Background: Little attention has been given to the risk of high-risk human papillomavirus (hr-HPV) infection and cervical precancerous lesions among female migrant head porters (kayayei) in Ghana, as a vulnerable group, and to promote cervical screening in these women. This pilot study aimed to determine the prevalence of hr-HPV infection and cervical lesions among kayayei in Accra, the capital of the Greater Accra Region of Ghana and to describe our approach to triaging and treating these women. Methods: This descriptive cross-sectional cohort study involved the screening of 63 kayayei aged ≥ 18 years at the Tema Station and Agbogbloshie markets in March 2022 and May 2022. Concurrent hr-HPV DNA testing (with the MA-6000 platform) and visual inspection with acetic acid (VIA) was performed. We present prevalence estimates for hr-HPV DNA positivity and VIA 'positivity' as rates, together with their 95% confidence intervals (CIs). We performed univariate and multivariable nominal logistic regression to explore factors associated with hr-HPV infection. Results: Gross vulvovaginal inspection revealed vulval warts in 3 (5.0%) and vaginal warts in 2 (3.3%) women. Overall, the rate of hr-HPV positivity was 33.3% (95% CI, 21.7–46.7), whereas the VIA 'positivity' rate was 8.3% (95% CI, 2.8–18.4). In the univariate logistic regression analysis, none of the sociodemographic and clinical variables assessed, including age, number of prior pregnancies, parity, past contraceptive use, or the presence of abnormal vaginal discharge showed statistically significant association with hr-HPV positivity. After controlling for age and past contraceptive use, only having fewer than two prior pregnancies (compared to having ≥ 2) was independently associated with reduced odds of hr-HPV infection (adjusted odds ratio, 0.11; 95% CI, 0.02–0.69). Conclusion: In this relatively young cohort with a high hr-HPV positivity rate of 33.3% and 8.3% of women showing cervical lesions on visual inspection, we posit that kayayei may have an increased risk of developing cervical cancer if their accessibility to cervical precancer screening services is not increased.
Keywords: Human papillomavirus infections; Cervical cancer; Cancer screening; Internal migrant workers; Women's health; Health equality
Globally, cervical cancer ranks fourth for cancer incidence and mortality among women [[
Specific to the Ghanaian context, high levels of poverty in the Northern parts often compel people (in particular, young women) to migrate southward to major cities to gain employment with the intent of freeing themselves from economic destitution [[
In addition to the aforementioned attribution of the kayayo phenomenon to economic reasons, others believe that it is caused by a need to escape forced marriages and female genital mutilation, the perceived glamour of urban life, as well as a need to amass property for marriage [[
In describing the health status of these young female migrants, accurate data are usually fragmented or difficult to apply to policymaking. Recent research pertaining to the reproductive health needs of these vulnerable kayayei in Ghana has primarily focused on barriers to contraceptive use, health insurance coverage, care-seeking behavior, and risks of infectious diseases [[
We conducted this retrospective descriptive cross-sectional cohort study to determine the prevalence of hr-HPV infection and cervical lesions among kayayei in the Greater Accra Region of Ghana. This study involved the screening of 63 head porters aged ≥ 18 years recruited at the Tema Station (n = 13) and Agbogbloshie market (n = 50) in the Central Business District of the Accra Metropolis in Ghana on 20th March 2022 and 8th May 2022. The women were screened under the Ghanaian arm of the mPharma 10,000 Women Initiative that provided free cervical precancer screening with HPV DNA testing to 10,000 women in Ghana and Nigeria. The screening sessions were held on two Sundays since a majority of the kayayei worked during weekdays and Saturdays. Kayayei who were willing and able to participate in the screening sessions were included in the study.
The inclusion criteria were as follows: any female migrant head porter older than 25 years; intact uterus; verbal consent to undergo cervical precancer screening with HPV DNA testing and visual inspection with acetic acid (VIA); and willingness to undergo single-visit management if necessary. The exclusion criteria were inability or unwillingness to consent to screening procedures, retracted cervix, and prior gynecological procedures that would make it impossible to collect cervical tissue (such as total abdominal hysterectomy). Younger women (18 to 24 years old) who were parous, or had been or were sexually active and opted for screening after our education on risk factors for cervical cancer were also offered screening, and were included in the study.
Old Fadama Market (popularly known as Agbogbloshie Market) is situated in a densely populated resource-poor area. A large majority of the residents of Agbogbloshie have no access to potable water and sanitation [[
The study complied with the Declaration of Helsinki (1964) and its later amendments. All study participants provided verbal informed consent before questionnaire administration, cervical sample collection, and visual inspection procedures. The consent procedure was approved by the Ethical Review Committee of the Catholic Hospital, Battor (approval no. CHB-ERC 0120/06/22), which also gave the researchers permission to publish the study findings retrospectively.
No sample size calculation was performed because the work was not initially conducted in the context of a research study and was piloted to explore outcomes of cervical screening among the kayayei. Instead, we included a convenience sample of all kayayei who were eligible and consented to participate in the screening exercises. Moreover, there was a scarcity of research focusing on the risk of cervical precancer and cancer among kayayei, which would be essential for providing an objective basis for such a calculation.
All sociodemographic data presented were collected routinely as part of the screening process after obtaining verbal informed consent using a structured questionnaire administered by trained nurses who performed the screening. Following screening, questionnaire data and screening outcomes were entered into REDCap version 11.0.3 (Vanderbilt University, Nashville, TN, USA), and stored securely in databases managed by the Cervical Cancer Prevention and Training Centre (CCPTC), Battor, Ghana. All personal data were anonymized prior to the analyses.
We extracted participant data from the databases, including sociodemographic variables such as age, marital status, number of children, highest level of education, monthly income, National Health Insurance Scheme (NHIS) coverage, and religious faith. Data regarding self-reported risk factors were also extracted, including HIV status, current contraceptive use, and smoking status (ever/current). The outcomes of interest were a positive hr-HPV DNA test determined using the MA-6000 platform (Sansure Biotech Inc., Hunan, China) or the presence of clinically relevant lesions and/or major/minor changes on VIA.
All participants were subjected to concurrent hr-HPV DNA testing with the MA-6000 platform and VIA. Cervical visual inspection and sample collection were performed by trained nurses after placing the women in the dorsal lithotomy position. A sterile vaginal speculum was inserted to expose the cervix and a cytobrush or cotton-tipped applicator was used to take cervical samples, which was then placed in a sample collection tube and submitted to the laboratory for testing.
In the same session, VIA was performed by the trained nurses. During the procedure, the cervix was inspected carefully for abnormal changes under a good light source after applying 5% acetic acid and waiting for 90–120 s. The results of VIA were described qualitatively as 'negative' or 'positive' (presence of aceto-whitening at the transformation zone). Colposcopy with the Enhanced Visual Assessment (EVA) system (MobileODT, Tel Aviv, Israel) was immediately performed for kayayei who showed significant changes/lesions on VIA to obtain images for quality assurance. All kayayei were triaged and managed as per our algorithms for cervical screening with VIA/mobile colposcopy which have been described elsewhere [[
Cervicovaginal specimens were processed for MA-6000 testing in strict accordance with the manufacturer's instructions [[
We present descriptive statistics for categorical variables as frequencies and percentages. Continuous variables are described as medians with their ranges. The distributions of age and number of prior pregnancies among the kayayei, stratified by hr-HPV test result were compared using the Mann–Whitney U test. Prevalence estimates for hr-HPV DNA positivity and VIA 'positivity' are presented in rate form, together with their binomial 95% confidence intervals (CIs). We further explored the association between hr-HPV positivity and selected sociodemographic and clinical variables using univariate and multivariable binary logistic regression. The multivariable analysis was performed using the backward elimination procedure with an arbitrary threshold of p-value = 0.25. Effect estimates from the exploratory regression analyses are reported as crude odds ratios (ORs) and adjusted ORs (aORs) with 95% CIs. Due to the low number of head porters with positive findings on visual inspection, we did not explore factors associated with VIA or EVA positivity. All statistical analyses were performed using Stata version 15 (StataCorp LLC, College Station, TX, USA). The null hypothesis was rejected at a two-tailed alpha level of 5%.
In total, 63 migrant head porters presented for cervical precancer screening during the two days, the characteristics of whom are shown in Table 1. A majority of them (79%) were screened at Agbogbloshie market, while the remainder (21%) were screened at Tema Station. Three of the initial 63 kayayei had invalid HPV test results because their cervical samples were mistakenly placed in the wrong tubes; all of these three women showed negative VIA findings. Thus, a total of 60 women were screened concurrently with VIA and HPV DNA testing. All 63 migrant head porters were included in the descriptive analysis, whereas 60 out of the 63 were included in the risk factor analysis after excluding the 3 women with invalid hr-HPV DNA test results (Fig. 1).
The women had a median age of 23 years and were mostly married (59%) or had a steady partner (27%). A large majority of the participants had at least one child (81%) and had completed at least elementary school (71%). 91% of the head porters belonged to the Islamic faith, followed by Christianity (8%), and the African traditional religion (2%). As self-reported risk factors, most of the head porters had unknown HIV statuses or had never tested for HIV (87%), did not use any form of contraception (86%), and had never smoked (100%). Close to 80% of the kayayei covered their medical bills themselves or through the NHIS, while 3% and 6% relied on relatives and other sources, respectively (Table 1). In terms of gynecologic history, 5% had experienced postcoital bleeding, 18% had experienced abnormal vaginal discharge, and only one (2%) had undergone prior gynecological surgery. None (0%) of the participants had received prior cervical screening or prior HPV vaccination.
A flow chart of the screening and HPV test results of the kayayei is presented in Fig. 1, alongside the treatments offered to those with clinically significant lesions. Most of the head porters showed normal findings on gross vulval (95%) or vaginal (97%) inspection. Vulvovaginal inspection revealed vulval warts in 3 (5.0%) and vaginal warts in 2 (3.3%), while VIA yielded positive findings in 5 (8.3%). The commonest transformation zone types on visual inspection were types 2 (41%) and 3 (46%). Overall, the rate of hr-HPV positivity was 33.3% (95% CI, 21.7–46.7), whereas the VIA 'positivity' rate was 8.3% (95% CI, 2.8–18.4) (Table 2). As outcomes of concurrent testing, a majority (n = 37, 61.7%) were concurrently negative, whereas 2 (3.3%) women tested concurrently positive. The cervical lesions of both women who tested concurrently VIA and HPV positive were treated by thermal coagulation. Three (5%) head porters tested hr-HPV negative but VIA positive. One was treated via thermal coagulation, another with leukoplakia was scheduled for a LEEP (Fig. 2), while yet another (a pregnant woman) was scheduled to undergo rescreening after delivery.
Graph: Fig. 1Flow chart for cervical precancer screening among the migrant head porters. HPV, human papillomavirus; VIA, visual inspection with acetic acid; LEEP, loop electrosurgical excision procedure
Table 1 Sociodemographic and clinical characteristics of 63 migrant head porters who underwent cervical screening via concurrent hr-HPV DNA testing and VIA
Sociodemographic variables Estimate Age, years; median (range) 23.0 (19–40) No. of prior pregnancies, median (range) 1 (0–5) No. of children, median (range) 0 (0–2) Religion, n (%) Christianity 5 (7.9) Islamic 57 (90.5) African traditional religion 1 (1.6) Marital status, n (%) Single 7 (11.1) Has a steady partner 17 (27.0) Married 37 (58.7) Divorced 1 (1.6) Widowed 1 (1.6) Highest level of education, n (%) No formal education 18 (28.6) Elementary education 20 (31.8) Secondary education 25 (41.7) Monthly income, GH¢; n (%) <100 30 (47.6) 100–250 23 (36.5) 251–500 4 (6.4) >500 5 (7.9) Unable to tell 1 (1.6) Source of funds for medical bill payment¥ Self, n (%) 50 (79.4) Relatives, n (%) 2 (3.2) Current/former employer, n (%) 0 (0.0) NHIS, n (%) 50 (79.4) Other, n (%) 4 (6.4) Ever/current smoking, n (%) 0 (0.0) Ever/current alcohol consumption, n (%) 0 (0.0) Past contraceptive use¥, n (%) 27 (42.9) Condoms, n (%) 2 (3.2) Combined pill, n (%) 2 (3.2) Depot-Provera, n (%) 16 (25.4) Implant, n (%) 7 (11.1) Current contraceptive use, n (%) 9 (14.3) HIV status, n (%) Negative 8 (12.7) Unknown/never tested 55 (87.3) Gynecological history¥ Postcoital bleeding, n (%) 3 (4.8) Abnormal vaginal discharge, n (%) 11 (17.5) Intermenstrual bleeding, n (%) 0 (0.0) Known medical condition, n (%) 5 (7.9) Prior gynecological surgery, n (%) 1 (1.6) Previous cervical screening, n (%) 0 (0.0) Prior HPV vaccination, n (%) 0 (0.0)
HIV, human immunodeficiency virus
Table 2 Screening characteristics and outcomes of 63 migrant head porters who underwent cervical screening via concurrent hr-HPV DNA testing and VIA
Screening characteristic Estimate Normal vulval inspection findings, n (%) 60 (95.2) Normal vaginal inspection findings, n (%) 61 (96.8) Cervical TZ type on visual inspection (VIA) α, n (%) 1 8 (12.7) 2 26 (41.3) 3 29 (46.0) Overall hr-HPV positive¥, % (95% CI) 33.3 (21.7–46.7) VIA 'positive', % (95% CI) 8.3 (2.8–18.4)
hr-HPV, high-risk human papillomavirus; TZ, transformation zone; VIA, visual inspection with acetic acid; CI, confidence interval
Graph: Fig. 2Colposcopic images of a 30-year-old migrant head porter, para 3: (A) before applying acetic acid and (B) after applying acetic acid. HPV DNA testing was performed alongside visual inspection with acetic acid followed by mobile colposcopy with the Enhanced Visual Assessment (EVA) system in the same setting. Colposcopy was performed because there was leukoplakia (white patch) on the cervix even before acetic acid was applied. HPV DNA test result–negative for hr-HPV; colposcopy findings–transformation zone type 3, leukoplakia with aceto-whitening on the posterior lip of the cervix. Plan: Scheduled for LEEP
Among the female migrant head porters, there were no significant differences between those with and without hr-HPV infection regarding age and number of prior pregnancies. In the univariate logistic regression analysis, none of the sociodemographic and clinical variables assessed, including age (OR, 0.98; 95% CI, 0.87–1.10), number of prior pregnancies (OR, 1.18; 95% CI, 0.80–1.74), parity (OR, 1.05; 95% CI, 0.36–3.04), past contraceptive use (OR, 1.76; 95% CI, 0.60–5.23), and the presence of abnormal vaginal discharge (OR, 1.41; 95% CI, 0.36–5.53) showed significant associations with hr-HPV positivity. In the adjusted logistic regression analysis (Table 3), after controlling for age and past contraceptive use, only having fewer than two prior pregnancies (compared to having ≥ 2) was independently associated with reduced odds of hr-HPV infection among the migrant head porters (aOR, 0.11; 95% CI, 0.02–0.69). While unit increases in age were also associated with reduced odds of hr-HPV infection in the adjusted analysis, this association was only marginally significant (aOR, 0.80; 95% CI, 0.65–1.00) (Table 3).
Due to resource limitations, inadequate funding, and to mitigate the risks associated with loss to follow-up, a 'screen and treat' approach was used as much as possible in screening, with VIA and mobile colposcopy as the primary screening test in a single visit, followed by treatment. Although hr-HPV testing was performed, since the results were not available in real time, it was used to confirm the decision to treat in retrospect and help make follow-up recommendations. Women with lesions on the cervix (minor/major changes) were given the option of treatment on site even before the HPV results came in. For women who had major change (the HPV results were not available on the field), the standard approach would be to perform a biopsy which would then guide management. An alternative approach, if they could afford it, would have been to perform a 'diagnostic loop electrosurgical excision procedure (LEEP)' which has the added benefit of being both diagnostic and therapeutic and reduces the cost that comes with multiple visits and double payment for histopathology. Since the kayayei could mostly not afford the costs of biopsy, diagnostic LEEP, or histopathology, on counseling, those who showed major changes on VIA preferred to undergo thermal coagulation in the same visit and setting. Eligibility for thermal coagulation was assessed in strict accordance with the WHO guidelines [[
Table 3 Exploratory logistic regression analyses of sociodemographic and clinical factors associated with hr-HPV positivity among migrant head porters who underwent cervical screening via concurrent hr-HPV DNA testing and VIA
Univariate analysis Multivariable analysis Variable OR 95% CI aOR 95% CI Age, years (continuous) 0.98 0.87–1.10 0.757 0.80 0.65–1.00 0.050 Age group, years <23 1.46 0.50–4.31 0.491 - ≥23 Ref. Ref. Ref. - No. of prior pregnancies (discrete) 1.18 0.80–1.74 0.396 - No. of prior pregnancies <2 0.42 0.14–1.26 0.123 0.11 0.02–0.69 0.018* ≥2 Ref. Ref. Ref. Ref. Ref. Ref. No. of children (discrete) 1.05 0.36–3.04 0.924 - No. of children 0 Ref. Ref. Ref. - ≥1 0.91 0.24–3.36 0.883 - Marital status Married Ref. Ref. Ref. - Single/has a steady partner/ divorced/ widowed 1.09 0.35–3.35 0.882 - Education level None Ref. Ref. Ref. - Elementary school 0.52 0.13–2.10 0.361 - Secondary school 0.65 0.18–2.36 0.510 - Monthly income level <100 Ref. Ref. Ref. - ≥100 0.78 0.27–2.31 0.657 - Source of funds for medical bill payment Self 0.96 0.26–3.62 0.957 - NHIS 0.96 0.26–3.62 0.957 - Past contraceptive use 1.76 0.60–5.23 0.305 3.58 0.97–13.21 0.056 Abnormal vaginal discharge 1.41 0.36–5.53 0.623 -
hr-HPV, high-risk human papillomavirus; CI, confidence interval; OR, crude odds ratio; aOR, adjusted odds ratio; NHIS, National Health Insurance Scheme; Ref., reference category; VIA, visual inspection with acetic acid * Statistically significant
We conducted this pilot study to explore the prevalence of hr-HPV infection and cervical lesions among kayayei plying their trade in the Greater Accra Region and to describe our approach to triaging and treating cervical lesions found among them. It is logistically challenging to provide cervical precancer screening and treatment in low-resource settings. Major barriers include women's time and the cost of transportation to visit a clinic, laboratory procedures that make it nearly impossible to get same-day results, and unavailability of ablative therapy [[
Although only 63 women were screened in this cohort, the overall hr-HPV positivity rate among the kayayei (33.3%; 95% CI, 21.7–46.7) was similar to those reported among community-dwelling women in the North Tongu District of Ghana [[
Ghana has no national cervical cancer screening register or program or national HPV vaccination program. To further compound the high burden of hr-HPV infection found among the head porters, prior research has shown that kayayei have limited access to healthcare and tend to seek care in avenues outside the general healthcare system, including drug peddlers, herbalists, and chemist shops [[
Our study had some limitations. First, due to its pilot nature, the small sample size restricted our ability to present more granular details pertaining to risk factors for hr-HPV positivity in the study cohort. In addition, the limited sample size restricted the generalizability of the findings to the population of over 100,000 kayayei in Ghana. In hindsight, we may have been able to extend our cohort size through proper community entry via the Kayayei Youth Association, rather than through self-introduction and contacting volunteers directly at the marketplace. Further, the HIV prevalence presented here was likely under-reported as the data were collected via self-report and not based on field testing. Because this project had limited funding, the women who showed major lesions on VIA who would under normal circumstances have paid to have cervical biopsies and histopathology rather had upfront thermal coagulation. Therefore, we were unable to determine the histopathological diagnoses for the cervical lesions seen which were treated by ablation in this context. Finally, we did not perform this work in a research context. The kayayei were provided with the same level of care available to women seeking care at the CCPTC, Battor. Thus, having used the same prescreening forms for general attendees, we could not obtain data specific to kayayei to assess risk factors such as duration as a head porter, reasons for migrating to the south, dangers faced in their line of work (e.g., prior rape, place of residence, and risks faced in search of decent accommodation), as well as coping strategies for navigating the health system.
Despite these limitations, the findings of the present pilot study add to the body of evidence and discourse pertaining to cervical precancer screening in marginalized and vulnerable populations in Ghana. Kayayei represent a distinctive group in terms of sexual health needs and access to the healthcare system for general and cervical screening purposes. Our findings are expected to serve as a basis for further more rigorous investigations into how the adverse environmental challenges faced by migrant head porters affect their exposure to hr-HPV types, and thus their ability to obtain cervical screening services and follow-up care.
In this paper, we present, for the first time, pilot estimates of hr-HPV prevalence and cervical lesions among female migrant head porters (kayayei) in Ghana. In this relatively young cohort with a high hr-HPV infection rate of 33.3% and 8.3% of women showing cervical lesions on visual inspection, we posit that kayayei may have an increased risk of developing cervical cancer if they continue to have difficulty accessing cervical screening services. Thus, national cervical screening guidelines should include migrant head porters and other vulnerable groups to reduce the incidence of cervical cancer. Given the pilot nature of the present study with a limited sample size, further studies with larger samples more representative of this vulnerable group of migrant head porters are warranted and may clarify our results and aid in planning appropriate preventive strategies tailored to them.
The authors thank Ms. Georgina Tay, Faustina Tibu, and other staff of Catholic Hospital Battor for helping with the outreaches. Also, we are grateful to Dr. John Allotey and Ms. Helena Ama Frempong of mPharma for their support. We also acknowledge Madam Hajara Mohammed of the National Commission for Civic Education, and Ms. Edna Yeboah and Rev. Xornam Kevi of the Purim African Youth Development Platform for their immense contributions.
Conceptualization and design of the study: KE, ET, CMW, and JEA. Screening and data collection: ET, CMW, SK, ES, SD, and KE. Data management and formal analysis: JEA, SD, CMW, ET, NOME, ES, and KE. Writing– original draft: NOME, JS, JEA, ET, KE, and PKA. All the authors read and approved the manuscript in its current form.
This project was funded by mPharma as part of the 10,000 Women Initiative which aimed to provide free HPV testing to 10,000 women in Ghana and Nigeria. None of the authors has any financial interests to declare.
The datasets used and/or analyzed during the current study are available from the corresponding author on request.
The study complied with the Declaration of Helsinki (1964) and its later amendments. All study participants provided verbal informed consent before questionnaire administration, cervical sample collection, and visual inspection procedures. The consent procedure was approved by the Ethical Review Committee of the Catholic Hospital, Battor (approval no. CHB-ERC 0120/06/22), which also gave the researchers permission to publish the study findings retrospectively.
Not applicable.
The authors declare no competing interests.
• CCPTC
- Cervical Cancer Prevention and Training Centre
• CI
- confidence interval
• EVA
- Enhanced Visual Assessment
• hr-HPV
- high-risk human papillomavirus
• LEEP
- loop electrosurgical excision procedure
• NHIS
- National Health Insurance Scheme
• VIA
- visual inspection with acetic acid
• WHO
- World Health Organization
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