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Introduction

Human papilloma virus (HPV) is one of the risk factor for cervical cancer and it is believed to play a central role in the development of cervical cancer [1]. HPV serotypes such as types 6,11,16,18 that occur in the genital tract are thought to be acquired predominantly through sexual intercourse and up to fifty per cent of sexually active young women will be infected with this implicated organism at some time [2]. In most communities, commercial sex workers (CSWs) are believed to play an important role in the transmission of sexually transmitted infections (STIs), including human papilloma virus (HPV) infection which is implicated in the pathogenesis of cervical cancer [3]. Cervical cancer is a leading female malignancy in developing countries and the most important tumor-related cause of death among women throughout the world [4,5], in spite of this, practices such as screening for cervical cancer is poor especially in the developing countries [5]. Studies [6-8] have suggested a strong link with risk factors such as increased number of partners and increased frequency of sexual intercourse, inconsistent condom use, HIV sero-prevalence, younger age and being involved in sex work for less than one year as well as smoking. Screening to detect early lesion can help to drastically reduce the incidence of cervical cancer, screening methods that are available include papanicolaousmear, HPV DNA testing, visual inspection with acetic acid and electronic screening methods [9]. Knowledge about HPV infection and HPV vaccine as well as utilization of screening services have been reportedly low among CSW [10,11], while age and education were positively associated with willingness to undergo screening [12].

In Nigeria, cervical cancer is the commonest gynecological cancer which affects 28.5/100,000 women [4]. The reported prevalence of HPV infection (the implicated virus) which studies have shown to be associated with sexual activity in the general population, and among women that develop cervical cancer are 26.3% and 24.8% respectively [2]. Cervical cancer accounts for about 12% of all cancers worldwide and disproportionately affects women in developing countries where age standardized rate ranges between about 25-43 cases per 100,000 women with larger incidence among CSWs [5]. CSWs seem to have less knowledge about the fact that HPV can be transmitted or contracted through sexual intercourse, especially with multiple sexual partners compared to their knowledge about other STIs such as HIV/AIDS, gonorrhoea, syphilis [9,13,14]. Health workers who are supposed to be custodians of adequate knowledge about disease prevention have been found to have little or no knowledge about screening practices for cervical cancer as well as the risk factors [14], consequently the extent to which they can influence non health workers (such as CSWs) positively will be minimal. This study is focused on the CSWs as this group plays an important role in transmission of STIs not excluding HPV infection, which is the major factor in the development of cervical cancer. In most communities, this group of people is being patronized by men with stable partners or that are even married; these men tend to spread the HPV to their partners and consequently to members of the community at large [13,14]. This does not only have a negative effect on the health of the families or individuals but also on the economy of the society as more funds are being diverted to the treatment of cervical cancer rather than the more economical screening process and preventive measures. Thus, this study aimed to assess the knowledge and attitude of CSWs towards HPV infection and cervical cancer as well as those factors influencing the uptake of screening among this group of the population. Considering the outcome of this research, a feedback is intended to be given to the various hotels used, where the outcome of the study will be discussed, also the results will be used as an advocacy tool for getting stakeholders including NGOs involved in prevention of HPV infections among CSWs. This study will also serve as baseline for further researches among CSWs.

Materials and Methods

Description of study area

The study was conducted in Ogbomoso and Osogbo. Ogbomoso is an ancient city in Oyo State, South-Western Nigeria, it has the geographical coordinates of 80 81 011 North, 40 161 011 East. It was founded in the mid-17th century and is located along Ilorin-Ibadan express road [15]. It is about 95 km North -West of the Oyo state capital (Ibadan). Ogbomoso has five local government areas which are Ogbomoso North, Ogbomoso South, Surulere, Oriire and Ogo-Oluwa. The estimated population of Ogbomoso was 1.167 million in the 2006 national population census [16]. There are about 5 brothel in the city with approximately 30 CSWs per brothel. Osogbo is the capital of Osun State, South - Western Nigeria. It is 88km by road northeast of Ibadan [17]. It is also about 100km by road to the south of Ilorin and 115 km northwest of Akure. It is situated on latitude 9.70 North and longitude 4.50 East. Osogbo sits the headquarters of both osogbo local government and olorunda local government area [16]. The estimated population of Osogbo was 1.2 million in the 2006 national population census [16], there are about 7 brothels in the city with approximately 35 CSWs per brothel. The people residing in these cities are predominantly Yorubas but tribes from other parts of the country such as the Hausas, Igbos, Edos and other nationalities such as Ghanaians and Togolese also reside in these two cities. In the rural areas, majority of the inhabitants are farmers while in the urban areas, they are mostly traders, artisans and civil servants. Yams, Cassava, Maize and Tobacco are some of the notable agriculture products of the region.

Study population

Female commercial sex workers who work in brothels and/ or reside in brothels.

Study design

This is a descriptive cross-sectional study.

Sample size determination

Using the formula for study population of less than 10,000 and a proportion of 0.180 CSWs with good attitude to uptake of cervical cancer screening from previous study [18], the estimated minimum sample size was 139. However, a total of 400 questionnaires were distributed in order to cater for non-response, poorly filled questionnaires and to enhance representativeness. A total of 310 correctly filled questionnaires were eventually analyzed for this study.

Sampling techniques

Proportional allocations were used to estimate the numbers of questionnaires to be administered in each brothel. Five and seven Brothels were discovered in Ogbomoso and Osogbo respectively and. All CSWs in all the brothels who gave their consents were recruited for the research. One hundred and sixty-five questionnaires were distributed in Ogbomoso, and 265 in Osogbo. The questionnaires were self-administered by then respondents, and only respondents who have been engaged in commercial sex work for more than a year were recruited for the study.

Instrument for data collections

The Research instrument was a pre-tested semi-structured questionnaire with six sections which include Socio-demographic characteristics of respondents; knowledge about HPV infection and cervical cancer; knowledge about preventive measures; attitude of respondent to risk of contracting HPV infection; respondent preventive practices, and factors that determined the uptake of prevention. The questionnaire was pre-tested in another brothel in Oyo town, this helped the researcher to correct areas of ambiguity and to include relevant questions that would have been omitted.

Data collation and analysis

Questionnaires were manually checked for errors and entered into the computer. Statistical package for social sciences (SPSS) version 17 was used to analyze the data. The open ended questions on the knowledge and preventive practices were categorized to similar responses, allotted numbers and entered into the SPSS. Questions on attitude were scored thus: agree -3, indifferent -2, disagree -1. Mean score of all respondents' knowledge, attitude and preventive practice were computed and those that score below the mean score were reported as poor knowledge, attitude and preventive measures, while those that score the mean score or above were reported as good knowledge, attitude and preventive practices. Variables were presented in frequency tables and charts. Chi-square statistics was used to estimate the degree of association between the variables in the study. P values less than 0.05 was considered significant. Same was done for knowledge and practice.

Ethical approval

An Approval to conduct the study was given by the Departmental Review Board, the letter of approval was shown to the manager and coordinators of the Brothels, who also in turn gave permission to conduct the study. Each of the commercial sex workers gave verbal consent to be involved in the study after detailed explanation has been given about the study, and were given assurance of their withdrawal anytime they feel like withdrawing from the research without any penalty.

Limitation of the study

Major limitations of the study include, no formal documentation of existing brothels in the states/cities so the ones recruited were gotten informally from people around, therefore there may still be some brothels that were missed out. Also there was no documentation of the number of commercial sex workers in the state/cities where this study was conducted because of the social and legal challenges this set of people faced because of the type of work they engaged in.

Results

A total of 400 questionnaires were administered to the commercial sex workers; 52 were poorly filled, while 38 declined the interview leaving 310 questionnaires for analysis. The response rate was 77.5%.

Table 1 shows the socio-demographic characteristics of the respondents. Majority, (56.8%), of the respondents were in the age group (25-32 years), were Christians, (76.5%). Most, (55.8%), of the respondents, attained secondary education; were of the Igbo tribe (49.0%); single, (76.8%), and attained menarche within the age 12-16 years (76.5%).

Table 2 shows that 22.2% of the respondents did not know the age at risk of HPV infection, while 88.7% of the respondents did not know the treatment option for HPV. Only 42.0% knew that regular use of condom is a measure of preventing HPV infection, 69% of respondents who had heard about HPV had good knowledge of the preventive measures. Almost a half (48.7%) of the respondents knew having multiple sexual partners can predispose them to contracting the infection, while only 11.3% of them were aware of the availability of treatment options for the infection. Few (15.5%) had heard of HPV vaccine, but just 8.5% knowing it must be taken 3 times for full protection. Only 8.1% of the total respondents were aware of HPV screening centres and about 4% were aware it could be done in the teaching hospital, none of them mentioned primary health center. Only 13.8% of the respondents had good knowledge about HPV infection.

Table 3 shows that, half of the respondents (51.9%) had heard of cervical cancer. Just over one-quarter (28.5%) of the respondents knew the specific body part affected, a little over one-third (36.1%) of them knew the occupation at risk, and 36.1% knew the age range at risk of cervical cancer. About 34% of respondents had good knowledge of the preventive practices among which 30% was condom. Very few (25%) of them were aware of the availability of treatment options for cervical cancer, 54.2% knew it could be cured if detected early. Fifty seven percent of the respondents believed women with 3 or more years of sexual exposure should go for cervical cancer screening and 43% believed that women older than 21 years of age should go for the screening. Few (15.5%) respondents had heard of HPV vaccine, only 14% of the total respondents were aware of cervical screening centers and about 9% were aware it could be done in the teaching hospital. Only 26.2% of the respondents had good knowledge about cervical cancer. Figure 1 shows the knowledge of the respondents about risk of cervical cancer in which majority of the respondents (40%) knew cervical cancer could be caused by unresolved HPV infection, 28.9% through unsafe sex, and 15.6% through excessive smoking, 8.9% through excessive alcohol consumption and 6.7% believed poor personal hygiene and poor nutrition among others.

Table 4 shows that majority, 78.7% of the respondents agreed that they will access cervical screening services, however about 33.5% were indifferent to going for screening and another onethird, 33.9%, were indifferent to using condom as a means of preventing HPV infection.

Table 5 shows the willingness of the respondent to do screening and take the HPV vaccine. Majority, 94.5% will agree to be screened if only the service is brought to their brothel, 80.3% will have the vaccine if not free and 82.9% if free. Fifty four point eight percent would like to be screened in any brothel and only 13.2% would agree to be screened in any hospital. Tables 6 and 7 shows that there is significant relationship between knowledge of respondents about preventive measures against both HPV infection and cervical cancer and their attitude towards its preventive measures with p-value of 0.000. However, there is no significant relationship between attitude of respondents towards prevention of HPV and cervical cancer and their practice of prevention, with p-value of 0.917. Figure 2 show that only 1% had ever done cervical cancer screening before.

Discussion

The age range of our respondents was between age 18-44 years with majority being between the age 25-31 years with a mean age of 26.7 years. They were mostly single and educated up to secondary level of education. These findings is is similar to that of a study done among female sex workers in Lagos; majority of the respondents were between age 18-48 with mean age of 28.1(+/-6.8) years and mostly single [19], though, unlike in our study, most of the respondents in that study only completed primary education [19]. Another study done in Vietnam among female sex workers revealed that they were mainly unmarried the majority of the respondents educated up to primary school level [20]. This study and the previous ones [19,20], showed the fact that majority of CSWs fall within the reproductive age group, and are at risk of HPV infection and cervical cancer, as younger age has been identified as a major risk factor for HPV infection [8].

The overall knowledge about cervical cancer, its risk factors and methods of prevention was poor among CSWs. Most of the respondents have never heard about HPV infection though slightly above average of the total number of respondents were aware of a disease called cervical cancer. This finding is similar to studies done among female sex workers around the globe which shows a generally low level of knowledge about HPV infection and cervical cancer among CSWs [20-23]. However, this is in variant with studies done in Nigeria among female workers and Nurses, which reported a high level of knowledge about cervical cancer [24,25]. This may be due to the fact that the study populations had a higher percentage of educated people corroborating the fact that high educational status is usually linked with good knowledge about cervical cancer.

The most important source of information about HPV infection was through the mass media followed by school and hospital with health workers taking the least percentage. The reason for this finding could be explained by a Ugandan study [26], which observed that medical workers who should be responsible for opportunistic screening of women they care for were not keen on getting screened themselves, also, Medical students were observed to had poor skill in screening of women. Thus they leave medical school without adequate skills to be able to effectively screen women for cervical cancer wherever they go to practice. This finding was as well supported by a study conducted in a tertiary hospital which observed a paucity of knowledge about cervical cancer among female health workers [14], this group of personnel were expected to be the source of information to all healthcare seekers in the community. This findings may be detrimental to the good health seeking behavior of CSW as noted by some studies [27,28]. Our study also observed a significant relationship between educational status, marital status, and having another source of income with knowledge about HPV infection, cervical cancer and its preventive practices. Studies among CSWs in peru [19] Thailand [24] and in Nigeria [24,25] also established a link between educational status and good knowledge about HPV infection and cervical cancer. The overall attitude was relatively good as slightly above average of the total respondents had good attitude towards preventive practices against HPV infection and cervical cancer. Majority of our respondents believed cervical cancer screening could help detect the premalignant lesion early and facilitate early treatment. Only a few number of the respondents agreed they were at risk of contracting infection or could develop cervical cancer in relation to their job. This is corroborated by findings of a study among women in Okada south-southern, Nigeria, which also found that the women had good attitude towards the uptake of preventive practices, and that majority of them insisted they were not at risk of the disease [29]. Poor risk perception has been observed by other studies [30-32] and might be a major reason for poor uptake of screening services.

This study also revealed a generally poor uptake of preventive practices against cervical cancer among commercial sex workers. Almost all of our respondents had never been screened for HPV infection and majority had never done pap smear. This supports findings from various studies done among commercial sex workers globally which shows that most of them had never done Pap smear [9,14,18,23,25]. In the same vein, this study observed no association between having good knowledge and uptake of preventive practices as also supported by the studies from Lagos [7] and Nnewi [24]. However, a large percentage of our respondents always insist on use before sexual intercourse. This is similar to results of studies done among commercial sex workers in Lagos [19] and Thailand which found that majority of CSWs insist on condom before sex. However, the case is different among Spanish sex workers, in which a handful of respondents did not use condom with some regular partners, this exposed them to the possibility of contracting STIs [33]. The good condom use observed in our study is likely due to the wide awareness campaign about the HIV pandemic especially being carried out by both the Nigerian government and NGOs among this population. Thus campaign and program targeted at HIV prevention should be sustained as HIV prevalence had been linked with HPV infection [7]. Our study revealed that knowledge and attitude of respondents does not translate to their preventive practices and uptake of screening however, this was in contrast, with the studies done in China [18] and Oshogbo [14] which shows a significant association between knowledge about cervical cancer and uptake of preventive practices. The possible reason for the absence of no relationship between knowledge and uptake of preventive practices could be due to the fact that there is a wide time gap between infection with HPV and development of cervical cancer and the CSWs may not relate the disease to their previous job.

Factors affecting uptake identified by our study include the cost of both the screening and the vaccine as most of the respondents are willing to uptake the screening if it were #2,000 or less. This study is supporting a review done by Gonik, on strategies to foster acceptability of HPV vaccine, which observed that the cost of vaccination played a significant role in the acceptability of HPV vaccine [34], and another done in Ilorin, where respondents stated expensive cost of screening as a major reason for non-uptake of screening services. Also, the specific location where the screening will be done is a major factor as majority of our respondents would prefer the screening to be done in any brothel as compared to few of them who would still uptake the screening even if done in a hospital. Other reasons include they did not know where to go, fear of stigmatization, lack of time, not knowing about the test and not thinking it is important. Findings from studies done in Ibadan and Burkina Faso [30,31] also revealed that most women did not uptake screening because they did not know where to go and were afraid of pain.

Conclusion and Recommendation

The knowledge about HPV infection and vaccination as well as the uptake of preventive measures was observed to be poor among the CSWs in Ogbomoso and Osogbo, despite a favorable attitude towards prevention of HPV infection and consequently cervical cancer, Their self-risk perception was low despite the fact that they were among the high risk group with majority of CSWs having no reason for the poor uptake of preventive practice. It is therefore recommended that awareness campaign should be scaled up among CSWs concerning their risk of having cervical cancer. Appropriate medium should be utilized to educate this group of people on the importance of vaccination and screening for both HPV and cervical cancer. Also government should enact policies that will incorporate HPV vaccination into the present routine immunization schedule for adolescents and young adults as well as subsidize the cost of screening and HPV vaccination, to encourage better uptake. The Non-Governmental Organization should also provide coordinated support and technical assistance in the design of an appropriate program that will empower this key population in protecting themselves against HPV infection and consequently cervical cancer.

Disclosure

The authors will like to declare no conflict of interest. This study was solely funded by the authors.

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Cervical Cancer: Knowledge and Uptake of Screening among Commercial Sex Workers in Two Cities in South-Western Nigeria

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