Socio-demographic characteristics associated with high risk Human Papilloma Virus infection among reproductive women in Imo state Nigeria – a cross sectional study

doi:10.21203/rs.3.rs-5278630/v1

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Research Article

Socio-demographic characteristics associated with high risk Human Papilloma Virus infection among reproductive women in Imo state Nigeria – a cross sectional study

https://doi.org/10.21203/rs.3.rs-5278630/v1

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Background:

It has been established that hrHPV (High Risk Human Papilloma Virus) infection is necessary for cervical cancer. There are geographical and temporal determinants that affect the risk factors and ultimately the incidence and distribution of cervical cancer. Knowledge of socio demographic characteristics of those infected with High Risk Human Papilloma Virus is indispensable in planning and making policy decisions in the prevention of cervical cancer as well as in research on the subject matter.

Materials and methods:

This was a secondary analysis of a cross sectional population based study of women who had HPV DNA typing following community outreaches for women in Imo state-Nigeria between February and June 2023. A structured questionnaire was administered to the women by an interviewer and their responses noted. Speculum examinations was done for the purposes of collecting dry swab specimen for hr HPV DNA typing. Data analyses was done with SPSS version 26 IBM and socio-demographic variables were analyzed for any association with the HPV results using the χ2 test for categorical variables.

Results

Prevalence of high risk HPV infection was 43.6%. The significant characteristics such as occupation (P = 0.015, χ2 = 19.060, d.f = 8), ethnicity (P = 0.035) and the place of residence (P = 0.038, χ2 = 4.321, d.f = 1) showed significant association with the HPV infection. Associated reproductive factors of hrHPV infection in this study included coitarche (P = 0.040, χ² = 8.336), number of pregnancies in the past (P = 0.008, χ² = 13.80), number of living children (P = 0.003, χ² = 16.02) and number of sexual partners (P = 0.012, χ² = 12.88). Others include: frequency of genital tract infections (P = 0.019, χ² = 11.80) and type of genital tract infection had (P = 0.001, χ² = 21.88). Behavioral characteristics associated with HPV infection included use of habit forming drugs (P = 0.001, χ² = 13.79) and use of tobacco (P = 0.017, χ² = 8.117).

Conclusion

Prevalence of hrHPV is high in this study and knowledge of socio-demographic determinants will be very useful in primary prevention of cervical cancer using lifestyle changes.

Trial registration

Ethical approval was obtained from the Federal Medical Centre institutional review board ref FMC/OW/HREC/VOL.II/053.

Prevalence

High Risk HPV

Socio-demographic

Characteristics

Imo state-Nigeria

Cervical cancer is one of the major cancers of the female genital tract and the fourth most common cancer in women. In 2022, about 660,000 new cases were detected and 94% of cervical cancer deaths were in developing countries especially sub Saharan Africa¹.. Whereas in 2020 there was an estimated 604 127 cervical cancer cases globally and 341 831 deaths². This depicts an increasing trend. There is also an increasing burden of cervical cancer in developing countries where 85% of the cervical cancer mortality occurs ³, In Nigeria, forty eight million women are at risk of cervical cancer and about 26 women die daily in Nigeria as a result of cervical cancer⁴.

It has been established that hrHPV infection is necessary for cervical cancer⁵.The causation of cervical cancer by HPV has been globally accepted and has subsequently led to the development of vaccines for primary prevention of HPV infection⁶. According to the International Agency for Research on Cancer, 2005, about 40 genotypes of HPV exist which are capable of infecting the female genital tract ⁷. Out of these, there are 15 which are oncogenic and capable of causing cervical cancer.

There are geographical and temporal determinants that affect the risk factors and ultimately the incidence and distribution of cervical cancer. These are defined risks factors associated with high risk HPV infection. These span from basic bio data, to social and economic factors, reproductive history as well as health seeking behaviors. This will include early coitarche, multiple sexual partners or having partners with multiple partners, Sexually Transmitted Infections, smoking, long use of oral contraceptives, being immunosuppressed among others. Social, economic and demographic parameters have been established to influence the occurrence and burden of cervical cancer. Incidence and burden is inversely proportional to the HDI of any country⁸.

Cervical cancer has notably been shown to occur at a lower age group in Nigeria according to reports in cancer registries in Nigeria presumably as a result of early coitarche and multiple sexual partners. Reported statistics include age-specific rate of 36.0, 30.3, and 21.0/100,000 women and a mean age of 56.1, 52.3, and 50.1 years in the Ibadan, Abuja, and Calabar cancer registries respectively⁹. A cancer hospital based study in Mumbai, found a statistically significant median age of 54 years and more than half were not literate ¹⁰.

Knowledge of socio demographic characteristics of cervical cancer patients is indispensable in planning and making policy decisions in the prevention of cervical cancer as well as in research on the subject matter. In Brazil, a hospital based study on a convenient sample of 99 women who had cervical cancer showed that they were predominantly between 40 and 54 years of age, started sexual activity between 15 and 18 years of age and had more than 5 lifetime sexual partners and never used condoms. Majority of the women were married, religious, and 70.7% were economically active professionals before the diagnosis but only 36% remained economically active after diagnosis¹¹. This was similar to findings in Northern Nigeria where low socioeconomic status, early age at first sexual exposure, multiple sexual partners and high parity place women at increased risk of cervical cancer¹²

Though existing studies have not described the socio-demographic characteristics of women with cervical cancer in Eastern Nigeria¹³ or Imo state, studies on the awareness of screening options for cervical cancer show high awareness but minimal uptake even among nurses¹⁴

This study will fill the gap of providing in literature, the prevalence and sociodemographic characteristic of women with high risk HPV infection, an established causative agent of cervical cancer in Imo state South East Nigeria.

The aim of this study is to determine the prevalence of hr HPV infection among women in Imo State Nigeria and evaluate the socio demographic characteristics associated with hr HPV prevalence in Imo state, Nigeria.

This was a secondary analysis of a cross sectional population based study of women who had HPV DNA typing following a community outreach for women in Imo state. Nigeria between February and June, 2023. The sample size was calculated for proportions with a HPV prevalence of 16.6%¹⁵ and α of 0.05 at 95% confidence interval. The sample size calculated was 257women of reproductive age. The sampling method was convenient sampling. Women 30 to 49 years who have ever been sexually active, not pregnant, not bleeding and who had not had a hysterectomy were screened for hr HPV. Bulk and individual consent was obtained from all the women. A structured questionnaire was administered to the women by an interviewer and their responses noted. Relevant information on the questionnaire included socio demographic variables like age, occupation, highest level of education, place of residence, etc, as well as sexual/ reproductive history like age of sexual debut, no of sexual partners, parity, marriage setting etc.

Thereafter, consenting recruited eligible women were placed in dorsal position in a secured privacy assured environment. Pelvic examination of the consenting study participants was done for the purposes of collecting specimen for hr HPV DNA testing. Initial inspection of the cervix was done to determine if there were gross macroscopic lesions on the cervix. Bimanual examination was done and a bivalve speculum was used to expose the cervix. The well labelled dry cervical swab was used to take a smear from the cervical canal by rotating 360 degrees. The swab stick was carefully replaced in the casing and stored in a refrigerator at 2-8^oC for 2–8 weeks in waiting for HPV DNA/ viral studies. The collected cervical cells were transported in frozen ice packs, to the Infectious Disease and Molecular Epidemiology laboratory of the Department of Public Health, Federal University of Technology, Owerri Imo State, Nigeria for molecular analyses. The specimens were decided as HPV positive using the high risk HPV DNA test of the Atila biosystems. The Atila AmpFire HPV High-risk genotyping assay is an isothermal nucleic acid amplification assay for qualitative genotyping of high-risk types of human papillomavirus (HPV).The assay genotypes HPV 16,18,31,33,35,39,45,51,52,53,56,58,59,66,68. Detection of any of the hr HPVs was taken as a HPV positive status¹⁶.

Data analyses

This was done with SPSS version 26 IBM and cross tabulation and tests for association were carried out. The socio-demographic variables were analyzed for any association with the HPV results using the Pearson’s χ² test or Fisher’s exact test for categorical variables. Test of association was at a 95% confidence interval (CI) p- value (P < 0.05)

Two hundred and fifty seven premenopausal women in Imo state were studied and a prevalence of high risk HPV infection of 43.6% (112) was found as depicted in the pie chart on Fig. 1. The socio-demographic characteristics of the study group are represented in Table 1. The age range for the study group was 30–49 years. Up to 35.7% (92) of the women were between 45–49 years of age, which was the oldest age group as well as the age group containing the largest number of participants. For the age group 35–39 years old, a frequency of 22.6% (58) was recorded. The youngest age group in the study (30–34 years) had the overall lowest number of participants (51: 19.8%). Majority of the women were married (202: 78.6%). A total of 31 women (12.1%) were single while 6 (2.3%) and 18 (7.0%) were separated and widowed respectively. On the highest level of education attained, more than half of the studied women (146: 56.3%) attained up to tertiary level of education. Over one quarter in all (68: 26.5%) attained secondary education level. Only two persons (0.8%) did not have any formal education.

Socio-demographic Characteristics in relation to risk of HPV infection

The major occupation for the participant was public or civil service employment with more than half of the study group altogether (146: 56.8%). Many participants were also engaged in trading and businesses (58: 22.6%). There were also 22 (8.6%) farmers, 9 (3.5%) full time house wives and 6 (2.3%) full time students.

The subjects were almost completely from same ethnicity as (253; 98.4%) were from Igbo ethnic group which was not a surprise considering the location and area of the study. Similarly, the subjects were predominantly of Christian religion (128: 99.2%) which is the dominant religion practiced within South Eastern Nigeria.

The relationship between HPV infection status and the socio-demographic factor for the study group is presented in Table 1. The table shows that occupation (P = 0.015, χ² = 19.060, d.f = 8), ethnicity (P = 0.035) and the place of residence (P = 0.038, χ² = 4.321, d.f = 1) showed significant association with the HPV infection. HPV infection was high among students (66.7%), business women (58.6%) and housewives (55.6%). Only four of the women were not of Igbo tribe, and they all tested positive for HPV. The hr HPV infection was found more among women resident at the rural area (56.8%) compared to the rate among women from the urban area (37.6%).

Age was not found as a significant factor but HPV infection had highest frequency among the 30–34 years (52.9%), followed by the 40–44 years (42.9%) and 45–49 years (41.3%). The hrHPV infection rate was more on the widowed (66.7%) and the singles (51.6%) compared to the rate among married women (40.6%). The infection rate was found to be relatively higher among women with primary and secondary levels of education at 50% and 51.5% respectively compared to 42.5% rate found among women with tertiary level of education. Christian women dominated the study group and the rate of HPV infection among them was 43.9%.

Table 1

Association between socio-demographic characteristics and high risk HPV infection
Socio-demographic factors	Total	HPV: Positive	HPV: Negative	χ²	P value
Socio-demographic factors		Number (%)	Number (%)
Age (Years)
30–34 years	51	27 (52.9)	24 (47.1)
35–39 years	58	23 (39.7)	35 (60.3)
40–44 years	56	24 (42.9)	32 (57.1)
45–49 years	92	38 (41.3)	54 (58.7)
Total	357	112 (43.6)	145 (56.4)	2.387	0.496
Marital status
Single	31	16 (51.6)	15 (48.4)
Married	202	82 (40.6)	120 (59.4)
Separated	6	2 (33.3)	4 (66.7)
Widowed	18	12 (66.7)	6 (33.3)
Total	275	112 (44.2)	145 (56.4)	5.693	0.128^LR
Educational level
Non formal	2	2 (100)	0 (0 )
Primary	12	6 (50.0)	6 (50)
Secondary	68	35 (51.5)	33 (48.5)
Tertiary	146	62 (42.5)	84 (57.5)
Others	29	7 (24.1)	22 (75.9)
Total	257	112 (43.6)	145 (56.4)	9.044	0.060
Occupation
Applicant	6	2 (33.3)	4 (66.7)
Housewife	9	5 (55.6)	4 (44.4)
Student	8	4 (66.7)	2 (33.3)
Civil servant	146	57 (39.0)	89 (61.0)
Business	58	34 (58.6)	24 (41.4)
Farmer	22	6 (27.3)	16 (72.7)
Artisan	2	2 (100)	0 (0)
Apprentice	4	0 (0)	4 (100)
Others	4	2 (50)	2 (50)
Total	257	112 (43.6)	145 (56.4)	19.060	0.015 ^LR
Ethnicity
Igbo	253	108 (42.7)	145 (57.3)
Others	4	4 (100)	0 (0)
Total	257	112 (43.6)	145 (56.4)		0.035^F
Religion
Christianity	255	112 (43.9)	143 (56.1)
Other	2	0 (0.0)	2 (100)
Total	257	112 (43.6)	145 (56.4)		0.506^F
Place of residence
Rural	93	50 (53.8)	43 (46.2)
Urban	102	62 (37.8)	102 (62.2)
Total	257	112 (43.6)	145 (56.4)	6.147	0.013
Note: LR = Likelihood Ratio Test, F = Fishers exact test. Test types are conducted if the assumptions of Chi-square test are not fulfilled.

Reproductive Characteristics in relation to risk of HPV infection

The reproductive characteristics of the studied women are contained in Table 2. The table shows that majority of the women (195: 75.9%) had coitarche when they were above 18 years old. Four of the women (1.6%) had coitarche before the age of 13, while 46 (17.9%) had coitarche between age 13 and 18 years. A total of 96 (37.4%) had 3–4 pregnancies in the past while 127 (49.4%) had 1–2 pregnancies in the past. The women whose past pregnancies were up to 5 and above were 3 (1.2%). Up to 121 (47.1%) in all indicated that they have not had any miscarriage or abortion but 90 (35%) responded that they have witnessed 1–2 miscarriages/ abortions while 29 (11.3%) indicated that they had miscarriages or abortions on 3–4 times.

In terms of parity, a total of 28 (10.9%) were nulliparous, 56 (21.8%) and 91 (35.4%) had parity of 1–2 times and 3–4 times respectively while 62 (24.1%) had 5 or more pregnancies. A hundred and four (40.5%) have 3–4 living children while 73 (28.4%) and 53 (20.6%) have 1–2 and 5 or more living children respectively. A hundred and ninety-three (75.1%) have one sex partner, 18 (7.0%) do not have sexual partners and 26 (10.2%) have at least two sex partners. A total of 214 (82.3%) of the women were the only wives of their husbands, 2 (0.8%) had co wives, 4 (1.6%) had spouses with concubines. Majority of the women had recorded genital tract infections in the past (176: 68.5%), and the frequency of genital tract infections occurring once, 2–4 times and 5 or more times were 35.4%, 48.6% and 3.3% respectively. The commonest genital tract infection witnessed by the women that have genital infections include candidiasis (96, 53.0%), bacterial vaginosis (39: 21.5%) and syphilis (10: 5.5%). Others include gonorrhea (2: 1.1%) and chlamydia (4: 2.2%). Those who had HIV test in the past were 201 (78.1%) and only two persons among them (0.9%) indicated that she tested positive to HIV test, while 4 (2.0%) of them responded that they do not know of the test outcome.

At 5% level, significant associating reproductive factors of HPV infection in this study include coitarche (P = 0.040, χ² = 8.336), number of pregnancies in the past (P = 0.008, χ² = 13.80), number of living children (P = 0.003, χ² = 16.02) and number of sexual partners (P = 0.012, χ² = 12.88). Others include frequency of genital tract infections (P = 0.019, χ² = 11.80) and type of genital tract infection had (P = 0.001, χ² = 21.88) (Table 2).

The table also shows that all the 4 women (100%) that had coitarche at below 13 years of age tested positive to HPV compared to 39.1% and 42.1% found among the women that had coitarche at 13–18 years and above 18 years old respectively.

Those that have not had any past pregnancy recorded the largest rate of hrHPV (76.9%), followed by those with 1–2 pregnancies (41.7%). Also hrHPV rate was highest among the women that do not have any child living (82.4%), followed by those that had just 1–2 number of living children (47.9%). Those having two to four sex partners had the highest hrHPV infection rate (63.6%).

hrHPV infection rate was quite high among women that had had abortions or miscarriages up to 5 times and above (66.7%) and 3–4 times (44.8%) but was not statistically significant (p > 0.05.

Table 2

Reproductive Characteristics in relation to risk of HPV infection
Reproductive Characteristics	HPV: POSITIVE		HPV: NEGATIVE		Total	χ²	P
Reproductive Characteristics	Freq	%	Freq	%	Total	χ²	P
Coitarche
< 13 Years	4	100.0	0	0.0	4
13–18 Years	18	39.1	28	60.9	46
> 18 Years	82	42.1	113	57.9	195
None response	8	66.7	4	33.3	12
Total	112	43.6	145	56.4	257	8.336	0.040
Number of Miscarriages/ Abortions Had
None	53	43.8	68	56.2	121
1–2	34	37.8	56	62.2	90
3–4	13	44.8	16	55.2	29
5 and above	4	66.7	2	33.3	6
Non response	8	72.7	3	27.3	11
Total	112	43.6	145	56.4	257	6.397	0.171^LR
Parity
None	10	35.7	18	64.3	28
1–2	29	51.8	27	48.2	56
3–4	40	44.0	51	56.0	91
5 and above	21	33.9	41	66.1	62
Non response	12	60.0	8	40.0	20
Total	112	43.6	145	56.4	257	8.813	0.146
Number of Living Children
None	14	82.4	3	17.6	17
1–2	35	47.9	38	52.1	73
3–4	40	38.5	64	61.5	104
5 and above	17	32.1	36	67.9	53
Non response	6	60.0	4	40.0	10
Total	112	43.6	145	56.4	257	16.017	0.003

LR = Likelihood Ratio Test, F = Fishers exact test. LR or F Test is conducted if the assumptions of Chi-square (χ²) test are not fulfilled.

Table 2

continued
Reproductive Characteristics	HPV: POSITIVE			HPV: NEGATIVE		Total	χ²	P
Reproductive Characteristics	Freq		%	Freq		Total	χ²	P
Number of Sexual Partners Had
None	11	61.1		7	38.9	18
One	75	38.9		118	61.1	193
Two – Four	14	63.6		8	36.4	22
Five and above	0	0.0		4	100.0	4
None Response	12	60.0		8	40.0	20
Total	112	43.6		145	56.4	257	12.88	0.012^LR
Frequency of Genital Tract Infections
Nil	3		25.0	9	75.0	12
Once	28		43.8	36	56.3	64
2–4 times	38		43.2	50	56.8	88
5 times and above	6		100.0	0	0.0	6
None response	37		42.5	50	57.5	87
Total	112		43.6	145	56.4	257	11.802	0.019^LR
Type of genital tract infection had
Syphilis	8		80.0	2	20.0	10
Gonorrhea	2		100	0	0.0	2
Bacteria	20		51.3	19	48.7	39
Chlamydia	0		0.0	4	100	4
Candidiasis	33		34.4	63	65.6	96
Others	0		0.0	3	100	3
None response	49		47.6	54	52.4	103
Total	112		43.6	145	56.4	257	21.885	0.001^LR
Tested for HIV in the Past
Yes	91		45.3	110	54.7	201
No	15		35.7	27	64.3	42
Non response	6		42.9	8	57.1	14
Total	112		43.6	145	56.4	257	1.294	0.524
HIV Test Result if Tested
Positive	2		100.0	0	0.0	2
Negative	94		42.5	127	57.5	221
Do Not Know	6		66.7	3	33.3	9
None response	10		40.0	15	60.0	25
Total	112		43.6	145	56.4	257	4.769	0.190

LR = Likelihood Ratio Test, F = Fishers exact test. LR or F Test is conducted if the assumptions of Chi-square (χ²) test are not fulfilled.

Behavioral Characteristics in relation to risk of HPV infection

Table 3 contains the behavioral characteristics responses of the study women in relation to the use of drugs, alcohol and tobacco. It shows that up to 86.4% (222) of the group indicated that they never use habit forming drugs, but 25 (9.7%) used it “sometimes”. Among those that do take habit forming drug ‘sometimes’, 36% indicated that their reason for taking the drugs is basically for pleasure and 40% indicated that they do take the drugs to deal with problems while 24% of them responded that they take the drugs purposely to socialize. A total of 44% of those that do take drugs responded that they do so when they are with friends, 48.0% responded that they take drugs when they are worried while 8.0% stated that they do so when they are alone.

In terms of alcohol intake, only 4 (1.6%) do take alcohol always, 122 (47.5%) take alcohol sometimes while 111 (43.2%) do not consume alcohol at all. Clear majority of the study group (219: 85.2%) indicated that they have never used tobacco in any form.

In Table 3, significant behavioral characteristics associated with hrHPV infection included use of habit forming drugs (P = 0.001, χ² = 13.79) and use of tobacco (P = 0.017, χ² = 8.117). Up to 36% of those that used habit forming drugs sometimes were hrHPV positive. Only two persons used tobacco always and both tested HPV positive.

Alcohol intake was not found significant and just 2 persons indicated that they take alcohol always, of which half of them (50.0%) were found hrHPV positive.

Table 3

Behavioral Characteristics in relation to risk of hr-HPV infection
Behavioral Characteristics	hrHPV: POSITIVE		hrHPV: NEGATIVE		Total	χ²	P
Behavioral Characteristics	Freq	%	Freq	%	Total	χ²	P
Use of Habit Forming Drugs
Sometimes	9	36.0	16	64.0	25
Never	93	41.9	129	58.1	222
None response	10	100.0	0	0.0	10
Total	112	43.6	145	56.4	257	13.79	0.001^LR
Alcohol intake
Always	2	50.0	2	50.0	4
Sometimes	55	45.1	67	54.9	122
Never	47	42.3	64	57.7	111
None response	8	40.0	12	60.0	20
Total	112	43.6	145	56.4	257	0.352	0.950
Use of Tobacco
Always	2	100.0	0	0.0	2
Never	88	40.2	131	59.8	219
None response	22	61.1	14	38.9	36
Total	112	43.6	145	56.4	257	8.117	0.017^LR
Note: LR = Likelihood Ratio Test, F = Fishers exact test. LR or F Test types are conducted if the assumptions of Chi-square (χ²) test are not fulfilled.

This study reports a high incidence of hrHPV infection of 43.6% and can be attributed to the low human development index (HDI) of Nigeria. Nigeria HDI of 0.548 is categorized as low and has been ascribed to gender disparities and poverty¹⁷. WHO reports that highest incidence of cervical cancer is found in low and middle income countries where there is poor access to national vaccination programs, screening and treatment of early disease¹.

There is a disparity in this study from the targeted literature search by Pimo and co-workers where ethnicity, education, employment status, circumcision, parity, dental issues, and marital/relationship status showed no clear association with HPV infection. However consistent with the literature search was the association with use of tobacco and recreational drugs as well as present or prior infection and risk of STIs. Factors like early coitarche, multiple sexual partners which measure sexual activity were also associated with HPV infection as in this study being reported¹⁸.

Tobacco use has been shown to increase the prevalence of HPV infection as well as that of CIN and cervical cancer¹⁹. It has been established that use of habit forming, usually recreational and illicit drug use has been associated with sexually transmitted infections such as HPV. The associated loss of inhibition will also predispose to more sexual adventures like non- use of condoms, having sex with multiple persons and sex in exchange for drugs²⁰.

Attaining coitarche before 18 years of age is an independent risk factor for development of premalignant lesions²¹. Age at coitarche and multiple sexual partners were the most important risk factors from a hospital based study in Lagos Nigeria²³.

In addition, occupation, ethnicity, place of residence, number of past pregnancies, number of living children and frequency of genital tract infections were found to be statistically significant in this study of reproductive age women in South East Nigeria. This is quite similar to findings in among a similar age group of women in western Uganda where rural residence, education, occupation, marital status, HIV status, use of alcohol, multiple sexual partners, coitarche, previous STIs and vaginal discharge were significantly associated with HPV infection. ²⁴. In northern Nigeria associated variables included level of education, age at sexual debut, parity, number of life time sexual partners and age at first pregnancy were significantly associated with HPV infection²⁵

This study like most others have reported that as age increased the incidence of HPV infection decreased⁵. Incidence of HPV infection appeared to be higher among business women, those with lower educational attainment, those who had early coitarche, multiple sexual partners, lower number of living children and this was similar to findings in Malaysia with the exception of place of residence which was more in urban residence²⁶. Rural residence was associated with higher odds of HPV infection in this study. Even in developed world rural residence is associated with higher HPV related morbidity and mortality than urban residence²⁷

Previous pregnancy history such as parity, number of living children, abortions / miscarriages have been associated with higher prevalence HPV infection. This may be due to the reduction in immune status and changes in hormonal milieu at transitional times during pregnancy and at childbirth or termination of pregnancy²⁴.

Some of the associated findings in our study are modifiable lifestyles and changes done following adequate awareness creation and health education will go a long way to reduce the infection rate with hr HPV and ultimately cervical cancer. This will serve as primary prevention.

The limitations of the study includes being a cross sectional study and therefore cannot give a cause or effect relationship. Secondly, there is a chance of recall bias in the supply of information for the questionnaires especially in private and stigmatizable information. This was reduced by a promise of confidentiality. The study population included women of reproductive age from 30 to 49 years and this may affect the prevalence result obtained to be mainly those with persistent infection. A larger sample size may bring up more robust information for better effect, generalizability, precision and statistical power.

This was a cross sectional analytical study and is the first report on the prevalence and typing of hr HPV infections among women in Imo State Nigeria. This study was a population based study, not hospital based and captured the prevalence in the general population without gynecological complaints. The study participants were taken from the three geopolitical zones of the states.

hrHPV

High Risk Human Papilloma Virus

HPV DNA

Human Pappiloma virus Deoxyribonucleic Acid

HDI

Human Development Index

HIV

Human Immunodeficiency virus

WHO

World Health Organization

this manuscript is original and has not been sent for publication in any format in any other journal or publication agency.

Ethics approval and consent to participate: ethical approval was obtained from the Ethical Review Committee of the Federal Medical Centre Owerri (now Federal Teaching Hospital Owerri) Imo State Nigeria with reference number: FMC/OW/HREC/VOL.II/053. An informed written consent was obtained from every participant.

Consent for publication: not applicable

Availability of data and materials: the data and materials used in this manuscript are available and can be transferred on request.

Competing interests: none

Funding: no external funding

Authors' contributions: Emily Akuabia Nzeribe was the principal investigator while Sally Ibe, Eunice Nwoko, Ikechukwu Dozie and Uche Chikwuocha supervised the research work from onset and also proof read and corrected the manuscript writing. Godswill Ekeleme, Ugonma Dozie and Precious Eteike were in the field with the Principal investigator while Greg Iwuoha analysed the data as the Biostatistitian.

Acknowledgements:

We extend our sincere appreciation to: Our participants for their willingness to share their experiences and insights; Our research team, for their dedication and expertise; the Department of Public Health, Federal University of Technology Owerri for providing research facilities and resources. We are also grateful for the support of our family members who endured the long hours and sacrifices made during this research. Thank you all

Authors' information (optional)

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Socio-demographic characteristics associated with high risk Human Papilloma Virus infection among reproductive women in Imo state Nigeria – a cross sectional study

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Background

Materials and Methods

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Socio-demographic Characteristics in relation to risk of HPV infection

Reproductive Characteristics in relation to risk of HPV infection

Behavioral Characteristics in relation to risk of HPV infection

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