Objective: To determine the factors that increase the chances of a woman in Accra having a Pap smear and whether women who have recently visited clinics have higher chances of having had Pap smears.Design: A cross-sectional studyMethods: A representative sample of women in Accra, Ghana was interviewed and the clinical and demographic factors influencing cervical cancer screening was assessed.Results: Out of 1193 women with complete data, only 25 (2.1%) had ever had a Pap smear performed though 171 (14.3%) had their last outpatient clinic visit for either a gynaecological consultation or a regular checkup. Simple logistic regression showed that a high educational level, high socioeconomic status and a history over the past month of postmenopausal or intermenstrual bleeding significantly increased the odds of ever having a pap smear. Neither monthly income nor lastclinic visit for a gynaecological consultation or regular check up increased the odds of having a pap smear. Multiple logistic regression showed that a high educational level and experiencing postmenopausal or intermenstrualbleeding were the most important determinants of ever having a Pap smear.Conclusion: While we wait for a national program for cervical cancer screening, there is a need for clinicians to put more individual effort into ensuring that asymptomatic women are screened for cervical cancer

Adanu, RMK

Anarfi, J

Darko, R

Duda, R

Hill, A

Seffah, JD

English

AJOL - African Journals Online

June 2010 Volume 44, Number 2 GHANA MEDICAL JOURNAL59CLINIC VISITS AND CERVICAL CANCER SCREENING IN ACCRAR. M. K. ADANU1, J. D. SEFFAH1, R. DUDA2, R. DARKO3, A. HILL4 and JOHN ANARFI51Department of Obstetrics and Gynaecology, University of Ghana Medical School, PO Box 4236, Accra, Gha-na Department of Surgery Beth Israel Deaconess Medical Center, Harvard Medical School, USA, 3Department of Surgery, University of Ghana Medical School, PO Box 4236, Accra, Ghana 4Department of Population and International Health, Harvard School of Public Health, USA and 5Institute of Social Statisti-cal and Economic Research, University of Ghana, Legon, GhanaAuthor for correspondence: Prof Richard M. K. Adanu Email: rmadanu@ug.edu.ghConflict of interest: None declaredSUMMARYObjective: To determine the factors that increase the chances of a woman in Accra having a Pap smear and whether women who have recently visited clinics have higher chances of having had Pap smears. Design: A cross-sectional studyMethods: A representative sample of women in Accra, Ghana was interviewed and the clinical and demo-graphic factors influencing cervical cancer screening was assessed. Results: Out of 1193 women with complete data, only 25 (2.1%) had ever had a Pap smear performed though 171 (14.3%) had their last outpatient clinic visit for either a gynaecological consultation or a regular check up. Simple logistic regression showed that a high edu-cational level, high socioeconomic status and a history over the past month of postmenopausal or intermen-strual bleeding significantly increased the odds of ever having a pap smear. Neither monthly income nor last clinic visit for a gynaecological consultation or regular check up increased the odds of having a pap smear. Multiple logistic regression showed that a high educa-tional level and experiencing postmenopausal or inter-menstrual bleeding were the most important determi-nants of ever having a Pap smear.Conclusion: While we wait for a national program for cervical cancer screening, there is a need for clinicians to put more individual effort into ensuring that asymp-tomatic women are screened for cervical cancer.Keywords: cervical cancer, cervical cancer screening, Pap smear, Accra, GhanaINTRODUCTIONCervical cancer is the commonest gynaecological ma-lignancy seen at the Korle Bu teaching hospital, being reported to make up 64% of gynaecological malignan-cies seen at the hospital.1  Cervical cancer is however known to be a preventable disease. Cervical cancer is strongly associated with Human Papilloma Virus(HPV) infection, which can be acquired through sexual inter-course.2This implies that prevention of cervical cancer can be achieved through the same measures recommended for prevention of HIV and sexually transmitted infections (STIs) and also through cervical cancer screening. Ab-stinence from sexual intercourse, having only one sex-ual partner and consistent correct condom use are the methods recommended to prevent STIs. Cervical can-cer screening in many hospitals in Accra is done by Papanicolau (Pap) smear and visual inspection of the cervix with acetic acid (VIA).3,4 Cervical cancer screening procedures are able to detect pre-malignant lesions of the cervix which can be treated and so pre-vent progress to cervical cancer. Pre-malignant cervical lesions are generally asymptomatic, hence the need for cervical cancer screening programmes that target healthy women.Ghana currently does not have a national cervical can-cer screening programme. In the absence of this, most of the cervical cancer screening that takes place in the country can be described as opportunistic screening, where doctors request Pap smears or VIA for patients who are seen in clinics for either general medical ex-aminations or for consultations unrelated to cervical cancer. There has been a lot of public education in Ghana on cervical cancer and medical students are reg-ularly taught about the lethal nature of cervical cancer and the importance of cervical cancer screening. De-spite this education previous studies have shown very low rates of patronage of cervical cancer screening services.5-7In the absence of a national cervical cancer screening programme it is necessary to assess the effectiveness of doctors in the performance of opportunistic screening. A previous study has shown that very few women have regular medical check-ups5 and so one area in which opportunistic screening could be maximized is when women visit general and gynaecology clinics for cura-tive services since Pap smears could be performed easi-ly by general duty medical officers who have been trained to carry out the procedure. June 2010 R.M.K. Adanu et al                Cervical cancer screening in Accra60The Women’s Health Study of Accra (WHSA) is a representative study of women in Accra performed in 2003 to determine the burden of disease among wom-en. There have been a number of publications from this study on different health issues.6-11 This paper is a sub-analysis of the WHSA data focusing on the determi-nants of women in Accra having a Pap smear. The WHSA did not inquire about VIA since it was not available in many hospitals at the time of the study.The aim of this sub-analysis is to determine the factors that increase the chances of a woman in Accra having a Pap smear and whether women who have recently vis-ited clinics have higher chances of having had Pap smears. SUBJECTS AND METHODSThis study was a population-based cross-sectional sur-vey that was conducted in 2003.8 Using the data from the Ghana 2000 census, the 1731 enumeration areas in Accra were stratified by socio-economic status and 200 were selected with probability proportional to popula-tion size within the socio-economic strata. Each house-hold in the selected strata was visited in order to com-pile a list of women aged 18 and older who were usual-ly resident in the household. A random sample of 17 women per enumeration area was selected for the sur-vey. A total of 3183 women were interviewed at home, with a questionnaire, by trained interviewers between March and September 2003. The interview included questions on demographic characteristics, lifestyle hab-its, living conditions, general health and reproductive health. The questions on reproductive health included questions on family planning, abortion, deliveries, gy-naecological surgeries, gynaecology consultations and cervical cancer screening.For this sub-analysis, data on cervical cancer screening by the women interviewed were entered into Stata 8 software. Entries with incomplete data were dropped from the analysis and both simple and multiple logistic regressions were performed to determine significant determinants of ever having a pap smear performed. Statistical tests used were chi square tests for categori-cal data and the t test for comparing means. The inde-pendent variables studied were age, age at first inter-course, lifetime number of sexual partners, educational status, marital status, socio-economic status, history of abnormal vaginal bleeding and last visit to clinic being on account of gynaecological symptoms. A p value of 0.05 was considered as significant in the analysis.RESULTSOut of the total of 3183 women interviewed, 1899 (59.7%) either did not answer the question on cervical cancer screening or stated that they did not know whether they had ever had a Pap smear performed. Of the remaining 1284 respondents, 91(7.1%) were dropped because of incomplete data. The analysis was therefore restricted to 1193 respondents.Table 1 Selected demographic characteristics of wom-en from the 2003 Women’s Health Study of AccraCharacteristic Value/ NumberPercent-ageMean Age(yrs) 48.1 n/aMean age at first inter-course(yrs)18.9 n/aMean lifetime number of partners2.4 n/aHighest Educational levelNever been to school 362 30.3Primary education 121 10.1Junior secondary education 500 41.9Senior Secondary education 133 11.2Tertiary education 77 6.5Marital statusNever married 148 12.4Currently married 475 39.8Wid-owed/Divorced/Separated515 43.2Ever married/current status unknown55 4.6Socio-economic statusHighest socio-economic group243 20.4Fourth socio-economic group 248 20.8Middle socio-economic group225 18.9Second socio-economic group246 20.6Lowest socio-economic group231 19.4IncomeNot in formal employment 278 23.3Less than GHC 30 per month 301 25.2GHC 30 – GHC 50 per month244 20.5GHC 50 – GHC 100 per month289 24.2Above GHC 100 per month 81 6.8n/a – not applicableThe demographic characteristics of the 1193 respond-ents are shown in Table 1. The mean age was 48.1 years (SD 17.7). About 30% of the respondents had no formal education and 20% belonged to the highest so-cio-economic group. June 2010 Volume 44, Number 2 GHANA MEDICAL JOURNAL61The mean age at first intercourse was 24.4 (sd 20.5) with the mean number of lifetime sexual partners being 2.4. One hundred and seventy one (14.3%) of the re-spondents had their most recent clinic visit for either a general check-up or a gynaecological consultation. One hundred and twenty five women (10.5%) had a com-plaint of experiencing an abnormal vaginal bleed at the time of the last clinic visit.Only 25 respondents (2.1%) reported ever having had a Pap smear examination performed. Table 2 shows the comparison between the women who had a Pap smear performed and those who did not. The women who had ever had a Pap smear performed were of significantly higher educational status and higher socio-economic group than those who had never had a Pap smear. Of the 1168 women who had never had Pap smears per-formed, 164 (14.0%) had their last clinic visit for a general check-up or for a gynaecologic consultationWhereas 28% (7/25) of women who had ever had a Pap smear had a complaint of abnormal vaginal bleed-ing on the last clinic visit, the corresponding percent-age among women who had never had a Pap smear was 10.1%. There was a statistically significant difference in the proportion of women with abnormal vaginal bleeding in both groups.Table 3 shows a stratification of the Pap smear history of the respondents by a complaint of abnormal vaginal bleeding on the last clinic visit.Tables 4 shows the results of the simple and multiple logistic regressions performed. A woman from a low socio-economic group had an 86% reduction in the odds of ever having a Pap smear while having no for-mal education reduced a woman’s odds of ever having a Pap smear by 91%. Although having one’s last clinic visit for a gynaecological consultation or for a regular check-up did not significantly affect a woman’s chance of having had a Pap smear, a complaint of abnormal vaginal bleeding increased the odds of having a Pap smear almost four-fold. However upon controlling for the factors indicated in Table 4, only educational status and a complaint of abnormal vaginal bleeding on the last clinic visit significantly affected the odds of having a Pap smear performed.Table 2 Comparison between women from the 2003 Women’s Health Study of Accra who had a Pap smear and those who did notCharacteristic Pap smear (%)No Pap smear (%)p valueEver been to school24 (96.0) 811 (69.4)0.004Educated to ter-tiary level8 (32.0) 69 (5.9) <0.001High socio-economic status14 (56.0) 229 (19.6)<0.001Income above GHC 1003 (12.0) 78 (6.7) 0.47Mean age 53.3 48.0 0.14Age at first in-tercourse18.8 18.9 0.67Table 3 Comparison of women in the 2003 Women’s Health Study of Accra by Pap smear status and history of abnormal bleedingType of bleeding Pap smear (%)No Pap smear (%)p valuePostmenopausal bleed3 (12.0) 23 (2.0) 0.001Intermenstrual bleed3 (12.0) 35 (3.0) 0.011Menorrhagia 2 (8.0) 80 (6.9) 0.822Table 4 Crude and adjusted odds ratios from logistic regression of determinants of Pap smear status among women from 2003 Women’s Health Study of AccraComparison Crude odds ratioConfidence intervalp value Adjusted odds ratio*Confidence intervalp valueLow SES vs High SES 0.14 0.03 -0.64 0.01 0.28 0.05 -1.42 0.12No formal education versusFormal education0.04 0.01 – 0.70 0.02 0.10 0.01 – 0.87 0.004Last clinic visit for gynaecology consult versus no gynaecology consult2.39 0.98 – 5.79 0.06 1.99 0.78 – 5.12 0.15Abnormal vaginal bleed versus no abnormal vaginal bleed3.49 1.42 – 8.46 0.01 4.23 1.59 -11.3 0.004*Age, Age at first intercourse, lifetime number of partners and monthly income were all controlled for in the multiple logistic regression.June 2010 R.M.K. Adanu et al                Cervical cancer screening in Accra62DISCUSSIONThis study shows that only 2.1% of women in Accra have had a Pap smear performed. A woman is more likely to have a Pap smear if she has had some formal education and is of high socioeconomic status. Of the women who had never had a Pap smear, 14% had their last clinic visit being for a gynaecological consultation. Women who had ever had a Pap smear were more like-ly to have a history of abnormal vaginal bleeding.The low patronage of Pap smear services in Accra has been reported in earlier publications.5,10,11 This low patronage could be attributed to the absence of a na-tional cervical cancer screening programme. The effect of educational status on cervical cancer screening is confirmed by a recent publication which reports a 12% screening rate among university students.12The Pap smear detects premalignant lesions of the cer-vix so that a woman can be offered treatment before the disease progresses to invasive cancer. Premalignant cervical lesions are asymptomatic, whereas invasive cancer usually presents with post-coital bleeding. Due to the asymptomatic nature of premalignant cervical disease, the Pap smear is a screening test that is per-formed for women as part of a general gynaecological examination even in the absence of symptoms that are suggestive of cervical cancer. This study shows that many women who visited clinics with gynaecological symptoms did not have Pap smears performed as part of the general gynaecological consultation. Fourteen per cent of the women who had never had a Pap smear performed had last visited a hospital or clinic for a gy-naecology consultation. If a Pap smear had been per-formed for these women during their gynaecology con-sultation, the proportion of women in this sample who would have had Pap smears would have increased from 2.1% to 15.8%. There is therefore an obvious problem of missed opportunities in cervical cancer screening in Accra in particular and Ghana as a whole.One reason why these missed opportunities for cervical cancer screening might be present in Accra could be due to the set-up at gynaecology clinics. In order for a Pap smear to be performed in a public sector hospital, a doctor needs to make a special request for the woman to purchase a Pap smear kit which she brings to the clinic on another visit for the test to be performed. The Pap smear test is not covered by the national health insurance and costs GHC30 (US$20). Before the Pap smear test can be performed there might be the need for purchase of a disposable speculum at GHC1.50 (US$1). These costs are prohibitive for a large propor-tion of Ghanaian women, given the statistic that about 45% of the Ghanaian population lives on less than US$ 1 per day.13 Even though the cost of the Pap smear is a one- time cost, the average Ghanaian woman might find it difficult to justify spending this amount of mon-ey on a preventive health service in the face of compet-ing financial demands. This situation could explain the over-representation of the educated and those of high socio-economic standing among women who have had a Pap smear performed. The ideal situation, in a coun-try without a national cervical cancer screening pro-gramme, is one in which every woman who attends a gynaecology consultation has a Pap smear performed as part of the tests for her complaint. This situation can however be easily achieved only when the items for performing a Pap smear are present in the consultation room and the costs are covered by the national health insurance scheme.The finding that a history of abnormal bleeding is over-represented in women who have had a Pap smear sug-gests that doctors are requesting Pap smears mainly when women come in with symptoms that raise the possibility of a uterine or cervical malignancy. This practice suggests that the Pap smear is being used as a diagnostic test rather than as a screening test. The diffi-culty of getting a Pap smear performed and the cost of the procedure could have resulted in a practice where the test is no longer being used as a screening proce-dure but rather as a diagnostic test. However such a practice will not lead to effectively reducing the inci-dence of cervical cancer in Ghana.In order to reduce the incidence of cervical cancer in Ghana there is the need for a national cervical cancer screening programme, established by the Ministry of health and Ghana Health Service which is supported by the national health insurance scheme. However, until this happens there is the need for dialogue between pathology and gynaecology units so that the Pap smear kits can be easily available in gynaecology consulting rooms with arrangements for the recovery of the asso-ciated costs. Gynaecology units also need to establish a protocol whereby every new gynaecology patient who is sexually active should have a Pap smear performed as part of the required investigations.REFERENCES1. Nkyekyer K. Pattern of gynaecological cancers in Ghana. East Afr Med J 2000 Oct;77(10):534-8.2. Bekkers RL, Meijer CJ, Massuger LF, Snijders PJ, Melchers WJ. Effects of HPV detection in popula-tion-based screening programmes for cervical can-cer; a Dutch moment. Gynecol Oncol 2006 Mar;100(3):451-4.3. Sanghvi H, Limpaphayom KK, Plotkin M, Cha-rurat E, Kleine A, Lu E, et al. Cervical cancer screening using visual inspection with acetic acid: June 2010 Volume 44, Number 2 GHANA MEDICAL JOURNAL63operational experiences from Ghana and Thailand. Reprod Health Matters 2008 Nov;16(32):67-77.4. Adadevoh SW, Forkouh BK. Cervical cancer screening; first results and future directions in Ghana. Int J Gynaecol Obstet 1993 Oct;43(1):63-4.5. Adanu RM. Cervical cancer knowledge and screening in Accra, Ghana. J Womens Health Gend Based Med 2002 Jul;11(6):487-8.6. Duda RB, Chen GL, Hill AG, Darko R, Adanu RMK, Seffah J, et al. Screening for cervical cancer still not included as routine health care for women. International Journal of Tropical Medicine2005;1(1):1-6.7. Chen GL, Duda RB, Hill AG, Darko R, Adanu RMK, Seffah J, et al. Epidemiology of cervical cancer and dysplasia in a cross-sectional study of women in Accra, Ghana. International Journal of Tropical Medicine 2005;1(1):7-11.8. Hill AG, Darko R, Seffah J, Adanu RM, Anarfi JK, Duda RB. Health of urban Ghanaian women as identified by the Women's Health Study of Accra. Int J Gynaecol Obstet 2007 Nov;99(2):150-6.9. Adanu RM, Hill AG, Seffah JD, Darko R, Anarfi JK, Duda RB. Sexually transmitted infections and health seeking behaviour among Ghanaian women in Accra. Afr J Reprod Health 2008 Dec;12(3):151-8.10. Adanu RM, Hill AG, Seffah JD, Darko R, Anarfi JK, Duda RB. Secular trends in menarcheal age among Ghanaian women in Accra. J Obstet Gy-naecol 2006 Aug;26(6):550-4.11. Duda RB, Kim MP, Darko R, Adanu RM, Seffah J, Anarfi JK, et al. Results of the Women's Health Study of Accra: assessment of blood pressure in urban women. Int J Cardiol 2007 Apr 12;117(1):115-22.12. Abotchie PN, Shokar NK. Cervical cancer screen-ing among college students in Ghana: knowledge and health beliefs. Int J Gynecol Cancer 2009 Apr;19(3):412-6.13. Ibrahim Index of African Governance. Mo Ibrahim Foundation 2008http://www.moibrahimfoundation.org/en/section/the-ibrahim-index

Clinic visits and cervical cancer screening in Accra

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Clinic visits and cervical cancer screening in Accra

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