Background: Despite a high burden of cervical cancer in Ethiopia, the practice of cervical cancer screening was low. This study was aimed to assess cervical cancer screening practice and its associated factors among women aged 15 to 49 years in Bishoftu town, Eastern Ethiopia.
Methods: A community-based cross-sectional study was conducted in 2016 on 845 women aged 15 to 49 years residing in Bishoftu town. Data were collected through face to face interview using a pretested structured questionnaire and analyzed using SPSS version 20 software. Descriptive statistics and logistic regressions were used. A 95% CI and p-value of <0.05 were considered to be statistically significant.
Results: Among all study participants, 51.2% had good knowledge of cervical cancer screening, and 74.9% had a favourable attitude towards screening. However. only 5.8% had been screened ever for cervical cancer. The level of education and source of information was associated with a favourable attitude towards cervical cancer screening. Women who had good knowledge of cervical cancer screening were more likely to have been screened than those who had poor knowledge (AOR=6.95, 95% CI (2.59-18.57).
Conclusion: The knowledge level and attendance for cervical cancer screening among study participants were low. Thus, health education to raise awareness of the importance of cervical cancer screening should a priority for community health leaders.
Cervical cancer; Bishoftu town; Eastern Ethiopia
AIDS: Acquired Immune Deficiency Syndrome; AOR: Adjusted Odd Ratio; CC: Cervical Cancer; CI: Confidence Interval; COR: Crude Odd Ratio; FMOH: Federal Ministry of Health; HH: Household; HIV: Human Immuno Deficiency Virus; HPV: Human Papilloma Virus; KAP: Knowledge, Attitude and Practice; Pap-test: Papanicolaou Test; SPSS: Statistical Package for Social Sciences; STI: Sexual Transmitted Infections; VIA: Visual Inspection of the Cervix with Acetic Acid; WHO: World Health Organization
Cancer of the cervix is the fourth most common cancer worldwide and the second commonest female cancer . In Ethiopia, cervical cancer is the second most common female cancer among women of reproductive age . Globally, the majority of cervical cancer is caused by the Human Papilloma Virus (HPV), specifically types 16 and 18 which account for 70% of cases .
Cervical cancer screening aims to identify precancerous lesions. Currently, the options available are pap smear, visual inspection with acetic acid, and HPV testing for high-risk HPV types . Early detection and treatment of precancerous lesions can prevent cervical cancers . However, competing health care priorities, insufficient financial resources, weak health systems, and limited numbers of trained providers have made high coverage of cervical cancer screening difficult to achieve particularly in low-income countries, like Ethiopia [3-5,7,8]. Globally, in 2012, nearly a billion women were eligible for cervical cancer screening, most of who have never been screened in their life .
Study area and period
This study was conducted in Bishoftu town, Oromia Regional State, which lies approximately 47 km from Addis Ababa. Data were collected between 1st to 15th June 2016.Bishoftu town comprises of 9 administrative districts. There are more than ten governmental and non-governmental health facilities within the town. According to the Federal Democratic Republic of Ethiopian Central Statistical Agency, the population of Bishoftu town in 2016 was 153,847 of which 80,852 were women. Among the total female population; 39,989 were of childbearing age .
Community-based cross-sectional study design was employed to assess the practice of cervical cancer screening and its associated factors among women aged 15-49 years in Bishoftu town, Eastern Ethiopia.
All women aged 15 to 49 years residing in Bishoftu town.
Randomly selected women aged 15 to 49 years from selected districts of Bishoftu town.
The required sample size for the study was determined by using a single population proportion formula based on the following assumption. The proportion of attitude towards cervical cancer screening from similar study done in Kinshasa, Democratic Republic of Congo was 52% (p=0.52, q=0.48), Zα/2=1.96 (95% confidence interval) and d=5% (0.05) [10,11]. Based on this assumption and considering the design effect of 2 and a nonresponse rate of 10%, the final sample size was 845.
A multistage sampling technique was used in this study. First, 3 of the 9 districts were selected using a simple random sampling technique. A sampling frame was prepared using the house numbers and individual households in the selected 3 districts were selected using a simple random sampling technique. For households with more than one woman aged 15 to 49 years, only one woman was selected using a lottery method. Finally, proportionate sample size allocation was used for each selected district to get the final sample size. Closed houses during data collection were revisited by the interviewers three times, at different intervals, and those that remained unavailable were excluded from the study and were replaced by the next nearest house. Incomplete data collected by the interviewers were completed during the next field visit to achieve the maximum sample size.
Data collection and processing
A pre-tested structured questionnaire was developed after reviewing comparable relevant literature. The questionnaire was originally prepared in English and was translated into regional working language, Afaan Oromo, by experts. The Afaan Oromo was then translated back to the English language to check its accuracy. Fifteen female nurses were recruited and trained on the data collection procedure. All completed questionnaires were reviewed by the principal investigators.
Data analysis and quality management
Data entry was done using Epi-Info version 3.5.3 after checking for completeness. It was then cleaned and exported to SPSS Version 20 for analysis. Frequencies and other descriptive statistics were done. Bivariate analysis was used to examine the association between dependent and independent variables; Odds Ratios (ORs) and their 95% Confidence Intervals (CIs) were calculated. All variables that had a p-value of<0.2 in the bivariate analysis were included in the multivariate logistic regression analysis model to determine the factors associated with dependent variables. Statistical significance was set at a p-value of<0.05.
Knowledge of the respondents on cervical cancer screening was assessed using some basic knowledge assessing questions. A total of 12 correct responses were documented from 8 multiple-choice questions. Correct and incorrect responses were scored 1 and 0 respectively. The minimum score was 0 and the maximum was 12. Those respondents who scored less than the mean score were considered to have poor knowledge and those respondents who scored greater than or equal to the mean score were considered to have good knowledge of cervical cancer screening.
The attitude of the study participants towards cervical cancer screening was assessed using seven-question surveys with a Likert scale (Table 2). Participants were asked if they strongly agreed, agreed, were neutral, disagreed, or strongly disagree with each of the seven questions. The responses were summed up and a total score was obtained for each respondent with a maximum of 35 and a minimum score of 7 possible. Those who scored greater than or equal to the mean were considered to have a favourable attitude towards cervical cancer screening while those who scored less than the mean were considered to have an unfavourable attitude.
|Variables||Attitude status of the study participant on Likert scale|
|Strongly agree||Agree||Neutral||Disagree||Strongly disagree|
|Cancer of the cervix is highly prevalent in Ethiopia and is one of the leading cause of death from cancer||124 (14.7)||253 (29.9)||20 (2.4)||335 (39.6)||113 (13.4)|
|Any adult women including you can acquire cervical cancer||148 (17.5)||422 (49.9)||18 (2.1%)||217 (25.7)||40 (4.1)|
|Cancer of the cervix cannot be transmitted from one person to another||124 (14.7)||268 (31.7)||41 (4.9)||313 (37.0)||99 (11.7)|
|Screening helps in prevention of cancer of the cervix||179 (21.2)||518 (61.3)||25 (3.0)||87 (10.3)||36 (4.3)|
|Screening causes no harm to the client||154 (18.2)||401 (47.5)||21 (2.5)||220 (26.0)||49 (5.8)|
|Screening for pre-cancer cervical lesions is not expensive||110 (13.0)||273 (32.3)||48 (5.7)||382 (45.2)||32 (3.8)|
|If screening is charge-free and causes no harm, will you be the screen?||207 (24.5)||495 (58.6)||38 (4.5)||90 (10.7)||15 (1.8)|
Table 2: Attitude towards cervical cancer and screening among study participants in Bishoftu town, Eastern Ethiopia, 2016.
The practice of attending cervical screening was assessed. Those who had attended a screening for cervical cancer at least once or more in their lifetime were regarded as practising cervical screening. Those who had never attended a screening for cervical cancer were regarded as having no practice of cervical cancer screening.
Socio-demographic characteristics of the study population
A total of 845 women of reproductive age participated in this study, a response rate of 100%. The age of participants ranged from 15- 49 years with a mean age of 32 years (SD ± 6.8). The majority of participants were married (73.3%), self-employed (43.4%), parous (67.5%), and educated (94.2%).
Risk exposure among study participants
One hundred-seven (13.4%) of the study participants had first sexual intercourse before 18 years of age. Just, 1.0% of respondents had had more than one sexual partner. Of the study participants, 0.6% and 2.9% were cigarette smokers and HIV/AIDS positive respectively. The majority of study participants, 602 (71.2%), had used modern contraceptives at some point in time (Table 1).
|Age at first sexual intercourse (n=798)|
|≥ 18 years||691||86.6|
|Number of sexual partners (n=798)|
|Two or more||8||1.0|
|Hormonal contraception use|
|HIV test result (n=790)|
Table 1: Risk of exposure to cervical cancer among the study participants in Bishoftu town, Eastern Ethiopia, 2016.
Knowledge, attitude, and practice of cervical cancer screening
The majority of study participants, 73.3%, had some information about cervical cancer. 51.2% and 48.8% had good and poor knowledge scores respectively. 46.7% and 47.2% of participants did not know the cause and prevention of cervical cancer respectively. The majority, 85%, reported treatment options for cervical cancer.
However, only 28.4% believed in the existence of screening methods. Seven questions to assess attitudes were combined and a mean score was obtained to classify respondents as having either a favourable or unfavourable attitude towards cervical screening. The mean score was 24 with results ranging from 12-34. Most of the study participants, 74.9%, had a favourable attitude towards cervical cancer screening. Among 845 study participants, only 5.8% had ever been screened for cervical cancer, the main reason being lack of awareness about screening (Table 2).
Factors associated with the practice of cervical cancer screening
Women who knew someone diagnosed with cervical cancer were 2.88 times more likely to have attended for cervical cancer screening than those women who did not know someone diagnosed with cervical cancer (AOR=2.88, 95%CI (1.47-5.61). Women who had good knowledge of cervical cancer and its screening were more likely to have attended cervical cancer screening than those who had poor knowledge (AOR=6.95, 95% CI (2.59-18.57) (Table 3).
|Variables||Practice on cervical cancer screening||COR, 95% CI||AOR, 95% CI|
|No practice (%)||Practice (%)|
|25-34||392 (93.3)||28 (6.7)||1.04 (0.58-1.87)|
|35-49||307 (93.3)||21 (6.7)||1||NA|
|No formal/primary||297 (97.1)||9 (2.9)||1||1|
|Secondary||301 (93.8)||20 (6.2)||2.19 (0.98-4.89)||1.31 (0.56-3.02)|
|Higher education||198 (90.8)||20 (9.2)||3.33 (1.49-7.89)*|
|Age at first sex||1.51 (0.63-3.59)|
|<18 years||100 (93.5)||7 (6.5)||1||1|
|≥ 18 years||650 (94.1)||41 (5.9)||0.90 (0.39-2.06)|
|diagnosed with cervical cancer|
|Yes||83 (84.7)||15 (15.3)||3.79 (1.98-7.25)*||2.88 (1.47-5.61)*|
|No||713 (95.4)||34 (4.6)||1|
|Poor||407 (98.8)||5 (1.2)||1||1|
|Good||389 (89.8)||44 (10.2)||9.21 (3.61-23.46)*||6.95 (2.59-18.57)*|
|Favorable||206 (97.2)||6 (2.8)||1||1|
|unfavorable||590 (93.2)||43 (6.8)||2.50 (1.05-5.96)*||1.20 (0.47-3.07)|
|Number of children|
|Nulliparous||192 (95.5)||9 (4.5)||1||NA|
|1-4 children||532 (93.3)||38 (6.7)||1.52 (0.72-3.21)|
|≥ 5 children||72 (97.3)||2 (2.7)||0.59 (0.12-2.81)|
|Orthodox||517 (95.5)||26 (4.8)||0.56 (0.30-1.06)|
|Catholic||13 (92.9)||1 (7.1)||0.86 (0.10-7.01)|
|Muslim||75 (93.8)||5 (6.2)||0.74 (0.26-2.10)|
|Protestant||191 (91.8)||17 (8.2)||1||NA|
COR: Crude Odds Ratio: odds ratio by bivariate analysis; 95% CI: confidence interval at the 95% level
*p-value ≤ 0.05; AOR: Adjusted OR: odds ratio by multiple logistic regression
*NA: Not Applicable
Table 3: Association between practice on cervical cancer screening and different characteristics of study participants in Bishoftu town, Eastern Ethiopia, 2016.
In this study, the major sources of information were mass media and health professionals. This finding is consistent with a study conducted in Ogun State, Nigeria where health professionals and mass media were the commonest sources of information for cervical cancer and its screening [12,13]. As previous studies conducted in the Democratic Republic of Congo  and Ethiopia , participants with a higher level of education and those who obtained information from mass media and health professionals were associated with an increased level of knowledge
about cervical cancer and its screening. This highlights the importance of educating the community and the role of the media and health professionals in raising awareness.
This study showed that knowledge about the risk factors of cervical cancer (including smoking, multiple sexual partners, sexual intercourse at an early stage, and low socioeconomic status) was low. This finding is better than studies done in Nigeria, and Ghana [12,13]. This could be explained by differences in educational status. By contrast, one study from South Africa showed the majority of the respondents knew at least one risk factor for cervical cancer . This difference might be attributed to the fact that South Africa has a national cervical cancer screening policy. In Ethiopia, there are no organized and multidisciplinary preventive and curative strategies for cervical cancer which may account for the lower result of her .
As a result of effective screening options, HPV vaccination, and effective treatment options for precancerous lesions, cervical cancer is a preventable disease. But in this study, unlike other studies in Ethiopia and South Africa [4,14], only half of the respondents mentioned at least one preventive option for cervical cancer.
Most of the study participants had a favourable attitude towards cervical cancer screening. This might be explained by the higher level of education of study participants. The role of mass media and health professionals in increasing awareness of the participants towards cervical cancer and its screening might be reasons for a favourable attitude towards screening. But it is still lower than in other studies conducted in Northeast Ethiopia  and India .
Despite good knowledge and a favourable attitude, the screening practice of study participants was found to be low though this service is given free of charge. This may be related to the discomfort associated with the screening procedure. Therefore, this low rate of attendance requires further exploration to fully understand why women do not attend for this life-saving intervention. The finding is consistent with other studies in Sub-Saharan Africa and other developing countries [4,7,11,16,17]. On the other hand, because of relative improvement in awareness about cervical cancer in Ethiopia, the level of current cervical cancer screening practice is higher than comparative studies in Kenya  and South Ghana .
Like other studies conducted in Ethiopia and Tanzania [7,18-20], women who practised cervical cancer screening are women with good knowledge scores and those who know someone diagnosed with cervical cancer.
The study found that nearly half of the study participants had poor knowledge of the causes, risk factors, and preventive methods of cervical cancer and its screening. The majority of women had a favourable attitude towards cervical cancer screening but, the practice of attending for pre-cervical cancer screening was low. Thus, raising awareness of cervical cancer and its screening should be a priority for the community by trained health workers. This could be done through the use of mass media like television and radio, in health promotion and raising awareness.
The knowledge level and attendance for cervical cancer screening among study participants were low. Thus, health education to raise awareness of the importance of cervical cancer screening should be a priority for community health leaders.
Ethics approval and consent to participate
Ethical clearance was obtained from the Research Ethics Review Committee (RERC) of Wollega University. Bishoftu town health office was informed of the study’s aims and objectives and permission was obtained. Following an explanation of the purpose and objectives of the study, written informed consent was obtained from each study participant. Additionally, written consent was obtained from guardians for those below 18 years of age. The participants were assured that all information was used only for the study. Confidentiality was assured by not recording the participant’s name on the questionnaire.
Consent to publish
Availability of data and materials
The data sets are available from the corresponding author on a reasonable request.
Authors declare that they have no financial and non-financial competing interests.
The study has been funded by Wollega University who did not influence the study design, on the collection, analysis, and interpretation of data and in writing the manuscript.
Ebo GG conceived the study, its overall design, and execution, designed the questionnaire, performed data collection, performed the statistical analysis, and served as the lead author of the manuscript.
Heyi WD conceived the study, participated in the design of the questionnaire, performed the statistical analysis, drafted the manuscript, and assisted in the design of the study and data analysis.
Tilahun T participated in the design of the questionnaire, in drafting and finalizing the manuscript, and assisted with the design of the study and data analysis. All authors read and finally approved this manuscript for submission.
The authors would like to thank Wollega University for all-round support. We would like to acknowledge the Oromia Health Bureau and Bishoftu Town Health Office for their participation and facilitating the fieldwork throughout the study period. Our appreciation also goes to the supervisors, data collectors, and all of the district community especially the women who generously and willingly participated in the study; without them, this study would have been unthinkable.
Tilahun T is Associate Professor of obstetrics and gynaecology, Institute of Health Sciences, Wollega University.
Citation: Ebo GG, Tilahun T, Heyi WD (2020) Cervical Cancer Screening Practice and Associated Factors in Bishoftu Town, Eastern Ethiopia. Gynecol Obstet (Sunnyvale) 10:538. doi: 10.35248/2161-10932.2020.10.538
Received Date: Aug 20, 2020 / Accepted Date: Sep 08, 2020 / Published Date: Sep 14, 2020
Copyright: © 2020 Ebo GG, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.