Knowledge and Awareness of Cervical Cancer among HIV-Infected Women in Ethiopia

Introduction. Cervical cancer is one of the leading causes of cancer death among Ethiopian women. Low awareness of cervical cancer, in combination with low health care seeking behavior, is a key challenge for cervical cancer prevention. This study assessed the knowledge of cervical cancer among HIV-infected women in Ethiopia. Methods. A facility-based cross-sectional survey was conducted from August to September 2012 among HIV-infected women between 21 and 49 years of age. Basic descriptive statistics were performed using SPSS. Results. A total of 432 HIV-infected women participated in this study. About 71% of participants had ever heard of cervical cancer. Among women who had ever heard of cervical cancer, 49% did not know the cause while 74% were able to identify at least one risk factor for cervical cancer. Only 33% of women were able to correctly address when women should seek care and 33% identified at least one treatment option for cervical cancer. Conclusion. This study revealed that knowledge about cervical cancer was generally low, in particular for health care seeking behavior and treatment of cervical cancer. Health awareness programs should be strengthened at both community and health facility levels with emphasis highlighting the causes, risk factors, care seeking behaviors, and treatment options for cervical cancer.


Introduction
In 2008, one in every six cancers worldwide was caused by an infection that could be prevented or treated [1]. Human papillomavirus (HPV) is responsible for 99% of cervical cancer and accounts for approximately half of the infectionrelated burden of cancer in women [1,2]. In 2012, about 85% of the global burden of cervical cancer was reported from developing countries with Sub-Saharan Africa as the region with the highest incidence of cervical cancer in the world [2][3][4].
In Ethiopia, an estimated 19,836 new cases (26.4 per 100,000 women) and 16,283 deaths (18.4 per 100,000 women) of cervical cancer were reported in 2012 [3]. These figures most likely underestimate the actual number of cases given the low level of awareness for cervical cancer, limited access to cervical cancer screening and treatment services, and lack of a representative population-based cancer registry. Historically, 2 Obstetrics and Gynecology International Ethiopia has invested little effort in cancer awareness as maternal health and other communicable diseases have been targeted as key health priorities by the Federal Ministry of Health (FMOH) [5,6].
Lack of effective screening programs aimed at detecting and treating precancerous cervical conditions, low public awareness, and overall low health care seeking behavior of women are key challenges for cervical cancer prevention (CCP) in developing countries [4,[7][8][9].
Access to cervical cancer screening was extremely limited for the majority of women in Ethiopia until the Single Visit Approach (SVA) for CCP service was introduced by Pathfinder International in 2009. The CCP project, named Addis Tesfa (which translates to New Hope), introduced the SVA to women infected with human immunodeficiency virus (HIV) in a phased approach in 14 public PEPFAR-affiliated health facilities. The SVA employed Visual Inspection of the cervix with Acetic acid wash (VIA) and offered immediate treatment of precancerous cervical lesions with cryotherapy [5,[10][11][12][13]. Women infected with HIV are at higher risk for precancerous lesions and are more likely to progress to invasive cervical cancer compared with uninfected women [14][15][16]. As a result, the FMOH of Ethiopia supported the integration of CCP services within selected HIV/AIDS centers. This study was designed to assess the level of knowledge and awareness of cervical cancer among HIV-infected women in Ethiopia who visited the Addis Tesfa supported health facilities.

Study Design, Sites, and Period.
This descriptive crosssectional study took place in five public health facilities providing SVA services from August to September 2012. The selected sites were all centers of excellence and were either teaching or referral hospitals within the Addis Tesfa project. These sites were located in urban settings in each of the five major regions in Ethiopia: Tigray, Amhara, Oromia, Southern Nations, Nationalities, and People's Region (SNNPR), and Addis Ababa City Administration.

Study Population.
Women infected with HIV between the ages of 21 and 49 years, visiting the selected facilities during the study period, and consenting to be interviewed were included in the study. Women who had a history of cervical cancer and/or hysterectomy were excluded.

Sample Size Determination and Sampling Method.
A sample size of 442 was calculated using a single population proportion formula ( 2 * (1 − )/ 2 ) with 15% nonresponse rate, population proportion of 50%, significance level of 0.05, and a confidence level of 95%. All five public health facilities that provided the SVA service were included as study sites. Enrollment to the study was based on quota sampling which was proportional to each facility's HIV client load. All eligible clients who presented for follow-up visit at the HIV/AIDS center in each of the five health facilities were approached for study enrollment. Clients who gave consent for participation were enrolled consecutively until the target sample size was met for each study site.

Data Collection Instrument.
A structured questionnaire was developed from similar cervical cancer knowledge and awareness studies implemented in developing countries [17][18][19][20]. Prior to study initiation, the questionnaire was translated into three local languages (Amharic, Oromiffa, and Tigrigna) and pilot tested on 44 women in one study site. The questionnaire captured information on sociodemographic characteristics and asked questions associated with the knowledge and awareness of cervical cancer.

Ethical
Considerations. Data collectors and supervisors received two days of training which included study overview, informed consent process, and detailed review and administration of the study questionnaire. Written consent was obtained from all study participants and ethical clearance was granted from the institutional review boards of the Ministry of Science and Technology of Ethiopia and the United States Centers for Disease Control and Prevention (CDC).

Data Collection and
Analysis. Data quality was checked at all levels of data collection and aggregation. The level of cervical cancer knowledge was measured by adding up the total score from ten questions on cause, risk factors, and prevention and treatment options for cervical cancer among HIV-infected women who had ever heard of cervical cancer. Response to each question was categorized into correct (1) and incorrect (0) and the combined score was calculated. The median of the ten questions was taken as a cutoff point to assess the knowledge level; participants who scored above the median were considered to be knowledgeable about cervical cancer while those who scored at or below the median were considered to be less knowledgeable. Basic descriptive statistics were performed using SPSS (version 20).

Sociodemographic Characteristics.
A total of 432 women infected with HIV participated in this study ( Table 1). The study had a participant response rate of 98%. The median age was 33 years with an age range from 21 to 49 years (M = 34.1, SD = 4.8). About four out of ten (39.6%) women were married and 33.1% had no formal education. One-third (32.6%) of participants were housewives and the majority (85%) resided in urban areas. About half of the participants were from health facilities in the Tigray (24.3%) and Amhara (23.1%) Regions. Six out of ten women who participated in this study came to the health facility as part of routine HIV/AIDS follow-up care (Table 1).

Cervical Cancer Cause, Risk, and Source of Information.
About seven out of ten (71.3%) participants had ever heard of cervical cancer and 57.3% stated that the main source of information for cervical cancer was from the health facility (Table 2). Among women that had ever heard of cervical cancer, about half (49.0%) did not know the cause of cervical cancer. About three out of ten (29.2%) participants did not know that cervical cancer was a sexually transmitted illness (STI) and 26.3% were unable to name a single risk factor for cervical cancer. Slightly over half (54.9%) of participants were able to mention HIV as a risk factor for cervical cancer. Among this group of HIV-infected women, about half (50.3%) considered themselves to be at risk for cervical cancer ( Table 2).

Cervical Cancer Prevention (CCP) and Treatment.
Most women believed that cervical cancer is a preventable (75.3%) and treatable (66.2%) health problem (Table 3). A majority of women (85.4%) acknowledged that cervical cancer can  (Table 3).

Comprehensive Knowledge of Cervical
Cancer. The median score used to determine the overall cervical cancer knowledge was two (M = 2.39, SD = 1.73) with participant scores ranging from zero to eight (out of ten possible points). Based on this median cutoff score, less than half of the participants (43.8%) were considered to be knowledgeable about cervical cancer. Fifty-two women (16.9%) who had ever heard of cervical cancer did not respond correctly to any of the ten knowledge questions (Table 4).
Obstetrics and Gynecology International 5

Discussion
This is the first study to our knowledge that investigated cervical cancer knowledge and awareness among HIVinfected women in Ethiopia. These differences are expected as the study was not designed to capture nationally representative data. Increasing knowledge and awareness of cervical cancer plays a major role in improving health care seeking behavior for CCP services [19]. The results of this study are consistent with published literature of cervical cancer knowledge and awareness among women in Sub-Saharan African countries [17][18][19][22][23][24][25]. The findings show that 71% of HIV-infected women in this study had ever heard of cervical cancer, which is comparable to the results found among women in the community of Gondar (79%) in the region of Amhara in northeast Ethiopia [18]. Between the two studies conducted in Ethiopia, women's awareness of cervical cancer-as defined by having heard of cervical cancer-was found to be slightly higher in the community-based study by Getahun et al. compared 6 Obstetrics and Gynecology International Correct answers used to measure cervical cancer knowledge Number ( = 308) % (1) The primary cause of cervical cancer is a germ/virus 122 39.6 (2) Women who have sex before 18 years of age are at high risk for cervical cancer 42 13.6 (3) Women exposed to repeated sexually transmitted illness are at high risk for cervical cancer 61 19.8 (4) Women infected with HIV are at high risk for cervical cancer 169 54.9 (5) Women with multiple sexual partners are at high risk for cervical cancer 102 33.1 (6) A wife of a man who had multiple sexual partners is at high risk for cervical cancer 45 14.6 (7) Women who have a mother or sister with cervical cancer are at high risk for cervical cancer 11 3.6 (8) Women should seek care related to cervical cancer once they become sexually active 96 31.2 (9) Cryotherapy is a treatment option for women diagnosed with precancerous cervical lesion 9 2.9 (10) Treatment options for women diagnosed with cervical cancer include chemotherapy, radiation, and surgery 79 25. to this facility-based study conducted among HIV-infected women. As the Getahun et al. study was implemented in one specific region, it appears that women in Gondar may have had higher awareness of key health topics, including cervical cancer, compared to other areas of the country. This theory may be supported by the findings from this study which showed that a large proportion of women from the health facility in Amhara Region had better knowledge of cervical cancer compared to women from other health facilities. The difference in knowledge among health facilities in this particular study may be related to the intensity of health education programs across the different regions of the Addis Tesfa project. Project documents have shown that implementation of demand creation activities occurred more frequently in Amhara and SNNPR compared to other regions of the project. The findings from this study support past research that has shown that awareness of cervical cancer does not translate into comprehensive knowledge of cervical cancer [18,22,23]. The results indicate that although 71% of women in this study had ever heard of cervical cancer, only 44% had cervical cancer knowledge above the median score. Similar studies have noted that adequate knowledge of cervical cancer remains relatively low, ranging from 37% in Ghana [22], to 31% in Ethiopia [18], to as low as 23% in Nigeria [23]. Knowledge of cervical cancer may be higher in this study because of the recruitment of HIV-infected women who were more likely to have prior exposure and interaction with the health system. The participants recruited in this study were all HIV-infected women coming to an HIV/AIDS center for either a routine HIV follow-up visit (60%), treatment for a current illness (7%), or getting a cervical cancer screening (33%).
Among women in this study that had ever heard of cervical cancer, over half (57%) of participants stated that the source of information for cervical cancer was from the health facility while close to a quarter (23%) mentioned the media. In the community-based survey conducted by Getahun et al. [18], the predominant source of information was reversed-61% of women stated that their source of cervical cancer information was the media while only 35% mentioned health facilities or health providers. The difference in the source of information may be a result of the study setting. Women recruited from the community may be more likely to receive cervical cancer information from the media while women recruited from health facilities may be more likely to receive this information from health professionals.
Having information on the cause and risk factors of cervical cancer is helpful for a woman to take preventive action. In this regard, only 40% of women in this study mentioned that a virus is the primary cause of cervical cancer. This result was higher than the study among HIV-infected women in Lagos, Nigeria, where only 8% knew that HPV causes cervical cancer [8]. In both countries, understanding disease transmission was extremely low; 15% of this study's participants linked the HPV transmission to sexual contact while 18% knew that HPV is contracted via sexual intercourse in Nigeria [8]. A higher proportion of women in this study (55%) knew that HIV was a risk factor for cervical cancer compared to the study conducted in Zimbabwe among HIVinfected women (27%) [20]. In a similar study conducted among educated women at the University of Ghana, 77% of women were able to identify at least one risk factor for cervical cancer [22]. The findings from these studies suggest that women with higher educational attainment, or those recruited from health facilities, were more likely to identify risk factors associated with cervical cancer.
Although close to three-quarters (74%) of women in this study were able to identify at least one risk factor for cervical cancer, only one-third (33%) were able to identify at least one treatment option for cervical cancer. In the study conducted in northeast Ethiopia, 66% of women in the community were able to identify at least one treatment option [18]. Even though the exact same questions were used in both surveys, women in the community in Gondar seem to know more about cervical cancer treatment options compared to HIV-infected women visiting health facilities throughout this study setting at different regions of Ethiopia. This difference may be due to the exposure of prior health 7 and cancer awareness programs in the community of Gondar which may increase overall cervical cancer knowledge within this population.
In resource-constrained settings, it is important to note the ethical considerations of raising disease awareness in communities where screening and treatment are not readily available. Awareness raising programs in the absence of services can be controversial and can erode public confidence in the health system, with the potential to negatively impact other preventative public health programs in a country. Health programs designed to increase awareness should be combined with initiatives that also provide the appropriate screening, diagnostic, and treatment services.
Several limitations exist in this study. As this study was conducted at an HIV/AIDS center, there is potential for selection bias as women who come to these health facilities are likely to have better health seeking behavior and health information compared to women from the general community. In addition, this study used quota sampling, a nonprobability sampling technique which does not allow calculation of sampling error; therefore statistical inferences from this sample were not possible. Social desirability bias might also be a concern due to the sensitive nature of this topic. Sexual and reproductive health topics are sensitive issues in a conservative community; therefore, participants may answer a survey question in a way that will be viewed more favorably by the research team.

Conclusion
The results of this study revealed that even though most HIVinfected women have heard of cervical cancer, the knowledge and awareness of cervical cancer among women attending clinical care services was generally low. In particular, the knowledge gaps were observed on care seeking behavior and treatment of cervical cancer in this study population. These knowledge gaps affect women's care seeking behavior and are detrimental to the national effort towards cervical cancer prevention, treatment, and control. Cervical cancer awareness should be strengthened both at the community and health facility level. Special emphasis must be placed on the causes, risk factors, care seeking behavior, and treatment options for cervical cancer. A successful cervical cancer prevention, treatment, and control program not only will focus on awareness raising efforts, but should also be combined with programs to ensure access to cervical cancer screening, diagnostic, and treatment services.