The Women Who Fear the Unknown: Potential Drivers of the Cervical Cancer Epidemic in Rural Nigeria

Background: Visual inspection of the cervix under acetic acid is the most cost-effective method for the control of cervical cancer in sub-Saharan Africa. The region bears about 90% of the global burden of the disease accounting for about 85% of new disease and more than 90% of the mortality. The WHO piloted a largely successful community-based cervical screening in six African countries including Nigeria between 2009 and 2012. Community-based cervical screening was subsequently adopted in Nigeria as a major strategy for preventing cervical cancer. An evaluation of the community-based cervical screening in two rural local government areas in Ogun state, Nigeria, however, revealed that more than 95% of sexually active women had never had cervical screening done despite availability of the services. A substantial number of these women would not want to have cervical screening done because of the fear of a positive cervical screening result. Aim: The current study explored the characteristics of women who are unwilling to have cervical screening because of the fear of a negative result in two rural local government areas in Nigeria. Methods: A post hoc analysis of data collected for the evaluation of community-based cervical screening in two rural LGAs in Nigeria. The analysis described the characteristics of 700 sexually active women aged 25 to 64 years who declined to have cervical screening. The socio-demographic characteristics, perception (0 to 6) and knowledge scores (0 to 36) of the participants were fitted into a multivariate logistic regression model to predict the fear of an unfavorable cervical screening result. Results: About 81% (567) of the women were unwilling to get a cervical screening due to the fear of a negative result. Age, gravidity, knowledge, and perception about cervical cancer and screening were associated with the women declining cervical screening due to the fear of a negative result. On multivariate logistic regression analysis age (OR: 0.968, P = 0.007) and knowledge score (OR: 0.914, P < 0.001) were found to predict the fear of a negative result. The adjusted outcome variable model showed fair discrimination (AUC = 0.67) and good calibration ( P = 0.416). Conclusion: Many women in rural Nigeria decline to have cervical screening mainly because of the fear of a negative result which is in turn predicted by younger age and poorer knowledge scores about cervical cancer and screening. There is a need for further qualitative research to explore the dimensions of fear as it relates to refusal to have cervical screening among rural women in Nigeria.