Cervical Cancer Screening Practice and Associated Factors Among Women Employees in Wolaita Zone Hospitals, Southern Ethiopia, 2017


 Background: Cervical cancer is a global public health problem accounting for the fourth most common cancer-affecting women worldwide with 527,624 women are diagnosed with cervical cancer and 265,672 die from the disease annually worldwide. Cervical cancer screening offers protective benefits and is associated with a reduction in the incidence of invasive cervical cancer and cervical cancer mortality. But there is very low participation rate in screening practice for cervical cancer in low-resource countries like Ethiopia. So the aims of this study is to assess cervical cancer screening practice and associated factors among women employees in Wolaita Zone hospitals, southern Ethiopia, 2017Methods: Facility based cross-sectional study design was conducted among age eligible women employees in Wolaita zone hospitals from March 1 -April 30, 2017. Sample size was allocated using probability proportionate allocation and finally simple random sampling technique was employed to select 401 study participants. Pre-tested semi-structured self-administered questionnaire was used. Data was entered and cleaned using Epi-data3.1 and analyzed using SPSS version 21. Logistic regression was performed to assess association between dependent and independent variables with 95% CI and p- value less than 0.05 was set to declare association.Results: About 120(30.5%) participants were screened for cervical cancer. Age (AOR=2.842(1.616, 5.00)), source of information from health professions, (AOR=3.301(1.899, 5.737)), being adherence supporter, (AOR= 3.741(1.414,9.899)),sex with more than one partner,(AOR=2.289(1.116,4.362) ,STI(AOR=3.13(1.784,5.493), increase in attitude score towards cervical cancer screening (AOR=1.468(1.334, 1.616)), increase in knowledge score (AOR=1.267(1.92, 1.346)) were significant predictors of cervical cancer screening practice.Conclusion: Magnitude of cervical cancer screening practice among age eligible women is still low. Age of the women, being adherence supporter, and source of information from health care professionals, history of multiple sexual partners, sexually transmitted disease, Knowledge and attitude were important predictors of cervical cancer screening practice. Hospitals in collaboration with town administration should put priority on cervical cancer prevention by establishing cervical cancer screening campaign.


Background
Cervical cancer is a global public health problem accounting for the fourth most common cancer-affecting women worldwide. In developing countries, it is the second most commonly diagnosed cancer after breast cancer and the third leading cause of cancer death after breast and lung cancers [1,2]. The world has estimated population of 2,716 million women aged 15 years and older who are at risk of developing cervical cancer and 527,624 women are diagnosed with cervical cancer and 265,672 die from the disease annually worldwide, 87% occurring in sub-Sahara countries [3]. In Ethiopia, there are 27.19 million women aged 15 years and older who are at risk of developing cervical cancer [4].The age adjusted incidence of cervical cancer is 26.4 per 100,000 women, which is second to breast cancer. Every year 7,095 women diagnosed with cervical cancer and 4,732 die from the disease [5] Though, the causes for many cancers are not well known. Evidences suggested that more than 99% of cervical cancer cases are linked to Human Papilloma-Virus (HPV). HPV infection mainly related to patterns of sexual behavior and sexual activity, which includes multiple sexual partners, early age at rst coitus, promiscuous male partners and lack of condom use and more than 75% of sexually active adults have had HPV infection in their lifetime, it can also be transmitted through direct skin to skin contact of the genial areas [6,7] Ethiopia adopted the WHO recommendation and recommended women to begin cervical cancer screening between 30-49 years of age at least once every three years. The "see and treat" strategy is being applied using Visual Inspection under Acetic acid (VAI) as screening method and cryotherapy as a treatment option [8]. According to study conducted In Botswana cervical cancer screening rate is low and 40.0% of study participants had ever had a Pap smear test [9]. In Uganda, only 19% of female health workers have ever had a cervical cancer screening [10]. The ministry of health of Ethiopia launched preparatory works that have been completed to prevent cervical cancer by Visual Inspection with Acetic Acid (VIA) screening and cryotherapy [11]. The disparity in cervical cancer diagnosis and subsequent mortality between high-and low-resource countries is due largely to the low rate of screening for pre-invasive cervical disease and limited treatment options in low resource settings. Even if, the Ministry of Health has been trying to deal with this problem by providing resources at its Family Guidance Clinics as well as the laboratories and training its staffs especially, nurses to be certi ed in conducting Pap smear screenings so as to help reduce the incidence of cervical cancer, In Ethiopia, only 1% of age eligible women receive effective screening for cervical cancer and 90% of women have never had a pelvic examination at all. [12,13]. The majority of cervical cancer deaths occur in women who never screened or treated and in women with well-described sexual and reproductive risk factors, such as an early sexual debut, a history of multiple sexual partners, and a high number of live births [14].Low level of awareness, lack of effective screening programs, overshadowed by other health priorities (such as AIDS, TB, malaria) and insu cient attention to women's health are the possible factors for the observed higher incidence rate of cervical cancer in the country [13,15]. Study in Botswana, where women with history of sexually transmitted diseases were 1.66 times more likely to undergo the screening than those without STDs [16]. Community-based study done in Uganda showed women who admitted as they were at risk of developing cervical cancer were 2 times more likely to seek screening for cervical cancer compared with those who believe they had a low risk [17]. Another studies done in Botswana and Zambia, which reported that HIV Sero-positive women were 1.97 and 2.62 more likely to be screened than sero negative women respectively [18,19].
The study done in Mekele, in northern parts of Ethiopia, revealed that only 19.8% of age eligible women have been screened for cervical cancer [20].Another study done in Gondar, Ethiopia from the participants that have knowledge about cervical cancer screening was only 14.7% [21]. On the supply side the MSIE based study in Ethiopia showed majority of centers didn't provide Pap smear and other cervical cancer screening and preventive treatment services yet. [22].
Study done in Mekele showed that Women who have admitted having recent history of multiple sexual partners were 1.635 times more likely to undergo screening compared to those who did not have such history (AOR = 1.635, 95%CI = 1.094-2.443) [20]. Study done in Africa showed that the association between sexual behavior and cervical cancer screening practice were higher in women who had recent history of multiple sexual partners than those who did not have such history [23].
Previous studies conducted in the country emphasize on knowledge, attitude and practice (KAP), accessibility of service and health seeking behavior related factors. The studies tried to assess level of knowledge of study participants on its risk factors, sign, symptoms, and prevention methods and also assessed the frequency of positive and negative attitude towards cervical cancer [24,25].
But little is known about the strength of association between factors affecting cervical cancer screening and screening practice and studies concerning cervical cancer screening practice and associated factors was not found in study area. Therefore, the main purpose of this research is to identify factors affecting cervical cancer screening practice and to recommend ways and set directions to increase cervical cancer screening and the study participants get an insight about cervical cancer and screening during the data collection period and long term bene t from study nding.

Study area and study Period
The study was conducted in Wolaita Zone, southern Ethiopia. Wolaita zone is located at a distance of 153km from capital of SNNPR

Study design
Facility based cross-sectional study design was employed.

Source population
All woman employees in the hospitals with the age range of 25-49 year.

Study population
All sampled woman employees in the hospitals with the age range of 25-49 year.

Inclusion and exclusion criteria
Inclusion criteria all woman employees with the age range of 25-49 year Exclusion criteria: Those who were critically sick and annual leave at the time of data collection.

Sample size determination
The sample size was determined using a single population proportion formula considering the following assumptions: 19.8% proportion of women who underwent cervical cancer screening [20], 95% con dence interval and 3% margin of error.
Single proportion formula Since the total number of study population is < 10,000 (N=880) using the correction formula Where, nf is the nal sample size, n is the calculated sample size which is 677, N is the total number of woman employees in the three study hospitals (880) .The nal sample size by adding non response rate 5% (382*0.05 +382) was 401.

Sampling procedure
The health facilities where routine cervical cancer screening and treatment by using visual inspection with acetic acid and providing the service for all women were included. The health facilities were; Otona hospital (460), Christian hospital (180) and Dubo hospital (240) with a total of 880 female employees. Then all the population was considered for sampling technique and the total sample size was allocated using probability proportionate to size. Finally, simple random sampling technique was employed to select participants from each respective Hospital.

Data Collection tools
A Pre-tested semi-Structured self-administered questionnaire was used and facilitated by four female nurses and Supervised by two health o cers. Questionnaire was designed to assess socio demographic variables, knowledge, attitude, life style and sexual behavior factors towards cervical cancer screening. Questionnaire was adapted from similar studies and it had ve parts. The rst part has socio demographic characteristics, the second, the third, fourth and fth parts are knowledge, attitude, practice on cervical cancer screening and their life style and behavioral factors .The questionnaire was distributed by the data collector .

Data quality control
Pretesting on 5% of a sample drawn from Arbaminch hospital was conducted prior to data collection to assess the cultural sensitivity and clarity of the items in the questionnaire. As already mentioned semi-structured questionnaire in English was translated into Amharic language and back translated into English by another person to check its validity. Clari cation was provided to participants prior to distribution of the paper. Four data collectors and two supervisors were trained before the actual data collection period regarding the approach, objective of the study and ethical issue. The entered data was checked for completeness at the beginning and middle stage of the work. Data cleaning was conducted at the end of the data entry. Further, con rmatory principal component analysis was performed to validate and check whether items were loaded to their respective constructs. Factor loading score of ≥40% and varimax method of rotation was considered to load items. It showed that the items measuring attitude towards cervical cancer, Here, Eigen value of >1 was considered for construct validity.

Data Processing and Analysis:
After the data collection, data was checked manually for its completeness. The data was entered and coded by using EPI-Data3.1 and after its completion; it was exported to SPSS Version 21 for further analysis. Variables reached a p-value of 0.25 on bivariate analysis were included in multiple logistic regression analysis. Multivariate analysis using backward stepwise selection method was employed and p-values of less than 0.05 were taken to represent signi cance. The degree of association between the independent and dependent variables was analyzed using odds ratios with 95% con dence intervals. Statistical signi cance was declared at P value < 0.05. Data were presented using tables and gures.

Operational de nitions
Knowledge about cervical cancer screening: was assessed by using items with Yes or No response format about sign and symptoms, risk factors, method of prevention, frequency of screening, procedure of screening and eligibility for screening. Totally knowledge was assessed by nineteen items. Finally Measures for knowledge about cervical cancer was scored and knowledge of study participants analyzed as continuous variable.

Attitude assessment
Attitude was assessed by six questions put on Likert's scale. The questions on Likert's scale had positive and negative responses that ranged from strongly agree, agree, neither agree nor disagree, disagree and strongly disagree. The scoring system used with respects to respondents' responses as follows: strongly agree scored 5, agree 4, neither agree nor disagree 3, disagree 2, strongly disagree 1. The responses were summed up and a total score computed for each respondent. Finally attitude of study participants analyzed as continuous variable.

Practice
To asses practice, question was delivered in yes or no option to assess the past ve year respondent's action towards screening and those who ever screened once or more within the past ve years regarded as having screening practice and those who never screened was regarded as having no practice on screening.

Result
A total of 393 women employees participated in this study with (98%) response rate. The mean score of knowledge was 8.63 ± (SD 8.67(S.D 4.127)), with the minimum knowledge score of 2 and maximum score of 18. Mean score of attitude was 22.46 ± (SD 3.961), the minimum score was 11and maximum score was 30.

Socio -Demographic Characteristics
The tables below shows that, of 393 total respondents, 203(51.6%) were in the age range 25-29 year. Majority of the respondents, 270 (68.7%) were married (shown in Table 1) Reason mentioned for not to screen cervical cancer.
The majority of respondents never had cervical cancer screening. Respondents who have no screening practice were asked for their reasons for not to screen and among those who heard of screening ninety ve mentioned as they were not decided well, 80 mentioned as they were afraid of screening result.

Source of information for cervical cancer screening
The source information for cervical cancer screening. About 393(98%) of study subjects heard about cervical cancer. But the source from which they heard was different. Most of them heard from health professionals (44%) and secondly from radio/television (33%).

Life style and sexual behavior factors
Risk exposure of participants had assessed and out of all the study participants, 135(34.3%) had used modern contraceptives. Of those who used modern contraceptives 75(55.5%) used oral contraceptive for greater than ve year. Over all participants, 21(5.3%), had sex before the age of fteen years. Some of the study participants had sexually transmitted infection 94(23.9%).

Predictors of cervical cancer screening practice
In multivariate analysis age, occupation, source of information from health professionals, having high knowledge score and high attitude score were found to be statistically signi cant.
Respondents with age range 30-34 yrs two point nine times more likely to practice cervical cancer screening than women whose age range 25-29yrs (AOR = 2.987, 95% CI (1.626, 5.49). Women those who got information from health professionals were two point six times more likely to practice screening than those who did not mention health professionals as source of information (AOR = 2.521, 95% CI (1.487,4.275) shown on Table 2.  [21,20,10].This might be due to socio demographic characteristics and Screening has become a routine procedure in current study area. Working environment exposure and awareness creation interventions such as health education on cervical cancer screening might be high when compared to previous one. On the contrary, this study is lower than study conducted in Botswana. This may partly be due to difference in the socio-demographic characteristics of the study subjects, difference in health delivery system and priority given by two countries and in Botswana Ministry of Health's had set goal to reach cervical cancer screening for at least 75% and more nationally [9].
From this study it was found that, age of study participant was one of the signi cant predictors of cervical cancer screening uptake. Women from age 30-34 was 2.9 times more likely to be screened compared to women in age range 25- [20,23]. This might be due to information's and related facts dissemination .Nowadays information's about cervical cancer are more probably focused on age group greater than 30years and WHO recommendations put age range from 30-49 for all women and below that for women at high risk to be screened. Most of the individual woman sees her as being at risk and seeks care after recognizes symptoms and perceive susceptibility.
Occupation of study participants was one of the signi cant variables associated with cervical cancer screening practice. Working as counselor or as adherence supporter in ART was 3.41times more likely associated with screening practice (AOR=3.741 (1.414, 9.899)) and being health professionals was 4.103 times more likely associated with screening practice (AOR=3.741 (1.414, 9.899)). This might be perception of risk exposure status and educational back ground of the respondent. The nding was consistent with ndings of a community-based study done in Uganda, the study showed respondents who admitted as they were at risk of developing cervical cancer were 2 times more likely to seek screening for cervical cancer compared with those who believe they had a low risk [17]. Another nding of the present study is that history of multiple sexual partners is also important predictor of cervical cancer screening uptake. Women who have admitted having a recent history of multiple sexual partners were 2.289 times more likely to undergo screening compared to those who did not have such history 2.289(AOR=1.336,3.922) this nding was higher but consistent with study done in Mekele (AOR = 1.635, 95%CI = 1.094-2.443) and study done in Africa [20,9] respectively.
Another nding related to this was women with sexually transmitted infection was 3.13 times more likely to be screened than those without STI (AOR=3.13(1.784,5.493).The same result was also reported from Botswana, where women with history of sexually transmitted diseases were 1.66 times more likely to undergo the screening than those without STDs [16]. This was revealed by another study done on sexual behavior of women in association to screening service uptake and that Women with frequent use of physician services and those requesting annual general and gynecological examinations had a higher probability of also having had cervical cancer screening. Source of information from health care professionals were predictor variable and women who heard information from health care professional were 4.103 times more likely to practice cervical cancer screening compared women did not hear from health professionals (AOR=4.103(2.282,7.377)). This was consistent in study done in Gonder [21].The reason might be health professionals are more acceptable in community and information heard from them could be loyal .Another reason might be study participants in current study were those health professionals and those working with them.
Knowledge and attitude was another important variable predicts screening practice. As knowledge score increases by one the cervical cancer screening practice increases by 1.267(AOR=1.267(1.192, 1.346) and those having high score in attitude practice 1.468 more likely (AOR= 1.468(1.334, 1.616). A study conducted in Uganda health workers (physicians, nurses and others) showed that 65% of female health workers who are eligible for screening did not think they were susceptible to cervical cancer [19] Another study conducted in Botswana witnessed that negative attitude of health service providers and limited access to the doctors were among the major barriers to cervical cancer screening services [9].

LIMITATIONS OF THE STUDY
Cross sectional nature of the study that might be bring bias

Conclusions And Recommendations
Magnitude of cervical cancer screening service uptake among age eligible women is still low. Age of the women, adherence supporter, and source of information from health care professionals, history of multiple sexual partners, sexually transmitted disease, Knowledge and attitude were important predictors of cervical cancer screening practice. Wolaita zonal health department in collaboration with other stake holders should make efforts to promote cervical cancer screening among women employees and Disseminating information that focuses on educating the women about cervical cancer risks and efforts should focus on informing and educating women employees in different institutions. Hospitals in collaboration with town administration should put priority on cervical cancer prevention by establishing cervical cancer screening campaign.

Ethical consideration
Ethical clearance was obtained from research Ethics committee of school of public health in Jimma University. Following this, SNNPR health bureau and Wolaita Zonal health department were informed on study objective and study permission was obtained. Then a written consent was secured from the study participants through informed consent. The participants assured that the information they were going to give was used only for the purpose of the study and con dentiality was kept. Though having conversation about cervical cancer might cause anxiety. But to handle such conditions the data collectors assured the participants well about the objective of the study.