Cancer of the cervix is the second most common gynecologic malignancy in the world, with an estimated 493,000 new cases and 274,000 deaths annually. About 83% of the cases occur in low income countries, representing 15% of female deaths annually [1] [2] . Awareness and uptake of cervical cancer screening services has remained poor over the years in low income countries.

Countries that have organized screening programs have substantially reduced cervical cancer incidence and mortality [1] . This is because screening programs have the potential of being effective since the cervix is easily accessible to biopsy, and there is a long latent period easily recognizable before development of cancer. Also treatment is effective in the early stages of the disease [1] .

In Cameroon, there is a national cervical cancer-screening program, but the service is limited to some main cities [3] . There have been significant developments in cervical cancer prevention. Initially, efforts to implement cytology-based screening in low income countries have been conducted since the early 1980s but they have failed to reduce the mortality rates. Amongst other factors [4] -[6] , this failure can be attributed to limited knowledge and wrong perceptions of the risk factors of cervical cancer [1] .

This study is aimed at evaluating the knowledge, attitude, and practice of women towards cervical cancer and Pap smear screening in the Buea Health District.

This was a community-based cross-sectional descriptive study on women enrolled from the Buea Health District, South West Region of Cameroon with an estimated population of 90.088 inhabitants [7] . Ethical approval and administrative clearance were obtained from the Faculty of Health Sciences Institutional Review Board (IRB) and the Regional Delegate of Health respectively. The target age for Pap smear screening is between 21 - 65 years according to US Preventive Services Task Force recommendation statement [8] . However, for the purpose of this study, after formal approval by assent or consent, women from 18 years were recruited from 9^th October to 20^th November 2013. The aim of including women between the ages of 18 - 24 years was to identify participants that were likely to benefit subsequently from Pap smear screening. Using multistage cluster sampling, 309 participants were recruited based on a KAP study on cervical cancer screening in Maroua, Cameroon [9] . Data was collected from the participants using an interviewer-administered pretest questionnaire. The data were entered using EPI Info version 3.5.1 (CDC/WHO, Atlanta, USA) and systematically checked for errors during data entry by using legal values and specified ranges in Epi-info. In addition, 25% of the questionnaires were double checked by a co-investigator, different from the original data entry person. For categorical data, frequencies were computed. Pearson’s Chi-square, Fisher’s exact tests were used to determine the strength of the association between variables. A p-value less than 0.05 was considered statistically significant.

In this study, the socio-demographic characteristics knowledge, attitude and practice of women towards cervical cancer and Pap smear screening in the Buea Health District, Cameroon were assessed.

The mean age of the participants was 32.3 years (range 18 - 67 years), similar to that of 34.6 years in a study in Rewa subdivision, Fiji by Susana [10] in 2009. Most of the participants were students with a tertiary level of education. Unlike Susana’s study where majority of them were married, in this study, we found out that only half of the women were married. This is probably due to the fact that, there is a state university in Buea where a

Fisher’s p = 0.0001.

x² = 8.51; p = 0.01.

large proportion of its population is unmarried students.

A minority of the participants, 11 (3.6%) had “good” knowledge about cervical cancer and Pap smear screening. About half of the women had “fair” knowledge while, 40.7%, had “poor” knowledge (Table 1). This appears to be a common problem in other parts of the country like in Maroua [9] and other sub Saharan countries where similar findings were documented [11] [12] .

In Dares Salaam, however, awareness was found to be high as three quarters of the respondents were aware of carcinoma of the cervix [13] . This can be explained by the fact that Tanzania, though a low income country, has adopted a good health policy especially with respect to cervical cancer. Similarly, women are more exposed to health facilities, screening services and information from a variety of news media. The Tanzanian approach could be emulated to increase the practice of cervical cancer screening program in Cameroon. Contrary to what was found in the indigenous population in Buea, a study carried out in six hospitals in Yaoundé, Cameroon by Catherine et al., 2011 [14] among health care providers showed that they had “good” knowledge on cervical cancer and Pap smear screening. Yaoundé being an urban area has better health facilities and trained health workers unlike the rural areas. It might be interesting to assess whether awareness on cervical cancer and Pap smear screening is also high among health providers working in rural areas.

The risk factors for cervical cancer were known by 25.6% of the participants. The most common risk factor was multiple sexual partners (Table 1). This was also reported in Ghana [15] . However, in Ilala Municipality, Dar es Salaam, multiparity was the most common cited risk factor among respondents [13] . In another survey in Niger [16] , 22% of the participants could not list any risk factors of cervical cancer. Knowledge on risk factors is very important in the prevention of cervical cancer. Knowledge plays a vital role in disease prevention. Since level of knowledge in this study was mostly “fair” or “poor”, health education on this important aspect of cancer prevention should be emphasized.

Participants were also ignorant about HPV infection and its link with cervical cancer. Only 72 (23.3%) participants mentioned HPV as an important factor among the causes of cervical cancer. This is similar to what was found in a study in the urban area of Songea by James in 2011 [17] , where only 10 women mentioned HPV as a causative agent for Cervical cancer. This can negatively affect HPV prevention by vaccination, whenever it becomes available in our community, if the link between the virus and cervical cancer is not well understood by the target population.

Differences in levels of knowledge between low income and high income countries could be as a result of the cultural and ethnic differences, levels of intervention such as existing population-based screening programs, or mass media campaigns on cervical cancer screening which are effectively done in high income countries. Furthermore, health care services in high income countries are well organized. There is accessibility to cervical screening as well as trained and highly motivated health personnel.

With regards to cancer susceptibility, analysis showed that there is a significant relationship between the perceived susceptibility and risk of developing cervical cancer (p = 0.0005). Women who perceived that they could have pre-cancer lesions also perceived that they could have some degree of risk (Table 3). A similar trend was shown in the in Rewa subdivision, Fiji by Susana [10] . On the contrary, in Songea urban [17] and Ghana [15] , up to half of the participants expressed lack of personal susceptibility to cervical cancer and therefore believed it unnecessary to be screened. The problem lies with those who didn’t know their perceived susceptibility and perceived risks since these women were likely to neglect Pap smear screening as they were unaware of its impact on cervical cancer prevention. However, more positive findings about knowledge of the susceptibility to cervical cancer were reported in Mexico by Myriam [18] .

Looking at impact of cervical cancer as one of the variables affecting attitude, majority of the participants perceived cervical cancer as more severe than other forms of cancers. A third of them felt that the chance of cure is good (Table 4), while over half thought the disease worth treating (Table 5). Unlike the women in Rewa subdivision, Fiji [10] , our study population had a less optimistic attitude as regards the cure of cervical cancer. The presence of this positive attitude is very important as it is likely to motivate women to be screened and managed appropriately.

Like the study in Fiji [10] , there was a significant relationship between those who perceive some risks and a chance of cure of cervical cancer (Fisher’s p = 0.001) and those who perceive that treatment of cervical cancer is worth putting up with (Fisher’s p = 0.03). However, there was concern about those who had good knowledge and a positive attitude, but were not convinced about the efficacy of treatment. Therefore, these women needed to be targeted and advised appropriately if they were to benefit from any cervical cancer screening program.

The benefit of doing a Pap smear test was expressed by 77.5% of the study population. Though this is not up to 80% seen in the study in Rewa subdivision, Fiji [10] , with this positive attitude, there were hopes that women will practice and comply with the follow-up schedules even with other methods of screening like VIA/VILI and oncogenic HPV testing.

In this study only 19.7% of the participants had been screened for cervical cancer. 55.7% of them had only one Pap smear test. This is a problem in many African countries. In similar studies carried out in Ethiopia and South Africa, only 6.5% and 19% of all the participants respectively ever had a Pap smear screening test [12] , [19] . The situation was worse in Nigeria where only 5.7% of the study population had been screened for cervical cancer using Pap smears [20] . Generally, women in low income countries especially in sub Saharan Africa are not routinely screened for cervical premalignant lesions. This accounts for the high prevalence of advanced stages of cervical cancer in most health facilities in the SSA [21] unlike in high income countries [22] . However, most of the participants in our study envisaged continuing with Pap smear screening and were willing to go for follow-up clinics if their Pap smear results revealed precancerous or cancerous lesions.

Women below 30 years constituted the smallest proportion of those who had done a Pap smear Table 6. The situation was similar in Ruvuma, Tanzania where the 20 - 29 year’s age group was least screened [17] . The situation in Jordan was different, where older women were the least likely to have Pap smears [23] . The results of this study can be explained by the fact that younger women are likely to be healthier and thus seek less medical advice. The younger age group is also less likely to be screened if the U.S. Preventive Services Task Force recommendation statement of screening women as from 21 years is respected by health care providers [8] . However, some researchers recommend screening to be carried out for sexually active women irrespective of age [9] . The majority of women who were screened in this study were above 40 years. The other socio-demographic characteristics that appeared to affect screening behavior were; marital status, level of education (Table 7) and multiparity. A study in the United States, Tung showed that the educational level and marital status contributed significantly towards cervical cancer screening of Vietnamese and Cambodian women [24] . Similar barriers to screening were identified by Anorlu [11] and Adanu [25] in sub-Saharan Africa.

The barriers to cervical cancer screening were; fear of pain, lack of time, cost of test and the fear that something wrong will be detected. In other studies, factors that hindered screening were; fear of pain, shyness, cost and also the thought that they were healthy and didn’t have a reason to be screened [10] [17] . These findings suggest the importance of providing information about the value of cervical cancer screening to abate anxiety associated with these barriers. It is only by such actions, that practice of screening for cervical cancer can be increased with a concomitant decrease in cervical cancer morbidity and mortality in our community.

There is poor knowledge and perceived barriers by women about Pap smear screening and follow-up services. For an impact to be made in the prevention of cervical cancer, Pap smear screening is not the preferred method because of these limitations in this community.

None. The authors do not declare any conflict of interest

All authors contributed in the project conception, data collection and analysis, drafting and proof reading the manuscript. Gregory Edie Halle Ekane is the corresponding author.

This study was made possible by the administrative authorities of the Limbe Regional hospital who accepted that we should exploit the medical records. We wish to thank the statistician and Dr. Bessong J. Bessong who initially reviewed the manuscript. We are also highly indebted to some health personnel for helping us in sorting the relevant medical records.