"She Must Have Been Sleeping Around"...: Contextual Interpretations of Cervical Cancer and Views Regarding HPV Vaccination for Adolescents in Selected Communities in Ibadan, Nigeria

Human papillomavirus (HPV) vaccines for adolescents are pivotal in the control of cervical cancer, which was the most commonly occurring cancer in Nigerian women in 2013. The acceptability of the HPV vaccine has been high in the African countries that have introduced it, despite the low knowledge of cervical cancer that has been reported in these countries. The reason for this mismatch is not clear. In an effort to understand decision making regarding adolescents' uptake of HPV vaccine, this study explored contextual interpretations of stakeholders regarding cervical cancer and HPV vaccine in 5 selected communities in Ibadan, Nigeria. The purpose of illuminating the African outlook regarding the disease and vaccine is to help structure research and interventions targeted at cervical cancer control and to provide possible ways of promoting these interventions.

This study was carried out in Ibadan North Local Government Area (LGA), specifically, in Òjé, Yemetu, Òkè Aremo, Beere, and Aláàádorin. The traditional system of government is still operational in these communities, and the traditional chiefs are the custodians of the people's culture. The study communities are very religious and the religious leaders highly respected, which make them wield a lot of influence on what are viewed as norms by community members. Christianity and Islam are the dominant religions, but some traditionalists still worship the traditional gods. Traditional healers provide traditional medical care for different health conditions, including cervical cancer management. The HPV vaccine was already licensed in Nigeria at the time of this study but was not yet introduced into the routine immunisation programme.

Qualitative data were collected through 20 focus group discussions (FGDs), with 4-12 participants each, among parents of adolescents, religious and traditional leaders, school teachers, and adolescents. Four key informant interviews (KII) were also conducted with each identified traditional healers in the communities. In all, there were 190 participants, and 110 were males. All the traditional leaders were males and almost all the religious leaders, except the second group of Christian religious leaders, which had 2 women.

The following themes were identified:

• Awareness about cervical cancer: Almost all the groups included at least one person who had seen a patient with cervical cancer before. More women than men had heard about cervical cancer. The most common places where contact with cervical cancer information occurred were health facilities and church outreach programmes.
• Perceived causes of cervical cancer: Promiscuity of women was mentioned in all the groups as being the cause of cervical cancer. Generally, the older participants believe that cervical cancer is a new disease that came about as a result of civilisation and change in lifestyle. There was also a general notion that it was due to a curse.
• Perceived ways of prevention of cervical cancer: The traditional healers and some participants still believed that the traditional medicines were effective in the management of cervical cancer.
• Views about HPV vaccine for adolescents in the prevention of cervical cancer: Many participants believed the HPV vaccine was a good idea, but there were some who were not willing to take the vaccine or allow their children or worshippers to take it. This latter view was expressed more by both the Christian and Islamic religious leaders. The high cost of the vaccines and possibility of side effects were the main concerns about the introduction of HPV vaccine. The decision to take the vaccine rested with the fathers, whose views were heavily influenced by traditional and religious leaders.
• Suggested structure of a successful HPV vaccination programme for adolescents: The suggested steps included: increasing awareness about the vaccine, subsidising the cost of the vaccine, obtaining parental consent, vaccinating males as well, involving opinion leaders, and covering adolescents in hard-to-reach places.

In reflecting on these findings, the researchers worry that the general notion that cervical cancer is caused by promiscuity of women can result in the stigmatisation of cervical cancer patients, and this can affect the quality of care and support they receive. This is in addition to the already-existing complex of late presentation (of woman to the physician with symptoms), inadequate manpower and equipment to treat cervical cancer, and lack of supportive networks in the study area. This implies that patients diagnosed with cervical cancer in this environment are likely to have had harrowing experiences. A similar view about cervical cancer was reported by women in a South African study that looked at the constructions of cervical screening and womb cancer among rural black women. The female participants in this study said they would rather not report the symptoms should they have cervical cancer because the disease meant "disgrace" due to its association with promiscuity. "It is therefore important that more efforts should be channeled towards improving the knowledge about the HPV and cervical cancer, as this will remove the stigmatisation associated with the disease, thereby improving the acceptability of the preventive measures for cervical cancer."

The view that cervical cancer is a "curse" can also contribute to stigmatisation of women with cervical cancer. Curses are believed to be as a result of wrongdoing, and one of the results is disease, which in this case is cervical cancer. This belief can negatively affect the way women with cervical cancer are viewed, and it can extend to cervical cancer preventive services.

The notion that immunising adolescents with HPV vaccine would be a license to indulge in sexual activities is a concern that has been expressed by different stakeholders in different settings. It is rare for Nigerian parents to talk openly about sex with their adolescents, which has negative implications for Nigerian adolescents' sexual and reproductive health. Parents also believe that it is their responsibility to ensure that children, especially girls, remain chaste until they are married. Many of them, however, do not appreciate the fact that their control over their children's initiation of sex is highly limited, with the exposure adolescents now have to information around them and the experimental nature of adolescents themselves. However, this concern about HPV vaccine and promiscuity among adolescents has been repeatedly shown to be unfounded in the literature, as adolescents who had HPV vaccine were not found to be initiating sex earlier than those who did not receive the vaccine.

The association of contraceptive use with cervical cancer can impact negatively on the use of contraception in the study communities. The Islamic religious leaders associated condom use with cervical cancer, and almost every group mentioned contraception as a cause of the disease, because they have seen women bleeding due to complications of contraception use. It is also important to note that younger women believed that the use of condom can actually protect against cervical cancer, but the stigmatisation associated with possession of condoms in the study area was seen as a barrier to condom use in cervical cancer prevention. The use of modern contraception has remained suboptimal in Nigeria, and this stigmatisation may be one of the reasons for the low uptake. The researchers contend that this misconception can be corrected with intensive and well-targeted public health awareness programming.

Furthermore, "It is important to target older people for enlightenment about the correct cause of cervical cancer as they may find it difficult to allow their adolescents to uptake HPV vaccine if they don't appreciate that HPV virus [versus civilisation] is responsible for almost all cases of cervical cancer."

The reports of earlier successes by traditional healers in handling cervical cancer was difficult to verify, as traditional healers usually do not keep records and, where they exist, details of what was seen and done are usually kept secret. This secrecy has hindered the development of African traditional medicine, and it makes it difficult to modernise the activities of traditional healers. Collaboration among the traditional healers could help in developing this trade, but this apparently is uncommon, as only one of the traditional healers interviewed talked about having collaborations with other traditional healers.

Refusal of some religious leaders to accept HPV vaccine may be detrimental to the success of the vaccine programme for adolescents. This is because of the influence they have on their followers, who form a significant part of the population. "Although HPV was presented in this study as being sexually transmitted for research purpose, there is a need to desexualise HPV vaccine by emphasizing the other routes of transmission like instrumentation and mother to child routes. This may be useful in removing this misconception."

"In conclusion, knowledge about cervical cancer in Nigeria may not be as low as earlier reported in Nigeria as evidenced the increase in the number of people who reported having seen people with cervical cancer when they were presented with the symptomatology of cervical cancer in the present study. Cervical cancer research in Nigeria and Africa as a whole may give different outcomes if this approach is used, and this brings to fore the need to investigate local names cervical cancer is called in this region. The contextual interpretation of cervical cancer was highly varied in this study population and reflected the cultural values of the community about women being faithful to their partners. It also showed in their perceptions about what constituted unhealthy living which were believed to be responsible for cervical cancer. These interpretations are significant and it is important to address them to avoid stigmatisation of cervical cancer, improve disease detection, presentation and promote uptake of prevention procedures. HPV vaccine was seen as a good idea by many who were also willing to encourage its uptake, but health promotion intervention is required for the groups who were not favourable towards the vaccine."