Cervical cancer continues to be a major public health challenge, and the most common cause of cancer related death in women worldwide in 2018, and approximately 570, 000 cases of cervical cancer and 311,000 deaths occurred in 2018 globally as a result of this deadly disease [1]. About 7 to 8.57 million Ghanaian women above the age of 15 years are predisposed to cervical cancer in Ghana [2, 3, 4]. In Ghana, nearly 3,052 women are diagnosed of cervical cancer and 1,556 women die from the disease annually [5]. This is attributed to the inability of the disease to be detected at the initial stages, delay in the commencement of treatment, and lack of facilities for tertiary cancer management [6]. Despite cervical cancer being a prevalent problem in Ghana, there is insignificance of information on the perspectives of young adults and many studies have focused on older women’s experiences. The researchers therefore deemed it important to explore the perspectives of female younger adults between the ages of 17-24 regarding screening for cervical cancer, which may in turn circuitously encourage them to adopt healthy lifestyle behaviours.
In a study conducted in Ghana, revealed that over ninety percent of participants had low awareness level of cervical cancer [2]. Low awareness level of cervical cancer prevention has also been reported by several studies [7, 8]. In Saudi Arabia, [9] also reported a poor level of knowledge on cervical cancer and misinformation with regards to primary and secondary measures of preventing the disease among university students between the ages of 18-25. [10] revealed that every female aged 21 years and above is likely to get cervical cancer. Similarly, other studies also found those who do not partake in cervical cancer screening [11] and those who engage in sex at an early age [12] as susceptible to cervical cancer.
In the advanced countries, cervical cancer incidence has reduced drastically because of the successful initiation and implementation of screening programmes over the years but the situation is not the same in some African countries that continue to record a rise in cervical cancer cases because of lack of screening programmes, ineffective screening strategies and limited screening coverage [13]. Lack of education, low income, preference for a female physician, lack of knowledge, ineffective communication, and embarrassment were among the most frequently mentioned barriers to screening uptake [14, 15].
Younger people are more infected with the Human Papilloma Virus which is the main cause of cervical cancer because of their connection with numerous risk factors including multiple sexual partners, early sexual debut, and high HIV incidences, which increase the probabilities of developing cervical cancer. The study explored the perspectives of young adults on cervical cancer screening in the Sekondi-Takoradi municipality to help in complementing knowledge on cervical cancer screening so that they can adopt healthy lifestyle practices. A very positive approach and increase utilization of cervical cancer screening services among young adults will speed up the implementation of successful cervical cancer screening programmes to help prevent cervical cancer mortality in the municipality and Ghana at large.
An exploratory descriptive qualitative design was used in this study as it allowed the researcher to have a deeper understanding of the personal meaning young adults give to the uptake of cervical cancer screening.
The study was conducted at the Effia Nkwanta Regional Hospital located in the Sekondi Takoradi Metropolis. The hospital is the only facility with an ultramodern screening centre and trained midwives offering cervical cancer screening services to women. Thirteen (13) Young female adults aged 17-24 years seeking health care services at the ENRH who met the inclusion criteria, that is residents of Sekondi Takoradi were purposively sampled to participate in the study after data saturation was attained.
A semi-structured interview guide with open ended questions was used to conduct an in-depth one-on-one interview to facilitate the collection of data. The interview guide for the study was pretested on three young female adults with similar characteristics at Kwesimintsim Hospital in the Effia-Kwesimintsim Municipality to help reframe unclear questions before the main study. The prospective participants and the researcher met to discuss the relevance of the study to ensure that participants had a better understanding of the study and to identify those who were willing to participate in the study. Participants who met the inclusion criteria and expressed willingness to participate in the study were given information with regards to the objectives of the study, confidentiality, privacy, and voluntary participation and were made to sign a consent form. Participants below 18 years were requested to complete an assent form. Their contacts were then taken and allowed to choose days convenient for the interview. A convenient place within the hospital environment was chosen for the interview and each session lasted for 30-45 minutes. The data collection process started on the 11th of April, 2021 and lasted for a period of six (6) weeks.
The six-step approach to analysis as described by [16] was used for analysing the data. Each tape recorded interview was transcribed verbatim and coded. Data analysis was done using thematic content analysis. Similar patterns of data were categorized and categories were coded using descriptive subheadings to form the subthemes. Related subthemes were then grouped to form themes. Themes and subthemes were examined further for appropriateness and re-categorization based on the study objectives.
Ethical clearance was sought from the Ethical Review Committee of the Ghana Health Service (GHS), Research and Development Division, Accra and permission was also obtained from the Effia Nkwanta Regional Hospital. The purpose, potential benefits and risks of the study were explained to participants. They were also informed of their right to withdraw from participating at any point in the course of the study without any consequence. The actual names of the participant (s) were omitted instead, identification codes were assigned and used in the work in order to ensure anonymity. The audio recordings and transcribed data were stored electronically with a password known to the researchers alone. Field notes and all forms signed by the participants were kept under lock.
Thirteen female respondents, aged 17 to 24 years with eight having tertiary and 5 with secondary education were involved in the study. Table 1 presents the socio-demographic characteristics of participant. Participants were given the pseudonyms of; P1 = Participant 1; to P13.
| Pseudo name | Age | Marital Status | Educational level | Religion |
| P1 | 24 | Single | Tertiary | Christian |
| P2 | 23 | Single | Bachelor’s degree | Christian |
| P3 | 20 | Single | Tertiary | Christian |
| P4 | 21 | Single | Tertiary | Christian |
| P5 | 22 | Single | SHS | Christian |
| P6 | 22 | Married | Tertiary | Christian |
| P7 | 21 | Single | Tertiary | Christian |
| P8 | 24 | Single | Tertiary | Christian |
| P9 | 21 | Single | Tertiary | Christian |
| P10 | 24 | Single | Tertiary | Christian |
| P11 | 17 | Single | SHS | Christian |
| P12 | 18 | Single | SHS | Christian |
| P13 | 19 | Single | SHS | Christian |
Four (4) main themes, 16 sub-themes with their corresponding sample codes were identified from the data as shown in Table 2.
| Themes | Subthemes | Codes |
| Knowledge on Cervical cancer and screening methods. | i. Cause and risk factors | . HPV. Multiple sexual partners. Smoking. Early sexual activity. Hormonal contraceptives. Douching. Vaginal bleeding. Pain during sexual intercourse |
| ii. Signs and symptoms | . Pelvic pain. Back pain. Abnormal vaginal odour | |
| iii. Prevention | . Avoid smoking. Avoid multiple sexual partners. Early screening from 15 years. Limit intake of hormonal contraceptives. Abstinence. Practicing safe sex | |
| iv. Complications | . Death. Infertility. Miscarriage | |
| v. Source | . Research. Media. Nurse | |
| vi. Knowledge on Screening methods | . Samples of vaginal fluid to test. Don’t know the actual thing. Pap Smear. Not heard | |
| Perceived beliefs and behaviourstowards cervical cancer screening | i. Screened for cervical cancer | · Haven’t gotten the chance· Happens to women above 30 years· Screening is for pregnant women· Don’t have multiple sex part· Don’t have multiple sexual partners |
| ii. Susceptibility | · No family history· Virgin· Still menstruating· Inserting chemicals in my vagina | |
| iii. Intension | · Very necessary. Not decided. Exposed to candidiasis. Affects females | |
| iv. Benefits | · Know your health status. Early treatment. Prevent complications. Create awareness. Detect abnormality | |
| Perceived barriers to cervical cancer screening uptake | i. Inadequate Information | · No guidance and counselling. Disbelief. No advise. Not showing signs and symptoms |
| ii. Shyness | . Private part. Sensitive area | |
| iii. Financial constraint | · Don’t have money· Costly· Insurance doesn’t cover screening | |
| iv. Lack of time | · Busy schedule· Procrastination· Heavy work load | |
| Emerging theme | i. Public education | · using the media· Time management· Lot of confrontation |
| Strategies in curbing perceived barriers to cervical cancer screening uptake | ii. Reduction in cost of screening | · Effective guidance and counselling· Keeping confidentiality· Free screening·Availability of screening centres· Treatment should be less costly· Screening services in remote areas |
The first research objective was to explore the knowledge of young adults in the Sekondi Takoradi metropolis on cervical cancer and its screening methods. Knowledge in the study refers to what is learned or understood on cervical cancer and its screening methods by the participants used for the study. Adequate Knowledge on cervical cancer and its screening can motivate young adults to participate in cervical cancer screening. In answering this research question seven (6) sub-themes emerged.
Most cervical cancers are caused by longstanding infection with one of the Human Papilloma Viruses (HPV) and has several predisposing factors. Participants for the study generally knew human papilloma virus causes cervical cancer even though some did not know it is the most essential cause of cervical cancer.
… Cervical cancer is caused by human papilloma virus. There are also other important causes that can put a person at risk of developing cervical cancer… (P4).
… We have something called HPV, It is a virus but I don’t know much about it but I know that one too can cause cervical cancer in a person… (P2).
Some of the participants mentioned that those with multiple sexual partners and those who smoke are predisposed to developing cervical cancer because if a person engages in sexual activity with lots of people, the likelihood of that person contracting other sexually transmitted infections is high.
Smoking and engaging in sexual activity with a lot of people are risk factors because the person may be having other sexually transmitted diseases like gonorrhoea, syphilis and the rest which suppresses the immunity... (P1).
All the thirteen participants interviewed had some sort of information in relation to the signs and symptoms of cervical cancer. Most of the participants listed vaginal bleeding, pelvic pain, and back pain and pain during sexual intercourse as some signs and symptoms of the cancer.
… The person usually complains of back pain and pelvic pain, or there will be bleeding from the vagina even when one is not menstruating.… (P7).
…It normally causes vaginal bleeding and also pains during sexual intercourse… (P4).
Avoiding multiple sex partners, quitting smoking and limiting the intake of hormonal contraceptives were listed as preventive measures by some participants of the study.
…We need to avoid smoking and also avoid having multiple sexual partners. The use of hormonal contraceptives should be avoided or its intake reduced to prevent it… (P9).
All the participants apart from one had something to say with regards to their view on the complications of cervical cancer. Most of them were of the view that cervical cancer can cause infertility and death.
…Yes infertility, when there is abnormality in the cervix, it doesn’t pave way for fertilization to occur causing somebody to be barren. It can also cause infection and lead to death … (P4).
Sources about cervical cancer and cervical cancer screening refers to where the individual retrieved their information about cervical cancer. With respect to the source of information regarding cervical cancer, majority of the respondents revealed they heard it through the media and research.
… When I heard it for the first time, I did research but did not actually get more information. I heard it from the television because I like watching Telenovela series and also healthy life series that is where I heard about cervical cancer… (P5).
The screening test involves a pelvic examination during which a smear of cervical cells is taken for the Pap smear test. Visual inspection with acetic acid (VIA) could also be done during the pelvic examination. Most of the participants did not know any of the screening methods even though some of them admitted that they have heard about cervical cancer screening before.
… Actually, I have heard about cervical cancer screening before but don’t know the actual thing or what goes into it, don’t know of the screening methods. I don’t know anyone who has even gone for the screening so can’t say anything about the screening method… (P3).
Few of the participants who mentioned the Pap smear screening method did not know what it entails.
…hmmmm I think the Pap smear screening methods, that’s all I know. I don’t know what the Pap smear method is about but I heard is the screening done to detect cervical cancer… (P1).
The second research objective was to investigate the perceived beliefs and behaviours of participants towards cervical cancer and its screening. This considers the key factors that are thought to influence health behaviours of an individual and how individuals conduct themselves towards cervical cancer screening. In answering this objective, four (4) sub-themes emerged.
Participants were asked if they have had cervical cancer screening before and all the respondents said no and majority had varied reasons for saying no. Some had not gone for the screening because they thought that cervical cancer screening was for women above 30 years, pregnant women and older people and indicated that they have not gone for the screening because they are yet to get to that stage.
… No please, I only know that cervical cancer screening is for pregnant women and older people and so they have to go for cervical cancer screening. I will go when I get pregnant or grow older, but for now am not to that level yet, am not even up to 30 years… (P4).
Generally, the majority of the participants did not perceive themselves as being at risk of cervical cancer and gave reasons like being virgins and not having multiple sexual partners.
… Because I don’t deal with multiple sexual partners which puts a person at risk… (P7).
…. Because I am still a virgin, and I have not had sex with anybody even though I have a boyfriend, I have not had sex with him before and I don’t intend having sex unless I have completed my schooling. Also in my family, nobody has suffered from any type of cancer including cervical cancer so I don’t see myself at risk of cervical cancer… (P13).
Intensions perform a very crucial role in bringing a person closer to an anticipated action. Majority of the respondents had intentions of going for cervical cancer and conveyed their intensions of going for the screening based on what they will derive from it including helping them detect abnormalities in their system.
… Yes, I do have plans of going for the screening because it is very necessary. I might be having the condition and not been aware of it. It’s through the screening that an abnormality can be noticed and be treated early before complications start developing. I will screen when my time is due for the screening… (P13).
Others opined that because the condition affects females and they are in their reproductive ages they will surely go for the screening.
…I am a female in my reproductive age, exposed to candidiasis and other conditions like cervical cancer which usually affects females so will access the screening services… (P10).
Some participants agreed that having cervical cancer screening helps in the detection of abnormalities early in order to receive timely intervention to prevent further harm.
… I know that if you are tested or you are screened earlier and you get to know that you are negative you protect yourself from it but if you are positive then you go to the hospital for it to be treated very early. It helps prevents complications that come along with untreated signs and symptoms at the initial stages… (P13).
These obstacles or barriers refer to various factors that prevent women from engaging in cervical cancer screening. Four (4) sub-themes emerged from the data collected from participants. It comprised lack of information, shyness, financial constraint and lack of time.
Most of the participants interviewed mentioned lack of knowledge on cervical cancer and cervical cancer screening as a main barrier to cervical cancer screening uptake.
… When the person is not educated to know the things that can cause cervical cancer. For instance myself like this even though I am educated and have heard about cervical cancer, I have not heard about its screening before and people like that will not bother to go for the screening because they are not aware… (P4).
Since cervical cancer screening involves a reproductive organ which is the cervix, it is not astonishing that shyness was mentioned as one of the barriers. Some participants indicated shyness to the fact that some nurses don’t keep confidentiality and lack effective communication skills.
… For confidentiality sake because some midwives like making expensive jokes like your vagina is too hairy. Because of that they will feel shy and lose trust. As for me if am going for cervical cancer screening, I will look for someone I can trust well because not all people are able to keep confidentiality… (P10).
Some participants also indicated that because the cervix is a private and a very sensitive area, people will not be comfortable exposing it for others to see explaining their unwillingness to access the screening services.
…People are usually shy because they don’t want their cervix, a private and a sensitive part of their body to be viewed by others especially those of the opposite sex… (P5).
Financial constraint was another factor identified by participants as an obstacle for cervical cancer screening. Some participants interviewed were of the view that screening requires that people should pay money when it is even difficult for them to get money to buy food to eat.
… Some people don’t go because they don’t have money. The screening is not free, you need to pay for it. Some people too is difficult for them getting money even to buy food to eat so even when you tell them to go, they will not go because they don’t have the money… (P13).
… Maybe you will be charge with fees that you will not be able to pay… (P11).
Participants reported that because of work schedule people do not have time for other activities that even affect their health and as such recommended the need for health workers to reach out to people and employers at the workplaces to talk to them on the essence of cervical cancer screening.
… Most people prefer their work to their own health so health workers need to let the people understand that their health matters most. They need to get permission from the workplace so that they can go for the screening. Health workers should let employers know that screening is good so that they can give free time for the women at the workplace to go for the screening… (P11)
Strategies for curbing barriers to cervical cancer screening uptake Two subthemes emerged and these were Public education and reduction of cost of screening.
The participants of the study buttressed on the fact that, to overcome the barriers so far as cervical cancer is concerned, public health education should be of utmost importance. They argued that public education will help to understand what cervical cancer is all about and this will enlighten the women especially those in the rural areas to appreciate the importance of screening.
… People should be informed on the causes as well as the signs and the symptoms of the condition. People should also be given information about the complications of the condition. When we educate them well it can also help dispel the fear in some of them so they can go for the screening… (P2).
Some of the participants interviewed had the perception that if cervical cancer screening cost and treatment is reduced, more people will engage in cervical cancer screening especially the poor and the youth.
… I think the screening should be free for now so that the poor people in the society can afford before there will be an outbreak or something. I also think the treatment charges after testing positive should be less costly especially with the youth because is difficult getting money to pay for the medicine and the therapies… (P6).
Findings of the present study indicated that younger adults have adequate knowledge on the cause and risk factors of cervical cancer which contradicts several findings in literature [17-20]. This disparity could be the fact that these studies considered older women experiences. Also studies by [2] in Ghana among young adults revealed a low knowledge level of cervical cancer and its risk factors among participants but similar to studies by [21] in which students identified promiscuity and smoking as risk factors for cervical cancer. The majority of participants in this study also indicated vaginal bleeding, pelvic pain, and pain during sexual intercourse as signs and symptoms of cervical cancer, while a few indicated vaginal discharges and odours. This is consistent with [7] and [22] findings that identified vaginal discharges, painful sex, and excessive bleeding as cervical cancer manifestations. However, the present study’s findings on signs and symptoms contradict those of [23], who found that the majority of young female students were unaware of any signs or symptoms of cervical cancer, and [24] who found that participants lacked adequate knowledge about cervical cancer signs and symptoms. The disparity could be explained by the fact that young adults, particularly female students, are increasingly glued to their mobile phones and eager to seek out any new information to which they are exposed.
In terms of cervical cancer screening methods, the study reported a very low level of knowledge, with the majority of participants unaware of any screening method. Some of the participants in the current study who had heard about screening methods mentioned the Pap smear screening as the only method, with a few of those who mentioned Pap smear been able to elaborate on it. This finding is consistent with that of [25], who discovered that the majority of students (84.0%) were unaware of alternative screening methods to the Pap smear test [26] also found a low level of knowledge about cervical cancer screening, with only 42.7% of respondents able to name the Pap smear test. The current study’s findings, on the other hand, contradict those of [27], who reported that the majority (61.3%) of women in their studies had heard of cervical cancer screening. A similar study conducted in Nigeria discovered that more than half of respondents are aware of the Pap smear cervical cancer screening method [28]. The disparity may be due to a lack of screening centres in the Sekondi Takoradi Metropolis, which discourages young adults from learning more about cervical cancer screening. Except for one participant in this study, every participant had something to say about their perceptions of cervical cancer complications. The majority of them believed cervical cancer could result in infertility or death. This is consistent with research conducted in Ethiopia by [29], which established that cervical cancer is fatal and can result in the death of women who have the disease. The current study’s findings contradict those of [30] among Vietnamese-Americans who believed cancer would jeopardize their relationship with their partner/husband, and the difference may be that all participants in the current study, with the exception of one, were single.
The majority of participants in this study stated that they obtained their information about cervical cancer from the media and research which corroborate that of Appiah [7], who identified the media as the primary source of information about cervical cancer and cervical cancer screening but contradicts studies by [27], where more than half of women (57.2%) who have heard about cervical cancer screening obtained the information from health care providers. Surprisingly, the hospital was not one of the first four sources of cervical cancer information in this study. This indicates that hospitals and other health care providers may not be doing enough to raise awareness about cervical cancer, either within the facility or throughout the community.
The majority of participants in this study held negative attitudes and behaviours about cervical cancer. All participants had not undergone screening and cited a variety of reasons for their failure to do so, including a lack of awareness about screening and incorrect perceptions that screening was only for women over 30, pregnant women, and older women. This conclusion is consistent with that of [31, 32], who all observed extremely poor cervical cancer screening uptake among study participants. In contrast to previous research indicating a low rate of cervical cancer screening, [33] discovered that the majority of Vietnamese Americans (75%) had been screened for cervical cancer. The findings from the present study may be explained by the fact that, young individuals receive no guidance from health care providers regarding the importance of adopting healthy lifestyle behaviours, including cervical cancer screening. In terms of perceived susceptibility to cervical cancer, the majority of young adults in this study did not believe they were at risk of developing the disease for a variety of reasons and this results contradicts [7] finding that women perceive themselves to be predisposed to developing cervical cancer. The discrepancy in data may be due to the widespread notion that cervical cancer affects older women, with little or no emphasis placed on younger adults. While [34] discovered that perceived susceptibility to cervical cancer influenced cervical cancer screening utilization, efforts to increase screening rates should focus on educating younger adults about their susceptibility, which will enable early detection and treatment of cancer [35]. Most of the respondents (84%) concur that detecting early changes in the cervix will make it easier for it to be treated although this result did not positively influence their willingness to partake in the screening. This concise with findings of [36] reporting that more than half of the study respondents (72.8%), believe that having Pap smear tests is important in early detection and early treatment of cervical carcinoma.
The majority of interviewees cited a lack of knowledge about cervical cancer and cervical cancer screening as major impediments to persons participating in cervical cancer screening. The current study’s findings are consistent with those of [28], in which the majority of participants cited a lack of proper information about cervical cancer and screening procedures as a reason for not screening. As a result, there is an immediate need to increase awareness of cervical cancer screening among young adults, particularly in our environment. This will require a collaborative effort on the part of the government and all parties. Additionally, participants in this study identified shyness, financial constraint and lack of time as barriers to cervical cancer screening uptake. This finding is consistent with that of [15]. According to some of the participants in this study, people are shy due to the fact that certain nurses do not maintain confidentiality and also lack adequate communication skills. This is supported by a study conducted by [37], which identified ineffective communication skills of health workers as a factor in participants’ low screening uptake. The health professional who collects the sample has a significant impact on women’s perceptions of screening; while the procedure is brief, women’s interactions with the health professional who collects the sample and communication throughout the procedure have a significant impact on future behaviour. The authors recommend that cervical cancer screening services be integrated into the National Health Insurance Scheme and that a national screening programme be established to increase access to cervical cancer screening services.
The majority of participants in this study indicated that public education is one of the strategies that can be used in curbing the barriers to cervical cancer screening uptake. This research corroborates the findings of a cervical cancer health education intervention study undertaken in Nigeria [38]. In terms of education, participants also indicated that education using the media was very essential and would help overcome the barrier of inadequate information. This is consistent with the findings of [39] who demonstrated that brief messages on media can have a beneficial effect on health information awareness. The findings imply that, education-based interventions are critical for promoting cervical cancer screening acceptance, since they can address important barriers to cervical cancer screening adoption such as fear, humiliation, and a lack of awareness.
Due to the qualitative nature of the study, only a few participants were required to gain a thorough understanding of young adults’ viewpoints on cervical cancer screening. As a result, the findings may be non-generalizable. Transferability is possible, though, with similar situation. To ensure that the findings are generalizable, a quantitative or mixed technique approach will be appropriate, as this will allow for a bigger sample size. Another significant constraint was encountered during data collection, particularly during this period when corona virus pandemic (COVID-19) norms such as social distance affect personal interviews and transit between locations. To mitigate the impact of this limitation, the researcher made personal protection equipment such as facemasks, face shields, and hand sanitizers available to all participants.
Several recommendations were made based on the findings of this study. The Ministry of Health and the Ghana Health service should collaborate with the government to include the expense of cervical cancer treatment in the National Health Insurance Scheme as a form of support and also develop an early national policy for cancer prevention and treatment in the country. These agencies should also establish cancer management units in all districts, municipalities, and regional hospitals throughout the country. This makes these units more accessible to patients. Given the low awareness of cervical cancer screening and the fact that a smaller proportion of participants identified the healthcare facility as their source of cervical cancer information, the Effia Nkwanta Regional Hospital should conduct regular outreach programmes in the surrounding communities to raise awareness about the disease and educate residents about the importance of routine screening.
In terms of cervical cancer screening methods, the study reported a very low level of knowledge, with the majority of participants unaware of the screening methods. In the light of these issues, health educators must emphasize the value of preventative health care and address issues such as access and a lack of awareness about the necessity of routine cervical cancer screening. As future health care professionals, young adults pursuing careers in health-related industries such as nursing must understand the value of routine Pap screenings, both for their own health and to better educate their customers about cervical cancer risks and prevention.
In conclusion, the purpose of this study was to ascertain the opinions of young adults in the Sekondi Takoradi Metropolis on cervical cancer screening. The study found that individuals had negative attitudes and behaviours toward cervical cancer screening and this was demonstrated by the fact that all the young adults had not been screened for cervical cancer. Ghana’s government should develop an early national policy for cancer screening and treatment, with a particular emphasis on human papillomavirus vaccinations for all girls and women to prevent cervical cancer. Cancer education programmes that contribute to the reduction of the economic burden of non-communicable illnesses must be policy driven and enforced.
The authors declare no conflict of interest.
The authors would like to thank the management of the Effia Nkwanta Regional Hospital and patients attending the adolescent health clinic and the obstetric and gynaecological wards of the facility who participated in this study for their cooperation.
Study concept and design: BP (Betty Pearce) LA (Lydia Aziato) and GAA (Gloria Achempim- Ansong); acquisition of data: BP (Betty Pearce: analysis and interpretation of data: BP (Betty Pearce) LA (Lydia Aziato) and GAA (Gloria Achempim-Ansong), drafting of the manuscript: GAA (Gloria Achempim-Ansong) and BP (Betty Pearce), critical revision of the manuscript and study supervision: LA (Lydia Aziato) and GAA (Gloria Achempim-Ansong).