Article Text

Original research
Pursuance of a Yoruba name for cervical cancer in Southwest Nigeria: a case study
  1. Folusho Mubowale Balogun1,2,
  2. Olayemi Omotade1
  1. 1 Institute of Child Health, University of Ibadan, Ibadan, Nigeria
  2. 2 University College Hospital, Ibadan, Nigeria
  1. Correspondence to Dr Folusho Mubowale Balogun; folushom{at}yahoo.com

Abstract

Objectives Participants’ comprehension of research process affects the quality of research output, which is the reason why translation of research instruments into local languages is standard practice. Literature has consistently reported that in Africa, knowledge about cervical cancer is low but paradoxically, expressed, and actual uptake of human papillomavirus vaccine for its prevention is high. This study explored the Yoruba names of cervical cancer among Yoruba people in Ibadan, Nigeria to guide the translation of cervical cancer research instruments to Yoruba language.

Design Exploratory case study design was used and data were obtained with 10 in-depth interviews and four focused group discussions. Data were analysed using content analysis.

Settings The study took place in Ibadan North local government area, Southwest Nigeria.

Participants These were 4 traditional healers, 3 Yoruba linguists, 3 public health educators and 38 parents of adolescents.

Measures These were Yoruba names for cervical cancer and their meanings.

Results Participants were aware of cervical cancer but only the traditional healers and public health educators had names for it. These names were highly varied. The public health educators gave names that were linked with different parts of the female reproductive system and external genital which were actually different medical conditions. Each traditional healer also had different names for cervical cancer, which either described the female body parts, or symptoms of female genital infections. These various names can lead to unnecessary misconceptions and misinformation about cervical cancer, its prevention, management, and research.

Conclusions There was no consensus Yoruba name for cervical cancer among the study participants. Efforts to educate the Yoruba speaking populace about cervical cancer, its prevention, management and participation in its research can be frustrated if a generally accepted Yoruba name is not provided for this cancer. Stakeholders’ collaboration is required to get an appropriate Yoruba name for cervical cancer.

  • Health Education
  • Gynaecological oncology
  • MEDICAL ETHICS
  • PUBLIC HEALTH
  • QUALITATIVE RESEARCH

Data availability statement

Data are available in a public, open access repository. The dataset for this study can be found as supplementary materials in an earlier publication.

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This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • Cervical cancer was described using its features to ensure the participants understood the focus of the research.

  • Maximum variation approach in the selection of the participants gave a fair representation of the relevant stakeholders.

  • Only Yoruba language speakers from Nigeria were included, which limits the application of the results.

Introduction

Cervical cancer occupies the first to second position of women-specific cancer in most sub-Saharan African countries. In 2020, there were 6 04 127 cases of cervical cancer globally and 27 806 of them were from West Africa.1 In the same year, there were 341 831 deaths from cervical cancer worldwide and 18 776 were also from West Africa.1 Within the same year, Nigeria recorded 12 075 cases of cervical cancer and 7968 associated deaths. It is approximated that women lose 8.0 Million disability-adjusted life years (DALY) to cervical cancer every year,2 thus reducing their quality of life. The cancer also significantly stretches the already overburdened health system in developing countries, draining the scarce resources that are available.3 Although the predisposing factors for cervical cancer like HIV, low socioeconomic class, early sexual debut, multiple sexual partners and multiparity4 are also abundant in Africa, the structures for cervical cancer prevention are still very weak in many African countries.5 6 Sub-Saharan Africa had the least number of women aged 30–45 years (median of 19.6%) who were screened for cervical cancer compared with other countries between 2005 and 2018.7 Also, less than 30% of countries in this region have human Papillomavirus (HPV) vaccination programme for adolescents with less than 3.0% of the eligible adolescents vaccinated in 2022.8 All these make cervical cancer an important public health problem of concern that requires attention in the African continent.

There has been much research conducted to address the problem of cervical cancer globally and in Africa. These researches have described the epidemiology,9 interpretations,10 11 behaviour towards12 13 and economic valuation14 15 of the uptake of the different preventive measures of the disease. Much public health research on this from Africa showed that the knowledge about cervical cancer has been low to average in different settings despite the high burden of the disease in these places.12 16 Paradoxically, the acceptability,17 intention to use18 19 and actual uptake20 of the preventive measures for cervical cancer (when they were made available through pilot programmes) had been moderate to high. These reports are contradictory and confusing as it is difficult to understand the reason why there will be high willingness to use, or actual utilisation of something that is not known or understood. A meta-analysis showed that the knowledge of cervical cancer increased the uptake of cervical cancer screening up to fivefold,21 which is contradictory to what literature reports about the knowledge of cervical cancer and the uptake of the HPV vaccine in Africa. Also, cancer scare has been shown to drive the uptake of the HPV vaccination among a sample of young American women22 and parents have expressed acceptance of the vaccine if it will protect their children from cervical cancer.23 These latter reasons may explain in part the willingness to take the vaccine in Africa. A closer look at how research about cervical cancer is conducted in Africa may provide some answers to this puzzle.

In research, ethics requires that research participants understand the research processes and procedures, and this is one of the reasons why standard practice requires the translation of research tools (consent forms, questionnaires, interview guides) to local languages for good comprehension.24 This also helps in the validation of the research questionnaires and interview guides to improve the results obtained from instruments.25 Incorrect translation of research instruments will, therefore, evoke wrong responses, which can lead to misinformation and misrepresentation of the true situation of research participants. This study is a part of a bigger study that sought to understand the interpretations of cervical cancer and the acceptability of the HPV vaccine for adolescents in selected communities of Ibadan in southwest Nigeria. Our initial data showed that the community members ascribed different names to cervical cancer. We then hypothesised that the cervix (from where the word ‘cervical’ is derived from) is a structure that will not be easily recognisable by laymen since it is not seen on the outside, and that this could affect the name that it is called. The cervix is a part of the female reproductive organ that is attached to the entrance of the womb. With the understanding of the importance of local language in the design of research tools and the large population of Yoruba speakers in Nigeria and West Africa, this study set out to determine the names of cervical cancer and their meanings among the Yoruba speaking people in Ibadan, southwest Nigeria.

Methods

Study area

This study was carried out in Ibadan North local government area (LGA), one of the six urban LGAs of Ibadan city. This was the most populated LGA in Ibadan, which is an ancient Yoruba city in Nigeria. The city is now cosmopolitan but the Yoruba language that is spoken by the indigenous residents is widely spoken in the city. The Yoruba language is also widely spoken in West Africa, specifically in Nigeria, Benin republic, Togo and Ghana.26 There are approximately 40 million speakers of the language in Nigeria, and it is the most spoken Nigeria language outside the country and outside Africa.27 It has the highest native speakers among the Niger-Congo languages. Ibadan has an estimated population of 3 565 108 residents28 in 2023 and most are of Yoruba ethnicity. Ibadan North LGA is the home to the premier university in Nigeria, the University of Ibadan and the first teaching hospital in Nigeria, which is the University College Hospital. The first cancer registry in Nigeria was established in this hospital in 1960 and this registry currently has the widest population coverage in the country.29

Study design, study population and sampling

This was an exploratory case study. The study population was stakeholders who will be involved in decision-making regarding the uptake of the HPV vaccine for the prevention of cervical cancer. These stakeholders are parents of adolescents, healthcare workers and traditional healers. The inclusion criteria were: (1) any stakeholder who had resided in any of the study communities for at least 1 year and (2) being a speaker of Yoruba language. All the participants were selected purposively with maximum variation approach30 to get representation of the stakeholders who will require the Yoruba name for cervical cancer. This was to capture as much variations as possible in naming cervical cancer. They include parents of adolescents who will be involved in taking decisions about accessing preventive measures for the cancer, traditional healers who see women with cervical cancer and can influence decisions about prevention and management of the cancer and health educators who give professional counsel about prevention, identification and management of cervical cancer in healthcare facilities. Yoruba linguists were included because of their expertise in Yoruba language and capacity to develop a Yoruba name for cervical cancer. Although adolescents are recognised stakeholders in decision-making for the uptake of the HPV vaccine, they were not included in the study because they are minors who are still learning the depth of Yoruba language and are unlikely to be versatile enough to be able to know the Yoruba name for cervical cancer or the meaning of the names. None of the stakeholders who were approached for participation in the research declined to participate. All the participants knew FMB as a doctoral student while none knew OO. The parents of adolescents and the traditional healers were identified with the assistance of the chairman of the Community Development Association of one of the study communities while the Yoruba linguists were approached directly by FMB.

Data collection procedure

Data were collected using four focus group discussions (two each for male and female parents of adolescents) and 10 key informant interviews (three for public health educators, three for Yoruba linguists and four for traditional healers). Interview guides (see online supplemental files) which were face and content validated were used for data collection. The guides described cervical cancer using its symptomatology (a woman who is 35 years or older with abnormal bleeding from the vagina, with or without foul smelling vaginal discharge and weight loss) and the participants were asked for the name of the disease that was described (except for the healthcare workers and Yoruba linguists who were asked directly for the name of cervical cancer in Yoruba language). There was then probe for the meaning of the names given. The interview guide for the Yoruba linguist had an additional question about how to get an acceptable general Yoruba name for cervical cancer.

Supplemental material

The focus group discussions took place at the community town hall in one of the communities within Ibadan North LGA. The health educators and Yoruba linguists were interviewed in their offices. Two traditional healers were also interviewed at the community town hall while the other two were interviewed in their homes. Data were collected by three trained research assistants (who had master’s degree in Public Health) and spoke Yoruba fluently. Each interview was conducted by at least two of them: one conducts the interview while another takes the notes and double as the timekeeper. All interviews were recorded using a digital audio recorder. The duration for the key informant interviews was 17 min to 24 min while the FGDs lasted between 42 min to 68 min. None of the authors participated in the data collection to avoid possible bias due to their background (FMB is a female paediatrician while OO is a male paediatrician). The biodata of the participants was taken before each interview, and each was identified by codes given before the commencement of the interview.

Data analysis

Each audio recordings were transcribed verbatim and those conducted in Yoruba language were translated into English. Content analysis method was used to analyse the data manually. Each transcription was read closely and coded deductively into predetermined themes generated from the research questions by two research assistants and FMB. The codes were then reconciled by the team by determining that the appropriate codes were grouped under each theme. Each Yoruba name for cervical cancer was interpreted by each team member independently and this was also reconciled at the meeting.

Trustworthiness of the research

The four criteria for trustworthiness in qualitative research31 32 were adhered to in this research as follows:

Credibility: both researchers were familiar with the research environment, and both speak Yoruba language fluently with a good understanding of the people’s culture. Both authors had no prior contact with any of the research participants before the interviews were conducted. Data were taken across different stakeholders, which helped in triangulating the data source for good representation. All the participants voluntarily participated in the research following informed consent. The codes of the data were also reconciled by the three coders to ensure agreement among the coders.

Transferability: the details of the research area and the research participants have been reported in this write up for good understanding of the results and replicability.

Dependability: The details of the research design, implementation and data analysis have also been described for reproducibility.

Confirmability: data were collected across different stakeholders who will be involved in the uptake of the HPV vaccine by adolescents for the prevention of cervical cancer. This was to help in the representativeness of the participants. Both researchers were not involved in the data collection process to remove undue bias in the data due to their medical education background. Consolidated criteria for reporting qualitative research (COREQ) reporting guideline was used in the preparation of this write up.33

Patient and public involvement

The parents and the traditional healers who participated in this study were identified with the assistance of the chairman of the community development committee of one of the communities in Ibadan North LGA. The parents, traditional healers and the Yoruba linguists had a health education session about cervical cancer, its causes and prevention after participation in the research.

Results

There were 48 participants in the study and 25 (52.1%) were women. All the available traditional healers were recruited, and they were all men. The mean age for the mothers, fathers, traditional healers, public health educators and Yoruba linguists were 49, 52, 54, 46 and 55 years, respectively. The other details about their demographic characteristics are shown in table 1.

Table 1

Sociodemographic characteristics of study participants

The following themes were generated from the data.

  • Yoruba names for cervical cancer.

  • Meaning of the Yoruba names for cervical cancer.

  • Procedure for getting an acceptable name for cervical cancer.

Yoruba names for cervical cancer

Neither of the parents nor the Yoruba linguists had any specific Yoruba name for cervical cancer while the health educators and each of the traditional healers had different names for the cancer as shown in table 2. The health educators were more spontaneous with the names that they provided, but each of the traditional healers took more time to come up with the names.

Table 2

The different names of cervical cancer in Yoruba and their meanings

Meaning of the Yoruba names for cervical cancer

The interpretations of these names are shown in table 2. While the names given by the public health educators described the cancer of the different parts of the female reproductive system, those mentioned by the traditional healers referred to vaginal discharge and syphilis. There were also some names given by traditional healers whose meanings were not known.

Procedure for getting an acceptable name for cervical cancer

All the Yoruba linguists said that there was no Yoruba name for cervical cancer. However, they suggested steps that could be taken to get an appropriate Yoruba name for the disease.

The first is the constitution of a committee for the task and this should include the healthcare workers, community members and Yoruba linguists as illustrated in the quote below.

…if you need terms for things like that, it is a collaborative effort…domain experts are those in that field who can define it and say this is what it is…the language experts are those who are in linguistics, who know how to find the terms because all these terminologies, they have principles. Yoruba Linguist, man, 54 years

It was also suggested that the name should be descriptive just like most Yoruba words. Second, the word should be assessed for acceptability among the Yoruba population and finally, the word should be introduced to the public.

Discussion

In this study, some of the participants had different Yoruba names for cervical cancer while some did not know any local name for the disease. Also, the names the earlier participants gave had different meanings, and the implications of these findings are discussed subsequently. For a disease with such a huge burden in the country and in Africa not to have a universally known Yoruba name has important implications, which can affect the way cervical cancer as a disease, its management, and prevention are perceived, as well as cervical cancer-related research.

Some of the names given to cervical cancer by some healthcare workers were names of other medical conditions similar to reports from minority tribes in Hong Kong where the local names used by translators for cervical cancer referred to uterine and ovarian cancers.34 These different names can influence the study participants’ comprehension of research questions and processes as well as their responses when participating in cervical cancer research that are conducted in Yoruba language because they will have different cancers on their minds. A study among Asian women in the USA showed that lack of translation for key words was a barrier for participation in cervical cancer research.35 This, therefore, calls into question the validity of earlier cervical cancer research in this Yoruba-speaking population. The University of Ibadan/University College Hospital Ethics research committee and the Oyo State Research Ethical Review Committee are the two main ethics review boards in Ibadan and both mandate that all research tools to be used among community members must be translated into Yoruba language. With the myriads of cervical cancer research that have been conducted among these Yoruba speakers, there is concern about the understanding of Yoruba speakers about the focus of cervical cancer-related research based on the findings from this study. It will be worthwhile to conduct further research to explore the Yoruba words coined for cervical cancer in the earlier Yoruba research tools on cervical cancer and compare the results of similar research that used different Yoruba names. This can further strengthen the need for a definitive Yoruba name for cervical cancer.

The lack of a common name for cervical cancer can negatively affect people’s understanding of the disease because any communication about it cannot be effective if the listeners do not have a clear understanding of what the object of the discussion is.24 This will affect every aspect of communication about the disease, including its identification, management, preventive measures and research. This was confirmed by Hong et al who stated that the diversity of expression of terms in cervical cancer can negatively affect the use of such terms in the sharing of medical knowledge, diagnosis, management and research of cervical cancer.36 This negative effect can be in two ways. The first is the stigmatisation of the disease because there will be many unknown things about the disease. Poor knowledge and understanding of a disease condition can lead to stigmatisation just as seen in HIV37 38 and COVID-19.39 40 Stigmatisation has contributed to avoidable mortalities from cervical cancer. Most cases of cervical cancer are preventable and early presentation following early detection from routine pap smear results in complete cure in most cases.7 However, stigmatisation has been identified as one of the reasons why women with cervical cancer do not present to the hospital on time and this leads to more complex treatment process with unnecessarily increased morbidities and mortalities. The stigmatisation can also affect the uptake of the available preventive measures like HPV vaccination, HPV screening and pap smear. Second, ineffective communication because of not having a definitive local name can lead to rumours about the disease, which will promote misinformation,41 thereby contributing also to stigmatisation. It can also lead to incorrect responses to research questions.

There is a need for parents to understand what cervical cancer is for decision-making about the uptake of the HPV vaccine by their adolescents, and this starts with attaching a definitive name to the disease. Parents are the major decision-makers when adolescents are to access healthcare services. The uptake of the HPV vaccine, which is targeted at adolescents, cannot be successful if parents are not involved. Some few African countries have recorded initial success with the HPV vaccine roll out but if a definite name is not gotten for the disease among the Yoruba-speaking populace, it can be a nidus for the spread of rumours, which can negate the success of the vaccine when it is eventually routine in Nigeria. It can also reverse any initial success of the programme because it will be difficult to compel parents to ensure the completion of the HPV vaccination by their adolescents, or compliance with regular routine pap smear by women where the services are available. A good understanding of the disease, which starts first with its identification, is required for commitment to the successful uptake of the preventive measures.

The public health educators consistently used the word ‘jejere’, which simply means cancer in Yoruba before each name that they gave. It was obvious that each of them decided to give it a name based on their understanding of the anatomy of the female reproductive system. There was a similar report among women from South Africa where women referred to cervical cancer as ‘cancer of the womb’.42 The implication of this is that they will be passing different information to the public by virtue of their professions as public health educators, and this will confuse the people since cervical cancer will be called different names during different contacts with healthcare facilities. It is even likely that they will end up believing that each of the names address different disease entities.

The other part of the names depicted different parts of the female reproductive system, which can also be misleading. The names which best represented cervical cancer were ‘jejere enu ònà ilé omo‘ and ‘Jejere orùn ilé omo’. This is because the cervix is located just at the entrance of the womb and it is sometimes classified as the first part of the womb. Similarly, Chan et al reported that Nepali and Urdu translators in Hong Kong interpreted cervical cancer as ‘cancer of the lower part of the womb’ or ‘cancer of the uterine mouth’.34 In both scenarios, cervical cancer was being named using the the location of the cervix with respect to the womb. Calling cervical cancer ‘jejere ilé omo’ is misleading as this best refers to cancer of the uterus (like endometrial cancer) just as reported in an earlier study from South Africa.43 Also, jejere ojú ara is misleading because the perineum is seen easily and this will make a woman to believe that she is fine even when she has been told that she has cervical cancer. Each of these names can be interpreted by the public in different ways, leading to misinformation and wrong constructions about the cervical cancer. Woods et al reported the different constructions which women in South Africa had about cervical screening because of the poor understanding that they had, with some believing that pap smear (a procedure to screen for cervical cancer) was for diagnosis of various diseases and treatment of cancers and infertility.10 These health workers were spontaneous in mentioning the Yoruba names of cervical cancer and this may be because the names were used routinely during their health talks in the clinic.

Traditional healers are popular in Nigeria and have claims of the ability to cure various illnesses including cancers.43 It was interesting to see that each of the four that were in this study had different names for cervical cancer, which may be because their practice are usually shrouded in secrecy.44 Also, despite having bodies to advance their interests, each traditional healers’ practices are not closely regulated like orthodox medical practitioners, giving them the liberty to individualise the conduct of their practice. The traditional healer who called cervical cancer jèrijèri (the Yoruba name for syphilis) would most likely have had clients with cervical cancer in the past and would have misdiagnosed them, depriving them of the standard care they require. The result will be late presentation in hospitals and subsequent death of such women after spending scarce resources to get a cure. It is important that traditional healers should be carried along in the efforts to control cervical cancer because of the influence that they have on the populace, especially those who patronise them and use orthodox medical services as well.

One limitation of this study is the non-inclusion of Yoruba speakers from the other West African countries, which could have improved the chance of identifying the Yoruba word for cervical cancer. However, Nigeria is home to about 50 million primary and secondary speakers of Yoruba language, which is the highest concentration in any country. Also, the use of the symptomatology of cervical cancer in the interview guides could have made the traditional healers mix up cervical cancer with other conditions with similar symptoms. However, the names that they gave either referred to different disease conditions, which did not fit into the symptomatology, or described just vaginal discharge, which can be seen in different disease conditions.

In conclusion, there was no universally acceptable Yoruba name for cervical cancer among the participants in this study. Therefore, earlier health education contents as well as research reports regarding the disease among Yoruba-speaking population may be questioned. It is important to follow the suggestion of the Yoruba linguists to get an appropriate and acceptable Yoruba name for cervical cancer as this will have positive impact on the prevention and the management of the disease as well as its research among Yoruba population. The committee to be saddled with this responsibility as suggested can be formed in the southwest region of Nigeria where the indigenous Yoruba people live, and the language is widely spoken. Also, a dedicated committee saddled with the responsibility of introducing new Yoruba words should be established to meet the ever-evolving vocabulary, especially in health-related matters. Rigorous validation of research tools could have addressed this problem earlier. There is a need to review earlier cervical cancer research tools previously submitted to the ethics review committees and the results of such research to understand the impact of the Yoruba names coined for cervical cancer on the research output.

Data availability statement

Data are available in a public, open access repository. The dataset for this study can be found as supplementary materials in an earlier publication.

Ethics statements

Patient consent for publication

Ethics approval

The study protocol was approved by the University of Ibadan/ University College Hospital Ethics Review Committee (UI/EC/16/0014). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We appreciate all the study participants for their time and valuable input. We also appreciate Prince Gbola Ahmed, the chairman of Yemetu Community Development Association for his assistance in recruiting the parents and the traditional healers for this study. The research findings reported here were presented at the African Studies Association Annual Meeting in 2018.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors FMB and OO conceptualised and designed the study. FMB supervised the data collection process and led the analysis of the data. Both authors interpreted the results, wrote the manuscript and approved its final draft. FMB is the guarantor and takes full responsibility for the overall content of the manuscript.

  • Funding This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No. G-19-57145), Sida (Grant No:54100113), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), and by the Wellcome Trust [reference number 107768/Z/15/Z] and the UK Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) program. The statements made and views expressed are solely the responsibility of the fellow.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer-reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.