportion of the respondents 59.68% had no idea on the cost of screening but 17.39% thought it was greater than 5000fcfa which is rather less than 5000fcfa in this district. The cost of screening can affect uptake as 6.32% of those who have never screened responded that they have not undergone screening because it could be expensive. Also, this research reveal that there was an association between distance and uptake of cervical cancer screening showing that the more the distance, the less likely the possibility to screen.
This was similar to those of a study carried out in Kenya by Morris, 2016 were 68% of the respondents could access a health unit. Long distances to screening center reduces the likelihood of women accessing screening [20]. When those who had never been screened were asked for reasons why they have never been screened, they advanced reasons such as not being informed, not haven decided, cost of screening, feeling healthy, it may be painful and being afraid of having a positive test were the most advanced reasons for not undergoing cervical cancer screening. These reasons are different from those in a study in China by [21,22] where the major barriers identified by the women as those that influence screening utilization were: anxious feeling of being diagnosed, no symptoms, unawareness of the benefits of screening, CC is incurable even if screening is effective and husband disapproval of screening. Being aware of the cost of screening is important as more than half of the participants had no idea on the cost of screening. Sensitization of the population is important as the more people are aware, the more they will take positive actions concerning their health.

Acknowledgements
We are grateful to all the women who participated in this research.