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Knowledge, attitude and perception of women towards cervical cancer vaccine in cross river state, Nigeria: A qualitative study



Cancer is responsible for more deaths globally than HIV/AIDS, malaria and TB combined. Cervical cancer (CC) is the 7th most common cancer worldwide accounting for about 5% of all cases*. It is the second most common female cancer after breast cancer. (Ref oncology channel, Walboomers, look for at least two more sources). About half a million new cases of cervical cancer are diagnosed yearly, with over 80% of these cases occurring in developing and under-developed countries. (okonofua). The incidence of CC in Africa is nine time that of the United States of America, while the mortality of the condition is twenty four times that of the United states.

CC refers to a malignant neoplasm that occurs in the tissue of the cervix, the organ that connects the uterus to the vagina in the female reproductive system( United States National Cancer institute)

The major causative agent for cervical cancer has been identified as the Human Papilloma Virus (HPV) (ref IARC) associated with 99.7% of all cases (Walboomers). However, women with HIV/AIDS have significantly increased risk of developing the condition, but it is unclear whether the HIV epidemic has had any effect on the incidence of in developing African countries, the reason being that CC incidence has remained unchanged between 1960-1990s in Nigeria and south Africa, but has increased in Zimbabwe, Kampala and Uganda within the same time frame (PARKIN). Other important causative factors include presence of sexually transmitted infections like herpes simplex virus-2 or Chlamydia trachomatis. Smoking and prolonged use of oral contraceptives also increase the chances of developing the disease (Cancer research Uk).

There are Over 30 HPV genotypes that affect the female genital tract. HPV type 16 and HPV type 18 have been implicated in over 70% of cervical cancers, while types 16, 18, 45, 31, 33, 52, 58 and 35 are isolated in 95% of cases (KHAN). In sub-Saharan Africa, a study conducted in three countries, Mozambique, Nigeria and Uganda isolated HPV 16, 18, 33, 45 and 31 as the five most frequent types found in the region (Karly et al)


CC is essentially a preventable disease. There are essentially two modes of prevention, the primary preventive strategy which involves the use of vaccines against HPV, and the secondary preventive strategy which involves screening programmes directed towards early detection and treatment of the condition. Despite the current availability of HPV vaccines to prevent CC, its effectiveness will not manifest in developing countries until the vaccines become affordable and can be integrated into the national immunization programmes of developing countries (Karly, Kane). It has been estimated that future burden of CC in sub-Saharan Africa is estimated to rise to about 118,000 new cases in 2025, representing a massive 67%increase from the values of 2002 (KARLY, FERLAY/Parkin D2004)

Evidence has shown that women in the United kingdom are 50% less likely to get a diagnosis of cervical cancer these days, when compared to 1988, when the cervical cancer screening programme was introduced in 1988(Uni of oxford).

Currently, the preventive strategy in sub-Saharan Africa where the disease is most prevalent focuses on secondary prevention using cervical cancer screening. Research is lacking on how effective a primary prevention approach using cervical cancer vaccine will be.

Most of the research done in Africa have been quantitative, directed toward detecting the prevalence of the condition, some qualitative research has been geared towards secondary strategies.

The magnitude of the effect of cervical cancer on the health of women in developin countries has been largely underestimated, mostly due to the paucity of epidemiological data,low levels of awareness, absent cancer related health policies and lack of political will to tackle this problem. (KARLY Louie et al, Denny et al, Parkin etal).

The existing literature on cervical cancer vaccine appears to be lacking information concerning vaccine deployment strategies in terms of (a) community acceptability, (b) possible health channels for vaccine delivery, (c) vaccination strategies including age, sex and catch-up models (Karly Louie)

This project proposes to address some of these gaps by exploring women's knowledge perceptions and attitudes towards cervical cancer vaccine in Nigeria, a developing country in sub-Saharan Africa. Specifically, the project will attempt to answer the following research questions:



Study Setting:

The study will be carried out in Nigeria, the most populous nation in Africa. It has an estimated population of 145 million (WHO), which is equivalent to approximately a quarter of Africa's total population. The country is located in the western part of sub-Saharan Africa on latitude 100North and Longitude 80East. It covers a total area of 923, 768 square kilometres. (Google for ref)

The country has numerous ethnic groups, but the three major ones are the Hausas located in the north, the Yorubas in the southwest and the Ibos in the southeast of the country respectively (APPENDIX). It has two major religions, with the southern population being Christian and the northern population being Muslim.

Nigeria's National health Policy (1998) stipulates Primary Health Care (PHC) as the cornerstone of the country's health system. It provides for a structured format with three levels of care, the primary, secondary and tertiary levels of care (FMOH). There is a referral system for management of patients between the three levels of care. The average life expectancy for men is 48 years, and for women is 49years. About 55% of the country's population is aged between 15-64 years, the same age group where cervical cancer is most prevalent among women.

Study design:

The project will be carried out using a qualitative study design. Qualitative research is suitable if the underlying process of the research is attempting to identify the meaning of or understand the perceptions in a given situation by a particular group of people. (Kendra, Strauss,) It is ideal if used to study social process answering questions such as why or how, enumerating the reasons behind human behavior (Check proj folder for ref)

Sampling: The sampling strategy used will be a multi-stage cluster sampling. The three regions of Nigeria will serve as the initial clusters. One state will be randomly selected from the list of available states within each region. This will be achieved using a random selection programme like Microsoft excel. Within each state, three health care facilities will be selected, each of them being a primary, secondary or tertiary health care centre respectively.

Inclusion criteria for participation will include