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Abstract
Background Cervical cancer ranks as the second most frequent cancer among all women in Ethiopia and the second most frequent cancer among women between 15 and 44 years of age, resulting in over 4884 moralities annually. Although there is a focus on health promotion through teaching and screening in Ethiopia’s intended transition toward universal healthcare, there is little information available on baseline levels of knowledge and screening uptake related to cervical cancer.
Objectives This study explored the levels of knowledge and screening rates of cervical cancer along with its associated factors among women of reproductive age in Assosa Zone, Benishangul-Gumuz, Ethiopia in 2022.
Methodology A facility-based cross-sectional study was conducted. A systematic sampling technique was used to select 213 reproductive-age women from selected health institutions, from 20 April 2022 to 20 July 2022. A validated and pretested questionnaire was used for data collection. Multi-logistic regression analyses were done to identify factors independently associated with cervical cancer screening. Adjusted OR with 95% CI was estimated to measure the strength of association. The level of statistical significance was declared at a p value of <0.05. The results were presented in tables and figures.
Result Knowledge of cervical cancer screening in this study was 53.5%, and 36% of respondents had practised cervical cancer screening. Family history of cervical cancer (AOR)=2.5, 95% CI (1.04 to 6.44)), place of residence (AOR=3.68, 95% CI (2.23, 6.54)) and availability of health services at nearby (AOR=2.03, 95% CI (1.134, 3.643)) were significantly associated with knowledge of cervical cancer screening, while educational status (AOR=2.811, 95% CI (1.038 to 7.610)), knowing someone diagnosed with cervical cancer (AOR=8.3, 95% CI (2.4, 28.69)), Knowledge of cervical cancer(AOR=2.17, 95%CI(1.077, 4.384) and feeling feeling at risk (AOR=3.26 95% CI (1.52, 5.04)) were associated with the practice of cervical cancer screening.
Conclusion and recommendation Knowledge and practice of cervical cancer screening in this study were low. Therefore, the reproductive women must be encouraged to have early cervical cancer screening at precancerous stage by informing their susceptibility to cervical cancer.
- Adult oncology
- Gynaecological oncology
- Urological tumours
Data availability statement
All data relevant to the study are included in the article or uploaded as supplemental information. All relevant data are within the paper and its supporting information files.
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
The study was unique, as it comprehensively examined the health factors associated with knowledge and practice of cervical cancer screening in the Benishangul- Gumuz region.
The results are generalizable to women of reproductive aged living in the Assosa Zone.
Because of the nature of the study (cross-sectional study design), inferring the causality was not possible.
Self-reported data (eg, previous human papillomavirus screening and vaccination) might have incurred recall bias.
Introduction
Cervical cancer is a type of cancer that occurs in the cells of the cervix, the lower part of the uterus that connects to the vagina.1 The major risk factor for cervical cancer is the infection with human papillomavirus (HPV). Cervical cancer is the fourth most common cancer among women.2 In 2020, about 604 000 women were diagnosed with cervical cancer worldwide and about 342 000 women died from the disease.3 About 85% of the cases and 90% of the deaths are occurring in low-income countries.3 4 Cervical cancer accounts for 22% of all female cancers and 12% of all newly diagnosed cancers every year in African women.5 6
According to the report from the WHO, globally, cervical cancer incidence was 7.9%.7 New cases of cervical cancer occur more often in developing countries than in developed countries.8 9 In sub-Saharan Africa, the incidence and mortality rates of cervical cancer were 25.2% and 23.2%, respectively.8 10 In South Africa, cervical cancer ranks as the second most frequent cancer among women and the first most frequent cancer, which accounts for 15.85% of all female cancers among women between 15 and 44 years of age11 About 3.2% of women in the general population are estimated to harbour cervical infection at a given time, and 64.2% of invasive cervical cancers are attributed to HPVs.12 In Tanzania, current estimates indicate that every year, 10 241 women are diagnosed with cervical cancer and 6525 die from the disease. Cervical cancer ranks as the first most frequent cancer among women in Tanzania and the first most frequent cancer among women between 15 and 44 years of age.13 According to the Tanzanian Cancer Registry, between 1998 and 2000, cervical cancer accounted for 29.8% of all cancers in women in Northern Tanzania.14 Ethiopia has a population of 33.7 million women aged 15 years and older who are at risk of developing cervical cancer. Current estimates indicate that every year, 7445 women are diagnosed with cervical cancer and 5338 die from the disease. Cervical cancer ranks as the second most frequent cancer among women in Ethiopia and the second most frequent cancer among women between 15 and 44 years of age.15 It accounted for a 16.5% mortality rate, and 5-year prevalence was 18.2%.16 The annual incidence of cervical cancer in Ethiopia is about 6294 new cases and the annual mortality is more than 4884. This shows that the disease has become a serious health problem in the country.17 Cervical cancer contributes to all the physical, psychosocial and economic impacts on the individual patient, family and community at large (ie, increased treatment-related expenses, loss of employment and consequent income, and changes in household responsibilities).12 16 Moreover, cervical cancer disproportionately affects women at the low socioeconomic level, and thus the disease can have dramatic consequences on the living conditions of patients, including falling into poverty or being pushed into deeper poverty.12 13 16
Even though it is a dangerous medical condition, the evidence from different literature shows that early screening can reduce 50% of cervical cancer-related death.17 Cervical cancer screening is a way to detect abnormal cervical cells, including precancerous cervical lesions, as well as early cervical cancers.8 Routine cervical screening has been shown to greatly reduce both the number of new cervical cancers and deaths and morbidity due to the disease.8 9 In 2020, the World Health Assembly adopted a new global strategy to eliminate cervical cancer as a public health problem that must be met by 2030 for countries to be on the path toward cervical cancer elimination by setting a 90-70-90 strategy (ie, 90% vaccinated for HPV, 70% screened for cervical cancer and 90% of identified disease received treatment). Awareness about cervical cancer and the method of screening is significantly important to increase the level of cervical cancer screening. Evidence shows knowledge of women about cervical cancer screening is a crucial component. Recent kinds of literature show that women with better knowledge of cervical cancer were more likely to attend cervical cancer screening.2 Lack of knowledge about cervical cancer remains an important factor that affects the participation of women in these screening practices.9 18 In spite of the importance of assessing the level of knowledge about cervical cancer and the level of practice among reproductive-aged women, little information was available about the knowledge and practice of women toward cervical cancer in Ethiopia in general and in the study area in particular.
Methods
Study setting
Data collection took place in Assosa Zone, Benishangul-Gumuz, Ethiopia, from 20 April 2022 to 20 July 2022. The distance from the zone and Ethiopia’s capital city, Addis Ababa, is 667 km. There are 24 health facilities, 191 health posts, 1 primary hospital, 1 general hospital and 1 in the zone.
A total of 310 822 people live in the area, 151 890 of them are women living in its various districts. From the list of public health institutions in the area, only two hospitals (Mange Hospital and Assosa Hospital) offer Pap smear screening services. However, all hospitals and health facilities offer screening services. These public health clinics provided reproductive health services that were both curative and preventive, including cervical cancer screening for women who were of reproductive age.19
Patient and public involvement
The research questions and study design were modified by the study’s researchers, who subsequently had them approved by the Assosa University’s Institutional Review Board. None of the participants in this study were involved in its conception, execution or dissemination strategies.
Study design and population
We conducted a facility-based cross-sectional study in the Assosa Zone. The source population were all women aged 15–49 years old attending health facilities in the Assosa Zone, and our source population was systematically selected group of women of reproductive age who were attending selected health facilities in Assosa Zone during the study period.
Sample size determination
Sample size was calculated using single population proportion formula with the assumption of knowledge about cervical cancer screening 14.8% (1). Assuming 95% confidence level, 5% margin of error: n=z²p (1−p)/d²=(1.96)²(0.148×0.852)/(0.05)²=194.
Where:
Z=95% confidence level (1.96)
p=14.8% of population proportion with knowledge of cervical cancer screening at Adama, Ethiopia20
d=the margin of error=5%
adding non-response rate of 10%. The sample size was 194; after adding 10% non-response rate, the final sample size becomes 213.
Sampling procedures
In Assosa Zone, there are eight districts. Three of them (Assosa District, Bambasi District and Homosha District) were chosen using computer-generated lottery method in consideration of homogeneity. Following that, based on the number of eligible individual flows at each health facility, which was determined from the quarterly report of the specified institution, the entire sample size was proportionally distributed to each facility as follows:
Where: ni=the sample size of the ith health facility
Ni=population size of the ith health facility
n=n1+n2+….n4 is the total sample size (213)
N=N1+N2+…Nth is the total population size of those health institutions (1200)
Finally, 213 study participants were selected using systematic sampling technique based on daily flow from the relevant healthcare facilities.
Data collection procedure
In this study, the data were obtained by an interviewer-administered, structured questionnaire that was adapted from different studies done in different areas.14 21 The content validity of the questionnaire was reviewed by qualified obstetricians and public health specialists. Sociodemographic parameters were assessed in the first section, knowledge and practice of cervical cancer screening were assessed in the second and third sections, and associated factors were covered in the last section. Five BSc nurses and two public health officers served as the data collectors and supervisors, respectively. In these cases, the data collectors read out the questions, clarified their meaning as necessary and recorded the responses. The questionnaire was available in both English and Amharic languages.
Data quality control
The supervisors and data collectors received 2 days of training before beginning the actual data collection. Data collectors conducted a pretest on 5% of the sample size in a nearby hospital (Mange Hospital), and all necessary adjustments were made as a result. It was determined whether the questionnaires were reliable (Cronbach’s alpha for the knowledge and practice questionnaires was 0.95 and 0.87, respectively). Prior to analysis, the completeness of all acquired data was verified.
Operational definition
Knowledge about cervical cancer screening: we used a 29-item composite score of the knowledge to measure the knowledge level of respondents regarding vulnerable groups, risk factors, signs and symptoms and prevention methods of cervical cancer. The cumulative Knowledge score of of participants about cervical cancer was estimated using the mean score. Based on this, those respondents who had scored greater than or equal to the mean value were considered as having good knowledge, whereas those respondents who had scored less than the mean value were considered as having poor knowledge.22
Good practice: those respondents who screened for cervical cancer at least once.20 22
Poor practice: those respondents who had not screened for cervical cancer.20 22
Data processing and analysis
The completed questionnaires were coded and entered into the computer program Epi-Data V.3.1. SPSS V.27.0 was used for the analysis. Data were cleaned and edited using simple frequencies and cross-tabulations before analysis. The cleaned final data were then analysed using SPSS V.27.0. Descriptive statistics, such as frequencies, tabulation, per cent and graphs, were used to analyse the descriptive component. Bivariable logistic regression analyses were done to see the association between each independent variable and the outcome variable. Variables with a p value of >0.2were the candidate for multivariable logistic regression analysis. The logistic regression model fitness was checked using Hosmer-Lemeshow, and statistics that were not significant were declared as a fitted model. Multicollinearity was checked (variance inflation factor <10) indicating the non-existence of multicollinearity among the variables in this study. Both crude and adjusted ORs along with 95% CI were estimated to measure the strength of association. The level of statistical significance was declared at a p value of less than 0.05.
Result
Sociodemographic characteristics of the study participants
A total of 213 women participated in the study, yielding 100% response rate. A high proportion (62, 29.1%) of the respondents were within the age group of 20–24 years, with a mean (±SD) age of 32.2 (±13.8) years, and most (115, 54%) of the study participants were married. Regarding their educational status, 81 (38%) were illiterate, while 75 (35.2%) and 47 (22.1%) of them had primary school and secondary school education, respectively (table 1).
Sociodemographic characteristics of the reproductive-age women living in Assosa Zone, Benishangul-Gumuz, Ethiopia, 2022 (n=213)
Knowledge of the participants about risk factors, main symptoms, treatment options and prevention of cervical cancer
The current study revealed that more than half (53.52%) of the participants had good knowledge toward cervical cancer screening. Seven out of 10 women (155) heard about cervical cancer, and the most common source of information was social media (75, 35.2%). Eighty-one women (38%) responded that the main cause of cervical cancer was HPV (see figure 1).
Overall knowledge of cervical cancer screening among women of reproductive age in Assosa Zone, Benishangul-Gumuz, Ethiopia, 2022.
Practice of cervical cancer screening among reproductive-aged women
Among all the respondents of the study, only 77 (36%) had practised cervical cancer screening (see figure 2). From those who screened for cervical cancer, 47 (22.1%) screened in hospitals and 6 (33.3%) screened at health centres. Fifty-one (23.9%) of them were screened by self-initiation and 10 (4.7%) were initiated by healthcare providers. Respondents who had not screened were asked for their reasons for not being screened, and 21 of them (16%) mentioned it was painful, 36 (26%) felt shy and 18 (15.3%) said their husband did not agree with their screening (see figure 3).
Overall practice of cervical cancer screening among women of reproductive age in Assosa Zone, Benishangul-Gumuz, Ethiopia, 2022.
Reasons for not being screened for cervical cancer among women of reproductive age in Assosa Zone, Benishangul-Gumuz, Ethiopia, 2022.
Factors associated with knowledge of reproductive-age women toward cervical cancer screening
In bi-variable logistic regression analysis, place of residence, marital status, education status, history of using family planning, family history of cervical cancer, having a partner diagnosed with sexually transmitted disease, information on cervical cancer, multiple sexual partners and availability of health service were associated with knowledge of cervical cancer screening.
In multivariate analysis,place of residence, family history of cervical cancer, and availability of health service were found to be associated with the knowledge of reproductive-age women toward cervical cancer screening at a p-value less than 0.05.
This study shows that those women living in the urban area were 3.68 times more likely to have knowledge about cervical cancer when compared with rural residents (AOR)=3.68, 95% CI (2.23, 6.54)). In the current study, women who had a family history of cervical cancer were 2.5 times more likely to have knowledge of cervical cancer screening when compared with their counterparts (AOR=2.5, 95% CI (1.04 to 6.44)). This study also revealed that,women whose health service facility was easily available were 2 times more likely to have Knowledge of cervical cancer screening when compared with their counterpart(AOR=2.03,95%CI(1.13,3.643)) (see table 2).
Multivariate logistic regression analysis for factors associated with knowledge of cervical cancer screening among reproductive-aged women in Assosa Zone, Benishangul-Gumuz, Ethiopia, August 2022
Factors associated with practice of reproductive-aged women toward cervical cancer screening
In bi-variable logistic regression analysis, educational status, use of family planning, history of abortion, having knowledge about cervical cancer, knowing someone diagnosed with cervical cancer, the source of information and the number of sexual partners were found to be associated with cervical cancer screening practice.
In multivariate analysis, educational status, having knowledge about cervical cancer, knowing someone diagnosed with cervical cancer, the source of information and not feeling at risk were found to be statistically significant.
In this study, women who have completed secondary education were 2.8 times more likely to practise cervical cancer screening when compared with women who were unable to read and write (AOR=2.811, 95% CI (1.038 to 7.610)). Women who know someone diagnosed with cervical cancer were 8.3 times more likely to practise cervical cancer screening than women who did not know someone diagnosed with cervical cancer (AOR=8.3, 95% CI (2.404 to 28.697)). Women who got information were 3.1 times more likely to practise screening than those who did not have information (AOR=3.1, 95% CI (1.382 to 7.162)). Those women who perceive their self as part of a risky group were 3.23 times more likely to seek for cervical screening when compared with their counterparts (AOR=3.20, 95% CI (1.524 to 5.049)) (see table 3).
Multivariate logistic regression analysis for potential factors associated with practice of cervical cancer screening among reproductive-aged women in Assosa Zone, Benishangul-Gumuz, Ethiopia, August 2022
Discussion
In this study, the knowledge and practice of cervical cancer screening among women of reproductive age in Assosa Zone, Ethiopia were investigated. The knowledge of cervical cancer among women attending maternal health services in this study was 53.52%, and 36% of respondents had practised cervical cancer screening. Our study contributes to the understanding of factors associated with cervical cancer screening in Assosa Zone, Ethiopia, where the cervical cancer screening prevalence remains low.23
This study investigated that family history of cervical cancer, place of residence and availability of health services nearby were significantly associated with knowledge of cervical cancer . On the other hand, educational status, knowing someone diagnosed with cervical cancer and feeling at risk for cervical cancer,information about cervical cancer and knowledge about the cervical cancer were independently associated with the practice of cervical cancer screening.
The level of knowledge found in this study is comparable with the prevalence reported by the study done in Gondar University,Ethiopia (59.33%).24 The present study’s finding is higher when compared with the studies done in Adama Town, Oromia, Gurage Zone in Southern Ethiopia, South Africa, and Tanzania City, which were 14.8%, 26.2%, 25% and 33%, respectively.11 14 20 21 The discrepancy might be due to the study period and the nature of the study participants. In the current study, more than two-thirds (72.8%) of the study participants heard about cervical cancer screening. This finding is found higher than the study done in Nigeria about hearing cervical cancer screening, which was 40%.25 The variety might be due to the gap in the study period and the recent WHO strategy which focuses on implementation of cervical cancer screening and information dissemination.26
In the recent study, those women living in the urban areas are 3.68 more likely to have good knowledge when compared with rural residents. This might be due to the fact that those participants living in urban areas are exposed to the information and healthcare facilities when compared with rural residents. This finding is supported by the study done in China.27 In this study, those respondents who had a family history of cervical cancer were 2.5 times more likely to have good knowledge about cervical cancer than their counterparts. This might be due to the fact that information can be easily disseminated in between the family. The finding of this study revealed that 36% of respondents had practised cervical cancer screening. This finding is higher than the studies done in Butajira Town, Addis Ababa, Ethiopia, Tanzania and Kenya (15.1%, 21.9%, 14% and 22%), where respondents had practised cervical cancer screening, respectively.16 21 28–30 This difference might due to the difference in the background of the respondents and the difference in the study period as the recent national policy highly emphasised the cervical cancer screening.
Respondents who had information about cervical cancer were 3.1 times more likely to practise cervical cancer screening than their counterparts. This might be due to the fact that those respondents who had awareness of cervical screening might enforce themselves to visit health institutions. In the current study, the women who perceive risk for cervical cancer were 3.26 times more likely to practise cervical cancer screening when compared with their counterparts. This could be due to the fact that positive health-seeking behaviour toward cervical cancer increases the level of screening. This finding is similar with the study conducted in Addis Ababa, Ethiopia and Uganda.30–32
In the current study, women of reproductive age who feel at risk are three times more likely to practise cervical cancer screening. This might be due to the reality that having good health seeking behaviour toward cervical cancer might facilitate women to undertake preventive measures and encourage adoption of accurate health information on the benefits of cervical cancer screening.33 Preceding studies have also reported that having a feeling of being at risk of cervical cancer was found to be a strong predictor of adherence to cervical cancer screening.34 35. This study revealed that, cervical cancer screening is increased by 2 folds in participants those who had good knowledge.
Strengths and limitations of this study
This study was unique, as it comprehensively examined the health factors associated with knowledge and practice of cervical cancer screening in the Benishangul- Gumuz region. The results are generalizable to the reproductive-aged women living in Assosa Zone. However, because of the nature of the study (cross-sectional study design), inferring the causality was not possible and self-reported data (eg, previous HPV screening and vaccination) might have incurred recall bias.
Clinical implication
Our main aim in this study was to assess the knowledge, practice and the associated factors of cervical cancer screening among reproductive-age women living in Assosa Zone. We quantitate the magnitude and the possible associated factors of knowledge and practice of cervical cancer screening. Accordingly, the first major practical contribution of the present research is that it provides much needed empirical data on the actual jobs of cervical cancer screening based on the identified factors in this study. This information is important given that there is limitation of data in the study area. The finding of this study will allow the stakeholders, trainers, consultants and others to design initiatives based on what have been identified as the risk factors of poor knowledge and poor practice. In this sense, we believe that our research is especially timely to meet the WHO strategy to eliminate cervical cancer.
Research implication
The finding of this study will serve as baseline data for the future research on the subject area. According to the current study, the place of residence is one of the factors which was significantly associated with knowledge of cervical cancer . Therefore, our study suggests that future researchers investigate more about the urban–rural disparity toward cervical cancer screening.
Conclusion
About 53.52% of reproductive health service clients in healthcare facilities in Assosa Zone have good knowledge about cervical cancer screening, Also,the practice of cervical cancer screening was generally low. Place of residency, family history of cervical cancer, and availability of health care service at nearby were significantly associated with knowledge of cervical cancer screening, while educational status, knowing someone diagnosed with cervical cancer, individual feeling of at being risk of cervical cancer, and Knowledge about cervical cancer were found to be statistically associated variables with practice of cervical cancer screening. Therefore, reproductive healthcare workers and regional policy stakeholders need to demonstrate more commitment in creating awareness about cervical cancer in different geographical areas of the provinces in the Benishangul-Gumuz region. Encouraging all women of reproductive age who visit health facilities toward cervical cancer screening, especially those residing in rural areas, is important to increase the cervical cancer screening practice.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplemental information. All relevant data are within the paper and its supporting information files.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Assosa University, Health Sciences College Health Research Ethics Review Committee (CHRERC). The permission and support letter were obtained from the Assosa Zone and each health facility (reference number: ASU/892/2014). The study does not involve a trial, so we simply obtained oral consent to interview the study participants.
Acknowledgments
The authors thank all study participants and all the data collectors and supervisors, because without them, this study would not have been possible.
Footnotes
Twitter @FrRegea
Contributors FRG designed the study, developed the proposal, participated in the data collection, performed analysis and drafted the manuscript. SLN, DEJ, DB, DTeso and DTeshome approved the proposal with revisions, participated in data analysis and revised subsequent drafts of the manuscript. All authors read and approved the final manuscript. FRG is responsible for the overall content as the guarantor
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.