Cervical cancer is one of the leading causes of cancer-related deaths in women. Every year, more than 500,000 women are diagnosed with cervical cancer, which results in over 300,000 deaths globally. Moreover, 90% of cervical cancers occur in low-middle-income countries that lack organised screening and HPV vaccination programmes. The study aimed to assess the knowledge level of women on cervical cancer in the Old Tafo market in the Ashanti Region.  A cross-sectional study was conducted using a pre-tested structured questionnaire. A total of 215 market women took part in the study. The predominant age group was 45-54 years. Out of the 215 respondents, only 39.0% had heard of cervical cancer. Furthermore, only 4.0% of the participants had undergone screening for cervical cancer. The participants had insufficient knowledge regarding the cause, risk factors, screening methods, and prevention of cervical cancer. The study showed that most of the participants did not know about cervical cancer while a lot more did not know about its screening and preventive measures. To address the low participation of women in cervical cancer screening, health promotion activities must be implemented to improve awareness of these important screening methods to help reduce the incidence of cervical cancer morbidity and mortality.

Keywords

Cervical cancer, vaccination, cervical cancer knowledge in Ghana, Cervical cancer awareness in Ghana, cervical cancer screening in Ghana.

Cervical cancer (CC) is a cancer of the cervix, and it is one of the leading causes of cancer-related deaths in women. High-risk subtypes of the Human Papillomavirus (HPV) are responsible for many CC cases (Walboomers et al., 1999). According to the Global Cancer Statistics (GLOBOCAN) 2020, CC accounted for approximately 604,000 new cancer cases and 342,000 deaths worldwide in 2020, and it was the fourth most common cancer in females worldwide in the same year, with over eighty percent of the CC cases recorded from resource-limited settings. (Sung et al., 2021). In Africa, CC is the leading cause of cancer-related deaths among women (Singh et al., 2023). The distribution of CC cases and mortality depends on the availability of CC screening resources.(Quinn et al., 1999; Willoughby et al., 2006).

Over the years, there have been a lot of advances in improving the knowledge and awareness of CC. Despite these advances, CC remains an important cause of cancer morbidity and mortality in low-resource-settings with limited access to CC screening and prevention programmes. The prevalence of CC is estimated to be about 15.7 per 100,000 women in resource-limited countries (Sung et al., 2021). This is higher compared to the prevalence in developed countries (Singh et al., 2023). In Ghana, it is estimated that, every year, approximately 3,151 women are diagnosed with CC and 2,119 die from the disease (Bray et al., 2018). The level of awareness of CC and its preventive measures remains low in sub-Saharan Africa. Education of women on the availability of cervical screening and preventive measures will help reduce the high CC morbidity and mortality in sub-Saharan Africa. (Ayinde et al., 2006; Bray et al., 2018; Pandey, 2017; Williams et al., 2018).

HPV infections play a relevant role in the aetiopathogenesis of CC and are detectable in more than 90 percent of CCs. CC is caused by high-risk subtypes of HPV. (Okunade, 2020; Schiffman et al., 2007). CC is associated with immunosuppression including HIV/AIDS and unsafe sexual practices (Comlan et al., 2012; Waggoner, 2003; Wong et al., 2009). Risk factors associated with HPV-related CCs include early onset of sexual activity, multiple sexual partners, high-risk sexual partners, history of sexually transmitted infections, early age at first birth, high parity and immunosuppression. (Anttila et al., 2001; Appleby et al., 2006; Berrington De González & Green, 2007; Castellsagué et al., 2002; Waggoner et al., 2010). Non-HPV-associated risk factors for CC include higher poverty status, oral contraceptive use, cigarette smoking and genetics (Singh et al., 2003; Yoo et al., 2017; Yu et al., 2019). The incidence of CC was found to be lower in women whose male sexual partners were circumcised (Castellsagué et al., 2002).

In the early stages of CC, patients may be asymptomatic, and CC may be picked up during routine CC screening. This emphasizes the need for CC screening. In symptomatic CC, the common symptoms at presentation include irregular vaginal bleeding and post-coital bleeding. Some patients may also present with malodorous vaginal discharge. In advanced CC, there may be lower backache, bowel and urinary symptoms. (Frumovitz, 2021).

The definitive diagnosis of CC requires histological evaluation of a cervical biopsy (Nakamura et al., 2015).  Symptomatic patients without visible cervical lesions and those with only abnormal cervical cytology should undergo colposcopy with directed biopsy (Frumovitz, 2021).

A key component of primary prevention of CC involves the use of HPV vaccines. These offer protection from CC.  It was found that the awareness about the CC vaccine is low (Chawla et al., 2016; Khoo et al., 2011). Health education can improve awareness of CC (Amosu et al., 2011)

CC is a preventable cancer. CC screening can detect early-stage disease and precursor lesions which when treated can prevent the development of invasive CC and reduce CC-related deaths. The available methods for CC screening include the use of the Papanicolaou smear (Pap smear), visual inspection with acetic acid (VIA), HPV testing, or a combination of the Pap smear and HPV testing. (Denny, 2019). This helps in the early detection of CC and ensures early treatment which saves lives and reduces mortality. There is low utilization of these screening options and there is a need to improve awareness about these cervical screening tools among women (Ndikom & Ofi, 2012; Wong et al., 2009).

The advancement of the care and treatment of CC remains key in the its management (Cohen et al., 2019; Grischke & Brucker, 2019).

A lot of women may not report to a health facility when they experience early symptoms of the disease because of the misconceptions about CC (Anorlu, 2008). This may account for the high CC mortality seen in developing countries as most women would only report in the late stages of the disease (Abotchie & Shokar, 2009). A study conducted in Ghana by Abotchie and Shokar found that the level of knowledge of CC and the awareness of CC screening were low. Only a few people were aware of the link between HPV and the development of CC; fewer were aware of CC screening projects based on visual inspection with acetic acid (Abotchie & Shokar, 2009).

Although various studies have assessed CC awareness in diverse groups, there is limited studies on the level of CC screening awareness among market women in the Ashanti Region. Thus, this study aimed to assess knowledge and awareness of prevention and screening measures of CC amongst market women in Old Tafo in the Ashanti Region.

A descriptive cross-sectional study was carried out among market women aged above 18 years at the Old Tafo market, one of the biggest markets in the Ashant Region. Old Tafo is a town in the Old Tafo Municipal area in the Ashanti Region of Ghana. The town is located approximately 9.8km from the city centre of Kumasi. The study was conducted among market women because they represented a population of women with varying levels of literacy and at different stages of their reproductive lives.

Data was collected using a pretested structured questionnaire.

A sample size of 215 was calculated using the Cochrane’s formula. N = Z² *p*q / e².

Where,                                                                                  

Z = z score corresponding to a 95% confidence interval (1.96)

p = prevalence of knowledge of CC screening in Ghana. This was found to be 8% based on a population level study in Ghana (Ebu et al., 2015) .

q = 1-p

e = sampling error (±5%)

N = 113.1 which is approximately 113.

A total of 215 market women were recruited into the study.

By systematic random sampling, structured questionnaires were distributed to the women at the Old Tafo market. The stalls and tables in each segment of the market were assigned numbers. After selecting the first stall purposively, the rest of the participants were recruited from every third stall.  A structured questionnaire was used to collect data from participants. The questionnaire had three parts. The first part dealt with the demographic features of the respondents while the other sections addressed the specific objectives.

The study was explained to clients who met the inclusion criteria. Signed informed consent was obtained from those who agreed to partake in the study. The questions were read and explained to participants who could not read. The questionnaires were collected and kept in a secure place, and the data was analysed with IBM’s Statistical Package (SPSS) version 19. The information gathered was entered into Microsoft Excel to generate the needed diagrams.

Ethical clearance and approval were obtained from the Committee of Human Research and Publication Ethics of the Kwame Nkrumah University of Science and Technology (CHRPE/AP/488/21) and permission was sought from the Old Tafo Municipal Assembly. Participants received adequate information about the topic and informed consent was obtained before data was collected and used. The participants had the option to withdraw from the study at any point in time.

Sociodemographic characteristics of participants

 A total of 215 participants were recruited, 27.4% were aged between 45-54 years, 24.5% were aged between 35-44 years and 20.5% were aged between 25-34 years. Most of the participants (50.7%) had no formal education, 23.7%, however, had education to the secondary level. While 53.5% were married, 23.3% were single.

Knowledge about cervical cancer

Less than half of the participants (39.0%) had heard of CC. Among those who had heard of CC, 50.0 % heard of it on television. Only 44 (20.5%) of the participants correctly answered the questions testing participants' knowledge of CC. Many of the participants (70.7%) did not know anything about CC as shown in Table 1.

Only 44 (20.5%) knew that CC is cancer of the cervix while 71 (33.0%) stated that CC affects women. Most of the participants (178, 82.3%) did not know what causes CC and only 10 (4.7%) of participants knew that CC is caused by a virus.

Table .1: Knowledge of cervical cancer

Knowledge of risk factors

The knowledge of risk factors for CC among the participants was low as shown below. Table 2 shows a summary of the frequencies (percentages) of the responses received.

Table.2: Risk factors of cervical cancer

Knowledge of treatment and prevention strategies for cervical cancer

Only 69 (32.1%) of respondents knew that treatment and prevention options for CC were available in the hospital. 43 (20%) knew that CC can be prevented by regular screening, while only 32 (14.9%) respondents knew CC can be prevented by using condoms during sexual intercourse. Only 19 (8.8%) respondents knew HPV vaccination as method of preventing CC.

Screening status

Only 9 (4%) of the respondents had been screened for CC, and 176 (82%) of the participants did not know about screening as a measure of early detection.

Awareness of cervical cancer

A total of 215 respondents took part in this study. The findings indicate that 39.0% had heard of CC.    This is low and may imply that awareness campaigns have not been adequate to create CC awareness in the Ashanti region. This finding is similar to a study conducted in Ghana among female university students between the ages of 20 and 35, where it was found that the awareness of CC was 53.4% (Binka et al., 2016). Furthermore, it was similar to a study conducted among market women in Lagos, Nigeria where only about a quarter of participants had heard of CC (Wright et al., 2010). In another study conducted among women living in Bosore in Ghana,  55.5% of the participants were aware of CC (Gyamfua et al., 2019).

There is however, a high incidence of CC morbidity and mortality in the sub-Saharan Africa region (Ayinde et al., 2006; Ba et al., 2021; Burt et al., 2021; Jedy‑Agba et al., 2020; Nyasenu et al., 2019; Singh et al., 2023; Williams et al., 2018). 

Participants indicated that they heard of CC mainly through the media, 50.0% of the participants said they heard of CC on television and 25.0% on the radio. These numbers imply that the media is an important communication tool by which women can be educated on CC.  Since less than 10% of participants had heard of CC from a health facility.  This suggests that health education on CC is not adequate. Health personnel should be motivated to educate women on CC.

Knowledge about cervical cancer

The study sought to assess the knowledge level of CC among women at the Old Tafo market. This low knowledge level may be attributable to the fact that most of the participants had not heard of CC before enrolling in the study. The findings of the study indicate that only a fifth of the participants knew that CC is cancer of the cervix while only a third of the participants correctly identified that CC affects only women. The low knowledge level of CC implies participants do not know how to protect themselves from the disease. Thus, educating individuals on CC is an important aspect of CC prevention (Ayinde et al., 2006).

CC is associated with high-risk sexual behaviours (Berrington De González & Green, 2007), however, most of the participants did not know that it is caused by HPV infection and that HPV is sexually transmitted. The knowledge of participants on the risk factors of CC was low.  Furthermore, most of the participants did not know that CC can be diagnosed early with a Pap smear. Only 23.7% of the participants knew that CC can be prevented and is also treatable which is similar, to a study conducted among market women in Nigeria, where 35.0% of participants knew about Pap smears (Adetule, 2016). This disparity may be explained by the vast difference in the level of education between the women in both studies.

Only a fifth of the participants knew that regular CC screening is protective against CC, while 14.9% of the participants were aware that the use of condoms protects against CC. Moreover, only 8.8% of participants knew that CC can be prevented by vaccination. This finding is somewhat lower compared to a study conducted by Khoo et al where 42.2% of rural dwellers in Malaysia knew of HPV vaccination. (Khoo et al., 2011). 

CC continues to affect women in low-resource settings due to the low awareness and low availability of CC screening methods (Ayinde et al., 2006). The study findings show a low level of knowledge and awareness of CC screening methods.

The availability of the Pap smear has revolutionised the early detection and management of CC since a Pap smear allows the early detection of pre-cancerous lesions and prevents the development of invasive CC (Denny, 2019). Therefore, it is important that awareness is created about CC screening methods to encourage more women undergo regular CC screening.

The level of awareness of CC and screening is low among market women in the Old Tafo Market. The knowledge of risk factors, symptoms and prevention is also very poor. The women had insufficient knowledge about cervical screening and vaccination. Consequently, the uptake of cervical screening services was also low.

The level of awareness of CC and screening is low among market women in the Old Tafo Market. The knowledge of risk factors, symptoms and prevention is also very poor. The women had insufficient knowledge about cervical screening and vaccination. Consequently, the uptake of cervical screening services was also low.

Limitations of the study

This is a single-centre study among women at the Old Tafo Market and may not be representative of other market women in the country.

Conflict of interest

There was no conflict of interest.

Abotchie, P. N., & Shokar, N. K. (2009). Cervical cancer screening among college students in Ghana knowledge and health beliefs. International Journal of Gynecological Cancer, 19(3), 412–416. https://doi.org/10.1111/IGC.0b013e3181a1d6de

Adetule, Y. C. (2016). Knowledge of cervical cancer preventive strategies among market women in Nigeria. Annals of Oncology. https://doi.org/10.1093/annonc/mdw385.20

Amosu, A. M., Degun.A.M., Babalola, O, A., & Thomas, M. A. (2011). Level of specific knowledge, awareness, perception, and screening behaviour regarding carcinoma of the cervix among rural women in Iwo local government area, Osun State, Nigeria. In Ann.Biol.Res.

Anorlu, R. I. (2008). Cervical cancer: the sub-Saharan African perspective. Reproductive Health Matters. https://doi.org/10.1016/S0968-8080(08)32415-X

Anttila, T., Saikku, P., Koskela, P., Bloigu, A., Dillner, J., Ikäheimo, I., Jellum, E., Lehtinen, M., Lenner, P., Hakulinen, T., Närvänen, A., Pukkala, E., Thoresen, S., Youngman, L., & Paavonen, J. (2001). Serotypes of Chlamydia trachomatis and risk for development of cervical squamous cell carcinoma. Journal of the American Medical Association. https://doi.org/10.1001/jama.285.1.47

Appleby, P., Beral, V., Berrington De González, A., Colin, D., Franceschi, S., Goodill, A., Green, J., Peto, J., Plummer, M., & Sweetland, S. (2006). Carcinoma of the cervix and tobacco smoking: Collaborative reanalysis of individual data on 13,541 women with carcinoma of the cervix and 23,017 women without carcinoma of the cervix from 23 epidemiological studies. International Journal of Cancer. https://doi.org/10.1002/ijc.21493

Ayinde, O. A., Ogunbode, O. O., & Adebayo, O. J. (2006). Determinants of cervical cancer knowledge and the utilisation of screening among a Nigerian female population. Tropical Journal of Obstetrics and Gynaecology. https://doi.org/10.4314/tjog.v22i1.14535

Ba, D. M., Ssentongo, P., Musa, J., Agbese, E., Diakite, B., Traore, C. B., Wang, S., & Maiga, M. (2021). Prevalence and determinants of cervical cancer screening in five sub-Saharan African countries: A population-based study. Cancer Epidemiology, 72, 101930. https://doi.org/10.1016/j.canep.2021.101930

Berrington De González, A., & Green, J. (2007). Comparison of risk factors for invasive squamous cell carcinoma and adenocarcinoma of the cervix: Collaborative reanalysis of individual data on 8,097 women with squamous cell carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies. International Journal of Cancer. https://doi.org/10.1002/ijc.22357

Binka, C., Nyarko, S. H., & Doku, D. T. (2016). Cervical cancer knowledge, perceptions and screening behaviour among female university students in ghana. Journal of Cancer Education, 31(2), 322–327. https://doi.org/10.1007/s13187-015-0852-x

Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R. L., Torre, L. A., & Jemal, A. (2018). Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians, 68(6), 394–424. https://doi.org/10.3322/caac.21492

Burt, L. M., McCormak, M., Lecuru, F., Kanyike, D. M., Bvochora-Nsingo, M., Ndlovu, N., Scott, A. A., Anorlu, R. I., Sharma, V., Plante, M., Nyongesa, C., Tigeneh, W., Fakie, N., Suneja, G., & Gaffney, D. K. (2021). Cervix Cancer in Sub-Saharan Africa: An Assessment of Cervical Cancer Management. JCO Global Oncology, 7, 173–182. https://doi.org/10.1200/GO.20.00079

Castellsagué, X., Bosch, F. X., Muñoz, N., Meijer, C. J. L. M., Shah, K. V., de Sanjosé, S., Eluf-Neto, J., Ngelangel, C. A., Chichareon, S., Smith, J. S., Herrero, R., & Franceschi, S. (2002). Male Circumcision, Penile Human Papillomavirus Infection, and Cervical Cancer in Female Partners. Obstetrical & Gynecological Survey. https://doi.org/10.1097/00006254-200209000-00009

Chawla, P. C., Chawla, A., & Chaudhary, S. (2016). Knowledge, attitude & practice on human papillomavirus vaccination: A cross-sectional study among healthcare providers. Indian Journal of Medical Research. https://doi.org/10.4103/ijmr.IJMR_1106_14

Cohen, P. A., Jhingran, A., Oaknin, A., & Denny, L. (2019). Cervical cancer. In The Lancet. https://doi.org/10.1016/S0140-6736(18)32470-X

Comlan, P., Mabika, B. M., Mouanga, A. M., Ngou, J. P. N. M., Ezinah, F., & Djeki, J. (2012). Knowledge, attitudes and practices of cervical cancer screening among a group of female sex workers in Libreville, Gabon. In African Newsletter on Occupational Health and Safety.

Denny, L. (2019). Screening for Cervical Cancer in resource-limited settings. UpToDate.

Ebu, N. I., Mupepi, S. C., Siakwa, M. P., & Sampselle, C. M. (2015). Knowledge, practice, and barriers toward cervical cancer screening in Elmina, Southern Ghana. International Journal of Women’s Health, 7, 31–39. https://doi.org/10.2147/IJWH.S71797

Frumovitz, M. (2021). Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis. Uptodate.

Grischke, E. M., & Brucker, S. Y. (2019). Cervical cancer. In Medizinische Monatsschrift fur Pharmazeuten. https://doi.org/10.7748/ns2009.07.23.46.59.c7172

Gyamfua, A. A., Nkrumah, I., Ibitoye, B. M., Agyemang, B. A., Ofosu, E. S., Tsoka-Gwegweni, J. M., & Cumber, S. N. (2019). The level of knowledge and associated socio-demographic factors on cervical cancer among women: A cross-sectional study at kenyase bosore community, Ghana. Pan African Medical Journal, 34. https://doi.org/10.11604/pamj.2019.34.44.19471

Jedy-Agba, E., Joko, W. Y., Liu, B., Buziba, N. G., Borok, M., Korir, A., Masamba, L., Manraj, S. S., Finesse, A., Wabinga, H., Somdyala, N., & Parkin, D. M. (2020). Trends in cervical cancer incidence in sub-Saharan Africa. British Journal of Cancer, 123(1), 148–154. https://doi.org/10.1038/s41416-020-0831-9

Khoo, C. L., Teoh, S., Rashid, A. K., Zakaria, U. U., Mansor, S., Salleh, F. N. M., & Nawi, M. N. M. (2011). Awareness of cervical cancer and HPV vaccination and its affordability among rural folks in penang Malaysia. Asian Pacific Journal of Cancer Prevention.

Nakamura, Y., Matsumoto, K., Satoh, T., Nishide, K., Nozue, A., Shimabukuro, K., Endo, S., Nagai, K., Oki, A., Minaguchi, T., Morishita, Y., Noguchi, M., & Yoshikawa, H. (2015). Optimizing biopsy procedures during colposcopy for women with abnormal cervical cancer screening results: a multicenter prospective study. International Journal of Clinical Oncology / Japan Society of Clinical Oncology, 20(3), 579–585. https://doi.org/10.1007/s10147-014-0739-6

Ndikom, C. M., & Ofi, B. A. (2012). Awareness, perception and factors affecting utilization of cervical cancer screening services among women in Ibadan, Nigeria: A qualitative study. Reproductive Health, 9(1). https://doi.org/10.1186/1742-4755-9-11

Nyasenu, Y. T., Gbeasor-Komlanvi, F. A., Ehlan, A., Issa, S. A.-R., Dossim, S., Kolou, M., Yambiyo, B. M., Prince-David, M., Salou, M., Ekouevi, D. K., & Dagnra, A. (2019). Prevalence and distribution of Human Papillomavirus (HPV) genotypes among HIV infected women in Lomé, Togo. Plos One, 14(2), e0212516. https://doi.org/10.1371/journal.pone.0212516

Okunade, K. S. (2020). Human papillomavirus and cervical cancer. In Journal of Obstetrics and Gynaecology. https://doi.org/10.1080/01443615.2019.1634030

Pandey, U. (2017). What is Cervical Cancer? Journal of Gynecology and Womens Health, 2(5). https://doi.org/10.19080/jgwh.2017.02.555599

Quinn, M., Babb, P., Jones, J., & Allen, E. (1999). Effect of screening on incidence of and mortality from cancer of cervix in England: Evaluation based on routinely collected statistics. British Medical Journal. https://doi.org/10.1136/bmj.318.7188.904

Schiffman, M., Castle, P. E., Jeronimo, J., Rodriguez, A. C., & Wacholder, S. (2007). Human papillomavirus and cervical cancer. In Lancet (Vol. 370, Issue 9590, pp. 890–907). https://doi.org/10.1016/S0140-6736(07)61416-0

Singh, D., Vignat, J., Lorenzoni, V., Eslahi, M., Ginsburg, O., Lauby-Secretan, B., Arbyn, M., Basu, P., Bray, F., & Vaccarella, S. (2023). Global estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO Global Cervical Cancer Elimination Initiative. The Lancet. Global Health, 11(2), e197–e206. https://doi.org/10.1016/S2214-109X(22)00501-0

Singh, G. K., Miller, B. A., & Hankey, B. F. (2003). Area socioeconomic variations in U.S. cancer incidence, mortality, stage, treatment, and survival, 1975–1999. National Cancer Institute Cancer Surveillance Monograph Series.

Sung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F. (2021). Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians. https://doi.org/10.3322/caac.21660

Waggoner, S. E. (2003). Cervical cancer. Lancet, 361(9376), 2217–2225. https://doi.org/10.1016/S0140-6736(03)13778-6

Waggoner, S. E., Darcy, K. M., Tian, C., & Lanciano, R. (2010). Smoking behavior in women with locally advanced cervical carcinoma: a Gynecologic Oncology Group study. American Journal of Obstetrics and Gynecology. https://doi.org/10.1016/j.ajog.2009.10.884

Walboomers, J. M., Jacobs, M. V., Manos, M. M., Bosch, F. X., Kummer, J. A., Shah, K. V., Snijders, P. J., Peto, J., Meijer, C. J., & Muñoz, N. (1999). Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. The Journal of Pathology, 189(1), 12–19. https://doi.org/10.1002/(SICI)1096-9896(199909)189:1<12::AID-PATH431>3.0.CO;2-F

Williams, M. S., Kenu, E., Dzubey, I., Dennis-Antwi, J. A., & Fontaine, K. (2018). A qualitative study of cervical cancer and cervical cancer screening awareness among nurses in Ghana. Health Care for Women International, 39(5), 584–594. https://doi.org/10.1080/07399332.2018.1424169

Willoughby, B. J., Faulkner, K., Stamp, E. C., & Whitaker, C. J. (2006). A descriptive study of the decline in cervical screening coverage rates in the North East and Yorkshire and the Humber Regions of the UK from 1995 to 2005. Journal of Public Health. https://doi.org/10.1093/pubmed/fdl062

Wong, L. P., Wong, Y. L., Low, W. Y., Khoo, E. M., & Shuib, R. (2009). Knowledge and awareness of cervical cancer and screening among Malaysian women who have never had a Pap smear: A qualitative study. Singapore Medical Journal.

Wright, K. O., Kuyinu, Y. A., & Faduyile, F. A. (2010). Community education on cervical cancer amongst market women in an Urban Area of Lagos, Nigeria. Asian Pacific Journal of Cancer Prevention.

Yoo, W., Kim, S., Huh, W. K., Dilley, S., Coughlin, S. S., Partridge, E. E., Chung, Y., Dicks, V., Lee, J. K., & Bae, S. (2017). Recent trends in racial and regional disparities in cervical cancer incidence and mortality in United States. PLoS ONE. https://doi.org/10.1371/journal.pone.0172548

Yu, L., Sabatino, S. A., & White, M. C. (2019). Rural-urban and racial/ethnic disparities in invasive cervical cancer incidence in the United States, 2010-2014. Preventing Chronic Disease. https://doi.org/10.5888/pcd16.180447

The authors appreciate the time and effort of all the market women who agreed to participate in the study.