Knowledge, Attitude, and Practice (KAP) toward Cervical Cancer Screening among Women in Southeast Nigeria

Background: Cervical cancer remains a significant public health concern, particularly in low-resource settings like Southeast Nigeria, where the burden of the disease is compounded by limited awareness and access to screening services. Understanding the knowledge, attitudes, and practices (KAP) of women in this region is essential for designing effective interventions to promote cervical cancer screening and reduce mortality rates.

Objective: To assess the knowledge, attitude, and practice (KAP) toward cervical cancer screening among women of reproductive age in Southeast Nigeria, and to identify the factors influencing these aspects.

Methods: A descriptive cross-sectional study design was employed to gather data from women aged 15-49 years residing in Southeast Nigeria. A sample of 235 women was selected using a multistage sampling technique, ensuring representation from both urban and rural communities across the five states in the region. Data were collected through a structured questionnaire, which was pre-tested for validity and reliability. The data were analyzed using the Statistical Package for Social Sciences (SPSS) software version 26, with descriptive statistics used to summarize the findings.

Results: The study revealed that 41.7% of participants had heard of cervical cancer, and 40% were aware of cervical cancer screening methods. However, only 25.96% had ever undergone screening. Fear of a positive result (33.86%), lack of awareness (33.41%), and cost (19.88%) were the primary barriers to screening. Despite the low screening rates, 89.79% of participants expressed willingness to undergo screening in the future, particularly if subsidized or free services were provided.

Conclusion: The findings highlight significant gaps in knowledge and practice concerning cervical cancer screening among women in Southeast Nigeria, despite generally positive attitudes toward screening. Addressing barriers such as fear, lack of awareness, and cost through targeted education campaigns and accessible screening services could improve screening uptake and ultimately reduce cervical cancer mortality in the region.

Cervical cancer remains a significant public health concern, particularly in low- and middle-income countries (LMICs) where the burden of the disease is disproportionately high. According to the World Health Organization (WHO), cervical cancer is the fourth most common cancer in women globally, with an estimated 604,000 new cases and 342,000 deaths in 2020 alone [1]. The high mortality rate associated with cervical cancer in LMICs is largely attributed to the lack of early detection and treatment, which underscores the importance of cervical cancer screening programs. In Nigeria, cervical cancer is the second most common cancer among women, following breast cancer. The incidence rate is alarmingly high, with approximately 14,089 new cases diagnosed annually, and a significant proportion of these cases result in death due to late-stage presentation [2]. The Southeast region of Nigeria, in particular, faces unique challenges in addressing cervical cancer due to sociocultural, economic, and infrastructural barriers that hinder effective screening and treatment [3]. This study aims to explore the knowledge, attitude, and practice (KAP) toward cervical cancer screening among women in Southeast Nigeria, with the goal of identifying factors that influence screening uptake and proposing strategies to improve participation in screening programs.

Cervical cancer is highly preventable through regular screening and vaccination against human papillomavirus (HPV), the primary cause of cervical cancer [4]. Screening methods such as the Papanicolaou (Pap) smear, visual inspection with acetic acid (VIA), and HPV DNA testing have been proven effective in detecting precancerous lesions early, thereby reducing the incidence and mortality associated with cervical cancer [5]. Despite the availability of these screening methods, participation in cervical cancer screening programs remains suboptimal in many LMICs, including Nigeria. Several factors contribute to low screening rates, including limited access to healthcare facilities, lack of awareness about cervical cancer and its risk factors, cultural beliefs, fear of diagnosis, and the stigma associated with the disease [6]. In addition, healthcare infrastructure in many LMICs is often inadequate, with a shortage of trained personnel, lack of screening equipment, and insufficient public health funding further exacerbating the problem [7]. The high burden of cervical cancer in Nigeria is reflective of the broader challenges faced by the healthcare system in the country. With a population of over 200 million people, Nigeria's healthcare infrastructure is underdeveloped, particularly in rural and semi-urban areas where access to essential health services is limited [8]. In the Southeast region, the situation is further compounded by cultural practices and beliefs that discourage women from seeking medical care, particularly for reproductive health issues [9].

Research indicates that awareness of cervical cancer and its prevention methods is generally low among Nigerian women, particularly those in rural areas. A study by Umeh and Rogan-Gibson found that only 23% of women in Southeast Nigeria were aware of cervical cancer screening services, and even fewer had undergone screening [10]. Factors such as low educational attainment, poverty, and limited exposure to health education campaigns contribute to this lack of awareness. Moreover, attitudes toward cervical cancer screening in Nigeria are influenced by sociocultural factors, including religious beliefs, gender norms, and perceptions of risk. For instance, some women perceive cervical cancer screening as unnecessary unless they exhibit symptoms, while others fear the potential stigma associated with a cancer diagnosis [8]. These attitudes, coupled with practical barriers such as cost and distance to healthcare facilities, contribute to the low uptake of cervical cancer screening services in the region.

The knowledge, attitude, and practice (KAP) model is a widely used framework in public health research to assess the knowledge, attitudes, and practices of a population concerning a particular health issue. In the context of cervical cancer screening, the KAP model can provide valuable insights into the factors that influence women's decisions to participate in screening programs [11]. Knowledge refers to the awareness and understanding of cervical cancer and the importance of early detection through screening. Attitude encompasses beliefs, perceptions, and feelings about the disease and the screening process, while practice involves the actual behaviors related to screening, such as undergoing a Pap smear or HPV test.

Understanding the KAP of women toward cervical cancer screening is vital for designing effective interventions aimed at increasing screening uptake. Studies have shown that women with higher levels of knowledge about cervical cancer and its prevention are more likely to have a positive attitude toward screening and are more likely to participate in screening programs [6]. Conversely, a lack of knowledge and negative attitudes are significant barriers to screening uptake [9]. Despite the growing body of research on cervical cancer in Nigeria, there is still a paucity of studies that specifically focus on the Southeast region, where cultural and socioeconomic factors may uniquely influence KAP toward cervical cancer screening. Additionally, while previous studies have identified some barriers to screening, there is a need for more comprehensive research that examines the interplay between knowledge, attitudes, and practices in this context [10]. This study seeks to fill this gap by conducting a detailed assessment of the KAP toward cervical cancer screening among women in Southeast Nigeria. The findings will not only contribute to the existing body of knowledge but will also inform the development of targeted interventions to improve screening uptake and reduce the burden of cervical cancer in the region.

Study Design

This research employed a descriptive cross-sectional study design. This design is chosen to assess the Knowledge, Attitude, and Practice (KAP) toward cervical cancer screening among women in Southeast Nigeria at a single point in time. The cross-sectional design is appropriate for determining the prevalence of particular attributes (knowledge, attitudes, and practices) and allows for the collection of data from a large population in a relatively short period [12].

Study Area

Southeast Nigeria, comprising Abia, Anambra, Ebonyi, Enugu, and Imo states, is an important region for studying the Knowledge, Attitude, and Practice (KAP) toward cervical cancer among women of reproductive age. This region is predominantly inhabited by the Igbo ethnic group and is characterized by a mix of urban and rural communities, with varying levels of access to healthcare services. Cultural beliefs, educational attainment, and economic status differ across these states, potentially influencing health-seeking behaviours and knowledge of cervical cancer. The region's healthcare infrastructure and the availability of screening services, such as Pap smears, also vary, making it a critical area for understanding the disparities in cervical cancer knowledge, attitude and practices toward cervical cancer screening. By focusing on Southeast Nigeria, the study can provide insights into regional differences in cervical cancer knowledge, attitudes, and practices, which are essential for targeted interventions and policy-making.

Study Population

The study population consisted of women of reproductive age (15-49 years) residing in Southeast Nigeria. These women were selected from both urban and rural areas to capture a comprehensive understanding of the KAP toward cervical cancer screening across different socioeconomic and cultural settings.

Sample Size Determination

The sample size will be determined using the Cochran formula for estimating proportions in a population outlined by Airaodion et al. [13]:

where n = minimum sample size

Z = 1.96 at 95% confidence level, 

P = known prevalence of cervical cancer in Nigeria 

e = error margin tolerated at 5% = 0.05

q = 1 - p

According to Omosun et al. [14], the existing prevalence of cervical cancer in Nigeria is 16.4%.

P = 16.4% = 0.164

q = 1 – p

= 1 – 0.164 

= 0.836

The minimum sample size was 211 and was adjusted to 235 to account for a non-response rate of 10 %. 

Sampling Technique

A multistage sampling technique was employed to select participants. This includes:

1. Selection of States: All five (Abia, Anambra, Ebonyi, Enugu, and Imo) states in Southeast Nigeria were included in the study to ensure a comprehensive regional representation.
2. Selection of Local Government Areas (LGAs): From each state, three LGAs were randomly selected.
3. Selection of Communities: In each selected LGA, two communities (one rural and one urban) were randomly chosen.
4. Selection of Participants: From each community, women of reproductive age were selected using systematic random sampling from households. The sampling frame consisted of a list of households within each community, and every 3rd household was chosen until the desired sample size was achieved.

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Women aged 15-49 years who have resided in the study area for at least one year.
• Women who give informed consent to participate in the study.

Exclusion Criteria:

• Women with a known history of cervical cancer, as they may have higher knowledge than the general population.
• Women who are healthcare professionals or are working in a related field, as their knowledge levels might differ significantly.
• Women who did not give informed consent to participate in the study.

Data Collection Instruments

Data were collected using a structured questionnaire. The questionnaire was developed based on existing validated tools used in similar studies, and it was divided into four sections:

• Section A: Socio-demographic characteristics (age, marital status, education, occupation, income level, etc.)
• Section B: Knowledge about cervical cancer and screening (causes, symptoms, prevention, and screening methods)
• Section C: Attitudes toward cervical cancer screening (perceived susceptibility, perceived severity, perceived benefits, and barriers to screening)
• Section D: Practices related to cervical cancer screening (history of screening, frequency, and reasons for screening or not screening).

The questionnaire was pre-tested in a different population with similar characteristics to ensure validity and reliability.

Data Collection Procedure

Trained research assistants administered the questionnaires through face-to-face interviews to ensure clarity and accuracy. The interviews were conducted in the local language (Igbo) where necessary, and translations were provided to maintain consistency.

Data Analysis

Data was analyzed using Statistical Package for Social Sciences (SPSS) software version 26. Descriptive statistics (frequencies, and percentages) were used to summarize the data. 

Ethical Considerations

The study adhered to the principles of the Declaration of Helsinki. Participants were informed about the study's objectives, their right to withdraw at any time, and the measures taken to ensure confidentiality. Written informed consent was obtained from all participants.

The study involved 235 women of reproductive age in Southeast Nigeria. The participants' age distribution was diverse, with the majority aged between 30-34 years (24.68%), followed by those aged 45-49 years (20.00%). Educational attainment was primarily at the secondary level (57.45%), with a smaller proportion having tertiary education (20.00%) or no formal education (8.09%). Most participants were married (55.32%), and a significant number were self-employed (32.77%). The majority lived in urban areas (51.06%) and had a monthly income between 50,001 - 100,000 Naira (44.26%). Most had 1-2 children (50.21%), with only 4.68% having five or more children. Awareness of cervical cancer was relatively low, with only 41.70% having heard of it, primarily through the Internet/social media (36.33%) and healthcare providers (21.22%). Among those aware, the most commonly recognized causes of cervical cancer included Human Papillomavirus (HPV) (24.37%) and multiple sexual partners (23.53%). However, knowledge about cervical cancer screening methods was even lower, with only 40.00% aware of such methods, and Pap smear testing being the most known (38.53%). Awareness of symptoms was moderate, with unusual vaginal discharge (30.21%) and abnormal vaginal bleeding (26.81%) being the most recognized. Preventive knowledge was fragmented, with only 41.70 Percentage believing cervical cancer could be prevented, mainly through regular screening (30.52%) and safe sexual practices (28.51%).

The majority of participants (63.40%) recognized cervical cancer as a serious health issue for women, and most considered screening important (85.11%). Comfort levels with getting a Pap smear were fairly high, with 76.60 percentage feeling comfortable or very comfortable. However, only 1.28 percentage believed they were at risk of developing cervical cancer. While a substantial portion (37.02%) believed screening was necessary even without symptoms, there was considerable uncertainty (43.83%). The potential for screening to prevent cervical cancer significantly influenced willingness to get screened, with 89.79 percentage indicating they would be more likely to undergo screening if they knew it could prevent the disease. A similarly high percentage (89.36%) would encourage their female family members or friends to get screened. Fear of a positive result (33.86%) and lack of awareness (13.19%) were the main barriers to screening. Despite the general positive attitude toward screening, actual practice was low, with only 25.96 percentage having ever undergone cervical cancer screening. Of those who had been screened, a significant portion (34.43%) had done so 2-5 years ago. For those who had never been screened, lack of awareness (33.41%) and no symptoms present (15.93%) were common reasons. Screening was mostly conducted through NGO/charity organizations (39.34%), reflecting the possible role of community outreach in screening access. Willingness to undergo screening in the future was high (89.79%), with factors like assurance of confidentiality (25.83%) and subsidized or free screening (21.63%) being key motivators. HPV vaccination rates were also low, with 

only 29.36 percentage having received the vaccine, and fear of side effects (36.44%) being the main deterrent.

Table 1: Socio-Demographic Information of Participants

Table 2: Knowledge about Cervical Cancer and Screening

* Indicates multiple responses

Table 3: Attitude Toward Cervical Cancer Screening

* Indicates multiple responses

Table 4: Practice of Cervical Cancer Screening

* Indicates multiple responses

The findings of this study provide significant insights into the knowledge, attitudes, and practices (KAP) toward cervical cancer screening among women in Southeast Nigeria. The results highlight critical gaps in awareness and misconceptions about cervical cancer and its prevention, despite the disease being a significant public health issue in the region. The study revealed that only 41.7% of the respondents had heard of cervical cancer, a figure that reflects a worrying lack of awareness. This is consistent with previous studies conducted in Nigeria and other developing countries, where awareness levels were found to be low [15,16]. The primary sources of information were the Internet and social media (36.33%), followed by healthcare providers (21.22%). This pattern indicates a shift towards digital platforms as key information sources, a trend also noted in similar studies [17]. However, the reliance on digital platforms raises concerns about the accuracy and reliability of the information being accessed. When asked about the causes of cervical cancer, 24.37% correctly identified Human Papillomavirus (HPV) as a primary cause, which aligns with findings from similar studies [18]. However, a significant proportion of respondents still held misconceptions, such as poor hygiene and genetic factors, which were selected by 12.61% and 9.24% of the participants, respectively. This indicates persistent knowledge gaps and the need for targeted education to dispel myths and provide accurate information.

Regarding awareness of cervical cancer screening methods, only 40% of respondents were aware of such methods, with the Pap smear test being the most recognized (38.53%). This is in line with findings from other regions in Nigeria where awareness of screening methods remains low [19]. The low awareness of HPV tests (17.75%) and visual inspection with acetic acid (VIA) (23.38%) suggests that these screening options are under-promoted, despite their importance in early detection and prevention. Furthermore, awareness of the Pap smear test’s purpose was limited, with only 31.49% correctly identifying it as a method to detect cervical cancer early. A considerable portion (42.13%) was unsure of its purpose, reflecting a critical gap in understanding, which could hinder screening uptake. Similar issues were noted in a study by Anorlu [20], which emphasized the need for clear communication about the purpose and benefits of cervical cancer screening. Attitudes toward cervical cancer screening were generally positive, with 63.4% of respondents recognizing cervical cancer as a serious health issue for women. Additionally, 48.51% considered screening important, and 36.6% viewed it as very important. These findings are consistent with studies in similar contexts, which found that while awareness might be low, those aware generally perceive the condition and its screening as important [21].

However, a significant barrier to screening uptake is the perception of personal risk. Only 1.28% of respondents believed they were at risk of developing cervical cancer, while 75.32% did not consider themselves at risk. This aligns with the findings of Agida et al. [22], who reported that many women do not perceive themselves at risk, even when they engage in high-risk behaviors. This lack of perceived risk is a significant barrier to screening and highlights the need for targeted risk communication strategies. The discomfort associated with the Pap smear test was another notable barrier, with 16.17% of respondents feeling uncomfortable or very uncomfortable with the idea of undergoing the test. Fear of a positive result (33.86%) and lack of awareness (13.19%) were also significant factors deterring screening, similar to findings by Ajah et al. [23]. These barriers underscore the importance of addressing psychological and cultural factors when promoting cervical cancer screening. The practice of cervical cancer screening was found to be suboptimal, with only 25.96% of respondents having ever undergone screening. This is consistent with other studies in Nigeria, where screening uptake remains low [24]. Among those who had been screened, a significant proportion had their last screening more than two years ago, indicating that even among those who get screened, regular follow-up is not common practice. The low rate of screening is often attributed to factors such as cost, fear, and lack of access to services, which were also identified in this study. Interestingly, despite the low screening rates, a high percentage of respondents (89.79%) expressed willingness to undergo screening in the future if they were made aware of its benefits, and 89.36% would encourage their female relatives and friends to do the same. These findings suggest that with adequate awareness and support, there is potential to significantly increase screening rates, a trend supported by another research [15]. The role of education and awareness campaigns was highlighted, with 15.01% of respondents indicating that these would encourage them to undergo screening. Subsidized or free screening (21.63%) and assurance of confidentiality (25.83%) were also important motivators, echoing findings from a study by Akinyemiju et al. [25], which emphasized the need for affordable and accessible screening services. Awareness of the HPV vaccine was low, with only 39.57% of respondents having heard of it. Among those who had heard of it, misconceptions about its purpose were prevalent, with 27.23 Percentage believing it cured HPV infection and 11.91 Percentage being unsure of its purpose. These findings are consistent with other studies that have reported low HPV vaccine awareness and understanding in Nigeria [26]. Moreover, only 29.36% of respondents had received the vaccine, and of those, a significant proportion did not complete the recommended doses. The main reasons for not receiving the vaccine included fear of side effects (36.44%) and the belief that it was unnecessary (23.56%). These findings suggest a need for more extensive education on the benefits and safety of the HPV vaccine. 

The study highlights significant gaps in the knowledge, attitudes, and practices related to cervical cancer screening among women in Southeast Nigeria. These findings are consistent with previous studies, indicating that despite some awareness, there are still considerable barriers to screening uptake, including misconceptions, fear, and lack of perceived risk. To improve cervical cancer prevention and control in this region, there is a need for comprehensive awareness campaigns, accessible and affordable screening services, and education on the importance of regular screening and HPV vaccination. Addressing these issues could lead to a significant increase in screening rates and ultimately reduce the burden of cervical cancer in Southeast Nigeria.