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Cervical cancer screening utilization and associated factors among women of 30–65 years in Girar Jarsoo district North shoa, Ethiopia, 2021

Open AccessPublished:April 15, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101048

      Abstract

      Background

      Cervical cancer screening is the method of early detection of cervical cancer before occurrence to decrease mortality and morbidity of the women. When women screened at least once in their lifetime for cervical cancer, their risk of cancer could be decreased by 25–36%. Despite this advantage the coverage of cervical cancer screening remains below 2% across country level. Therefore, this study aimed to assess cervical cancer screening utilization and associated factors among women 30–65 years in north shoa Ethiopia.

      Method

      Community-based cross-sectional study was conducted using stratified cluster sampling technique among 855 women in March 2021. Data were collected using pretested and semi-structured interviewer administered questionnaire. Adjusted odds ratio with a 95% confidence interval was used to report the association between predictors and the outcome variable.

      Result

      Cervical cancer screening utilization was found to be 21.2% (95% CI = 18.5–23.9).Being HIV positive [AOR = 16.49 (95% CI: 9.20–29.54)], knowing someone who had ever been screened for cervical cancer [AOR = 5.46 (95% CI: 2.53–11.79)], having good knowledge about cervical cancer screening [AOR = 3.8 (95% CI: 2.21–6.56)], women found in fourth quintile wealth index [AOR = 3.31 (95% CI: 1.13–9.70)] and having low perceived barriers for cervical cancer screening [AOR = 2.58 (95% CI: 1.43–4.64] were found to be significantly associated with cervical cancer screening utilization.

      Conclusion

      The study revealed the utilization of cervical cancer screening among women 30–65 years is low. Health education program and other multi-disciplinary approaches should be done to increase cervical cancer screening utilization.

      Keywords

      Abbreviations:

      FGAE (Family Guidance Association of Ethiopia), FMOH (Federal Ministry of Health), HIV (Human Immuno-Virus), HPV (Human Papilloma Virus), LMICs (Low- and Middle-Income Countries), SNNP (Southern Nation Nationality and Peoples), STI (Sexually Transmitted Infection), USA (United States of America)

      1. Introduction

      Cervical cancer starts from single cell via its transformation to malignant in its progression originating in the cervix.
      • NCIS C.C.
      Cervical Cancer - NCIS.
      It is considered preventable cancer because it has a long preinvasive state with an average age at diagnosis of 53 years & curability with early treatment is >95%.
      • Arbyn M.
      • Weiderpass E.
      • Bruni
      Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis.
      According to a report of International Agency for Research on Cancer, there are 12 types of HPV which are carcinogenic to human being. But, 70% of invasive cervical cancer cases were caused by HPV 16 and 18.
      • Cunningham M.
      • Skrastins E.
      • Fitzpatrick
      • et al.
      Cervical cancer screening and HPV vaccine acceptability among rural and urban women in Kilimanjaro Region, Tanzania.
      ,

      Brazil S-. SciELO - Brazil - Knowledge of Human Papillomavirus and Pap Test Among Brazilian University Students. doi:org/10.1590/1806-9282.65.5.625.

      Worldwide analysis on incidence and mortality of cervical cancer was estimated to be 570,000 and 311,000, respectively.
      • Teka B.
      • Gizaw M.
      • Ruddies
      • et al.
      Population-based human papillomavirus infection and genotype distribution among women in rural areas of South Central Ethiopia.
      Whereas, about 119,284 new cases and 81,687 deaths occur annually ranking as the 2nd leading cause of female cancer in Africa.
      • AFRICA R.
      Human papillomavirus and related diseases report AFRICA.
      Cervical cancer incidence rates are declining in high-resource areas while incidence, prevalence, and mortality rates continue to rise in low- and middle-income countries (LMICs).
      • Bray F.
      • Ferlay J.
      • et al.
      Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
      Furthermore, the greatest rise was in LMICs where currently 85% of incident cervical cancers and 87% of cervical cancer deaths occur.
      In Ethiopia, about 6,294 new cases and 4,884 death occur annually ranking as the 2nd leading cause of cancer-related death of women followed by breast cancer.
      • Teka B.
      • Gizaw M.R.
      • et al.
      Population-based human papillomavirus infection and genotype distribution among women in rural areas of South Central Ethiopia.
      The problem of cervical cancer worsens among women of 30–65 years which accounts 79% of new cases and 65.8% of annual death.
      • Teka B.
      • Gizaw M.
      • Ruddies
      • et al.
      Population-based human papillomavirus infection and genotype distribution among women in rural areas of South Central Ethiopia.
      ,
      • AFRICA R.
      Human papillomavirus and related diseases report AFRICA.
      A meta-analysis study in Ethiopia revealed that one among six of the study participants had a cervical lesion.
      • Semachew A.
      • Dagget T.
      • Beyene Y.
      • et al.
      Burden of Cervical Lesion in Ethiopia: Systematic Review and Meta-Analysis.
      Given the limited available data, the prevalence and death rate may be even higher than the number reported.
      • Getaneh A.
      • Tegene B.
      • Belachew
      • et al.
      Knowledge, attitude and practices on cervical cancer screening among undergraduate female students in University of Gondar, Northwest Ethiopia: an institution based cross sectional study.
      Cancer of the cervix is a highly preventable disease through HPV vaccination and cytological screening programs. But, those services are inadequate in LMICs and when women are screened at least once in their lifetime their risk of cancer could be decreased by 25–36%.
      • Sharma M.
      • Ortendahl J.
      • Van Der Ham
      • et al.
      Cost-effectiveness of human papillomavirus vaccination and cervical cancer screening in Thailand.
      The use of pap screening tests over the past 50 years has reduced mortality by 50–60%. But, in developing nations, the problem is still devastating due to scarcity of resources, deficiency of health care system, making cervical cancer screening opportunistic rather than being organized and largely relying on visual inspection with acetic acid.
      • Cunningham M.
      • Skrastins E.
      • Fitzpatrick
      • et al.
      Cervical cancer screening and HPV vaccine acceptability among rural and urban women in Kilimanjaro Region, Tanzania.
      Studies showed that perceived barriers like partner's resistance to women's participation in cervical cancer screening, embarrassed to participate in cervical cancer screening, not knowing where to go for cervical cancer screening, lack of information, lack of convenient clinic time, lack of female screeners, pain etc affects cervical cancer screening utilization.
      • Ibekwe C.M.
      • Hoque Msc M.E.
      • Ntuli-Ngcobo B.H.M.
      Perceived barriers of cervical cancer screening among women attending Mahalapye district hospital, Botswana.
      Another study revealed that poor level of knowledge and negative attitude about cervical cancer screening influences its utilization.
      • Aweke Y.H.
      • Ayanto S.Y.
      • et al.
      Knowledge, attitude and practice for cervical cancer prevention and control among women of childbearing age in Hossana Town, Hadiya zone, Southern Ethiopia.
      A meta-analysis study in sub-Saharan Africa showed that only 12.87% of women were screened for cervical cancer.
      • Yimer N.B.
      • Mohammed M.A.
      • Solomon K.
      • et al.
      Cervical cancer screening uptake in Sub-Saharan Africa: a systematic review and meta-analysis.
      Visual inspection with acetic acid (VIA) screening combined with access to cryotherapy was launched in Ethiopia in 2009 by the FMOH but the coverage remains below 2%. To increase the coverage up to 80% and awareness of cervical cancer screening, the Ethiopian government made some efforts. For instance, the cancer registry was finalized in Addis Ababa and regional states in 2015 to intervene in the consequences of cervical cancer, to promote cancer surveillance, to register and to research cervical cancer and a campaign has been made through media and still in progress. As a result, a total of 22,818 women aged 30–49 undergone cervical cancer screening in 2015.
      • Semachew A.
      • Dagget T.
      • Beyene
      • et al.
      Burden of Cervical Lesion in Ethiopia: Systematic Review and Meta-Analysis.
      ,
      • FMOH E.
      FMOH. Guideline for Cervical Cancer Preventionand Control in Ethiopia.
      Even though early cervical screening and detection are the most effective approach to prevent cervical cancer, the trend of cervical lesion was in increasing fashion. Moreover, as far as our level of knowledge there is no study done among women of 30–65 years where the prevalence of the problem is more prominent. Therefore, this study aimed to assess the prevalence of cervical cancer screening utilization and associated factors among women 30–65 years in Girar Jarsoo district, north shoa Ethiopia.

      2. Methods

      2.1 Study design and period

      A community-based cross-sectional study was conducted from March one to May one, 2021.

      2.2 Study area

      The study was conducted in Girar Jarsoo district, one of the twenty-one districts found in North Shoa zone, Oromia region Ethiopia. Girar Jarsoo district is located 122 km away from Addis Ababa, the capital city of Ethiopia. According to Girar Jarsoo district health office the total number of populations in the district is 140,680 where 22104 are reproductive age group. Administratively, the district encompasses 17 rural kebeles (the smallest administrative unit) and 4 urban kebeles. In this district there are Fitche general hospital and 5 health centers serving the community. Now a day's Fitche general hospital and 1 health center are functional for cervical cancer screening.

      2.3 Population and eligibility criteria

      All women aged 30–65 years living in Girar Jarsoo district were the source population. Study populations were all women aged 30–65 years living in the selected kebeles during the data collection period. Women who had lived a minimum of 6months in the district were included. Whereas, women who were seriously ill and unable to give required information during the study period were excluded from the study.

      2.4 Sample size determination and sampling procedure

      The sample size was calculated using single population proportion formula by considering proportion of cervical cancer screening utilization among women of 30–65 years was 19.8% at Mekele town,
      • Bayu H.
      • Berhe Y.
      • Mulat A.
      • Alemu A.
      Cervical cancer screening service uptake and associated factors among age eligible women in Mekelle zone, Northern Ethiopia, 2015: a community based study using health belief model.
      with 95% confidence interval, 4% margin of error:
      n=zα22p(1p)d2n=(1.96)20.198(0.802)(0.04)2=381


      where, z = standard normal distribution curve value for 95% confidence level = 1.96, α = level of significant, n = required sample size, p = proportion of cervical cancer screening utilization and d = margin of error.
      After using design effect 2 (since cluster sampling used) and a non-response rate of 10%, the total sample size was 838.
      Stratified cluster sampling technique was employed to reach the study participants. First, the total Girar Jarsoo district kebeles (21 kebeles) were stratified as rural (17 kebeles) and urban (4 kebeles). Then proportional size allocation technique was used in the determination of the number of kebeles in each stratum. Accordingly, five rural and one urban kebeles were selected randomly by lottery method from rural and urban kebeles respectively. All eligible participants in the selected cluster were included in the study, making the final sample size of 870. But, ten questionnaires were incomplete and five participants were refused to participate in the study, making the response rate of the study 98.3% and the final sample size was 855 (Fig. 1).
      Fig. 1
      Fig. 1Schematic representation of sampling procedure to assess cervical cancer screening utilization and associated factors among women of 30–65 years in Girar Jarsoo District, North Shoa, Oromia region Ethiopia 2021.

      2.5 Variables of the study

      Cervical cancer screening utilization was the outcome variable whereas, women's age, residence, marital status, religion, education status, occupation, wealth status, health insurance, contraceptive use, history of STIs, sero-HIV status, age at first sexual intercourse, parity, duration of marriage, history of gynecologic examination, perceived barriers to undergo cervical cancer screening, knowledge about cervical cancer screening and attitude about cervical cancer screening were independent variables.

      2.6 Data collection instrument and process

      Data regarding the socio-demographic information, reproductive health characteristics, knowledge of cervical cancer and screening, attitude of cervical cancer and screening, perceived barriers and house hold wealth status of respondents were collected through face-to-face interview using a semi-structured questionnaire adapted from related literatures.
      • Gebru Z.
      • Gerbaba M.
      Utilization of cervical carcinoma screening service and associated factors among currently married women in Arba Minch town, southern Ethiopia.
      • Ndejjo R.
      • Mukama T.
      • Musabyimana A.
      • Musoke D.
      Uptake of cervical cancer screening and associated factors among women in rural Uganda: a cross sectional study.

      Uptake of Cervical Cancer Screening Service and Associated Factors Among Age-Eligible Women in Ethiopia: Systematic Review and Meta-Analysis | Infectious Agents and Cancer | Full Text.

      • Gebregziabher D.
      • Berhanie E.
      • Birhanu T.
      • Tesfamariam K.
      Correlates of cervical cancer screening uptake among female under graduate students of Aksum University, College of Health Sciences, Tigray, Ethiopia.
      A total of one MSc midwife and six BSc midwives have participated in data collection process. One-day training was given to the data collectors and supervisor about the purpose of the study, data collection tools, collection techniques, and ethical issues during the selection of participants and collection of the data. The collected data were reviewed and checked for completeness before data entry and the incomplete data were discarded.

      2.7 Data processing and analysis

      The data entry was performed using the epidata version 4.6 and exported to SPSS (Statistical Package for Social science) version 23 for analysis. In descriptive statistics like texts, tables, graphs, mean and frequency were used to present participants’ characteristics. Bivariable and multivariable logistic regression was used to determine associated factors with cervical cancer screening utilization. Variables with a p-value of less than 0.25 in the bivariable analysis were included in the multivariable logistic regression to adjust for possible confounders. A p-value <0.05 with a 95% confidence interval for the adjusted odds ratio was used to determine the level of significance. Lastly, Hosmer and Lemeshow goodness of fit test was performed and decision was made at P > 0.05.

      2.8 Data quality assurance

      To assure the quality of the data, the tool was prepared first in English and then translated to local language (Afaan Oromo) with the assistance of language experts. Data collectors and supervisor were trained on the data collection process for one day. Pretest was conducted on 5% of the total sample size in one kebele which is not selected for actual data collection and modification was done accordingly. Moreover, data collection was closely monitored by investigators and supervisor.

      2.9 Operational definitions and measurement

      Cervical cancer screening utilization: Participants who had screened at least once in their lifetime were considered to have utilized cervical cancer screening". It was assessed by asking “Have you ever had cervical cancer screening in your lifetime?”, if the respondents answered, “yes “it is considered as utilize cervical screening and labeled as “1” for analysis, while if the respondents answered “no”, it is taken as didn't utilize cervical screening service and labeled as “0”.
      • Nigussie T.
      • Admassu B.
      • Nigussie A.
      Cervical cancer screening service utilization and associated factors among age-eligible women in Jimma town using health belief model, South West Ethiopia.
      Knowledge about cervical cancer screening: It was measured by 12 knowledge questions. Each correct response was categorized as 1 and the incorrect response was categorized as 0. The total minimum and maximum scores were ranged from 0 to 12 respectively. Finally, the mean of the total score was calculated. Participants who scored mean and above of the knowledge questions were considered as having good knowledge about cervical cancer and screening.
      • Cunningham M.
      • Skrastins E.
      • Fitzpatrick
      • et al.
      Cervical cancer screening and HPV vaccine acceptability among rural and urban women in Kilimanjaro Region, Tanzania.
      Attitude about cervical cancer screening: It was measured using 8 questions with the Likert Scale and each Likert scale has a different scoring system (1–5) based on the question type either positive or negative. For negative questions, Likert Scale scoring (strongly agree (1), agree (2), no opinion (3), disagree (4), and strongly disagree (5), and for positive questions reverse scoring was applied. The total attitude score varied from 8 to 40. Finally, the mean of the total score was calculated. Participants who scored mean and above of the attitude questions were considered to have a positive attitude for cervical cancer screening.
      • Kasa A.S.
      • Tesfaye T.D.
      • Temesgen W.A.
      Knowledge, attitude and practice towards cervical cancer among women in Finote Selam city administration, west Gojjam zone, Amhara region, north west Ethiopia.
      Perceived barriers to cervical cancer screening utilization: It was measured by 19 questions using the Likert Scale (strongly agree = 5, agree = 4, no opinion = 3, disagree = 2 and strongly disagree = 1). Finally, the mean of the total score computed. Participants who scored mean and above of the barrier questions were considered to have high perceived barriers to cervical cancer screening while, participants who scored below the mean of the barrier questions were considered to have low perceived barriers to cervical cancer screening.
      • Nigussie T.
      • Admassu B.
      • Nigussie A.
      Cervical cancer screening service utilization and associated factors among age-eligible women in Jimma town using health belief model, South West Ethiopia.

      3. Results

      3.1 Socio-demographic characteristics of study participants

      A total of 855 study participants were included in the analysis, making a response rate of 98.3%. More than two–thirds (69.8%) of the study participants were rural residents. The mean age of the respondents was 42.94 (SD ± 8.86) years. One hundred twenty-one (14.2%) study participants were attended college and above education. Seven hundred forty-seven (87.4%) respondents got married. Regarding occupation nearly half (51.8%) of respondents were housewives. Moreover, four hundred ninety-six (58%) study participants had health insurance (Table 1).
      Table 1Socio-demographic characteristic of women among 30–65 years for cervical cancer screening utilization in Girar Jarsoo district, 2021 (n = 855).
      VariableFrequencyPercentage (%)
      Age group
       30-3938344.8
       40-4927632.3
       50-6013515.8
       ≥60617.1
      Residence
       Urban25830.2
       Rural59769.8
      Religion
       Orthodox64375.2
       Protestant15117.7
       Muslim586.8
       Catholic30.3
      Marital status
       Single121.4
       Married74787.4
       Widowed455.2
       Divorced394.6
       Separated121.4
      Women Educational status
       Don't read and write27432.0
       Primary28633.5
       Secondary17420.3
       College and above12114.2
      Current occupation
       Housewife44351.8
       Merchant24829.0
       Daily laborer222.6
       Government employee11012.9
       Private employee323.7
      Health insurance
       Yes49658.0
       No35942.0
      Husband educational status
       Don't read and write23628
       Primary28333.6
       Secondary14116.7
       College and above18321.7
      Wealth status
       Lowest17420.4
       Second16719.5
       Middle20023.4
       Fourth14917.4
       Highest16519.31

      3.2 Reproductive characteristics of study participants

      Four hundred eighty-five (56.7%) of the study participants got married before the age of 20 years whereas, more than two-thirds (69.1%) of respondents started sexual intercourse before the age of 20 years. Almost all (98.0%) of women gave birth and five hundred thirty-two (62.2%) study participants had less than three children. More than three-fourths (87.5%) of the study participants were screened for HIV (Table 2).
      Table 2Reproductive characteristic of women among 30–65 years for cervical cancer screening utilization in Girar Jarsoo district,2021 (n = 855).
      VariableFrequency (n)(%)
      Age of first marriage
       <20 years48556.7
       ≥20 years37043.3
      Birth
       No170.2
       Yes83898.0
      Parity
       <353263.5
       ≥330636.5
      Mode of delivery
       Vaginal75189.6
       Cesearean485.7
       Both394.7
      Ever used modern contraceptive
       Yes47555.6
       No38044.4
      History of STI
       Yes738.5
       No78291.5
      HIV tested
       Yes80087.5
       No5512.5
      Self-reported HIV result
       Positive11614.5
       Negative68485.5
      Age of first sexual intercourse
       <20 years59169.1
       ≥20 years26430.9

      3.3 Knowledge, attitude and perceived barriers about cervical cancer screening

      Less than one-third (25.9%) of study participants had good knowledge about cervical cancer screening. Health care providers were the main source of information for about 31.76% of study participants (Fig. 2). More than half (55.4%) of study participants had a positive attitude toward cervical cancer screening. Moreover, more than half (53.2%) of study participants had low perceived barriers to cervical cancer screening.
      Fig. 2
      Fig. 2Source of information for women of 30–65 years about cervical cancer and screening in Girar Jarsoo District, 2021.

      3.4 Magnitude of cervical cancer screening utilization

      In this study, about 21.2% of study participants had ever undergone cervical cancer screening in their lifetime (95% CI = 18.5–23.9). More than two-thirds (68.5%) of study participants were requested by health care professionals for cervical cancer screening (Table 3).
      Table 3Distribution of practices related to cervical cancer screening among women of 30–65 years for cervical cancer screening in Girar Jarsoo District, 2021 (n = 181).
      VariablesFrequency(n)Percentage (%)
      Frequency of screening
      Once16390.1
      More than once189.9
      Last screening
      Before five years7340.3
      Within five years10859.7
      Indication for screening
      Request by health professional12468.5
      Personal initiative5731.5

      3.5 Participant reasons for not screened for cervical cancer

      Most women in Girar Jarsoo district were not screened for cervical cancer. The most common reason of not being screened was feeling healthy (Fig. 3).
      Fig. 3
      Fig. 3Reason for not to be screened among women 30–65 years in Girar Jarsoo District, 2021.

      3.6 Factors associated with cervical cancer screening

      In a bivariable analysis place of residence, women's educational status, current occupation, having health insurance, age of first marriage, parity, contraceptive use, history of STI, self-reported HIV test result, age of first sexual intercourse, knowing someone with cervical cancer, knowing someone who screened for cervical cancer, age, perceived barriers, wealth status of respondent, attitude and knowledge about cervical cancer screening were significantly associate with cervical cancer screening utilization at a p-value < 0.25. In the multivariable logistic regression, factors such as knowing someone ever screened for cervical cancer, being fourth quintile in wealth index, self-reported HIV test result positive, having good knowledge about cervical cancer screening, and low perceived barriers were significantly associated with cervical cancer screening utilization.
      Accordingly, women who knew someone ever screened for cervical cancer were 5.46 times more likely to utilize cervical cancer screening compared to women who didn't know someone ever screened for cervical cancer (AOR = 5.46; 95% CI: 2.53–11.79). Likewise, women found in the fourth wealth quintile were 3.31 times more likely to utilize cervical cancer screening compared to women found in the lowest wealth quintile (AOR = 3.31; 95% CI: 1.13–9.70).
      This study found that the odds of cervical cancer screening utilization among women who reported their HIV status positive were 16.49 (AOR = 16.49; 95% CI; 9.20–29.54) times higher as compared to women who reported their HIV status negative. Similarly, the odds of cervical cancer screening utilization among women who had good knowledge about cervical cancer screening were 3.8 (AOR = 3.8; 95% CI: 2.21–6.56) times higher as compared to women who had poor knowledge about cervical cancer screening. This study also found that women who had a low perceived barrier to cervical cancer screening were 2.58 times more likely to utilize cervical cancer screening compared to women who had high perceived barriers to cervical cancer screening (AOR = 2.58; 95% CI: 1.43–4.64) (Table 4).
      Table 4Bivariable and Multivariable analysis of factors associated with cervical cancer screening service utilization among 30–65 years’ women for cervical cancer screening in Girar Jarsoo District, 2021 (n = 855).
      VariableCervical cancer Screening utilizationCOR (95%)AOR (95%)
      YesNo
      Self-reported HIV result
      Negative836021
      Positive793815.07 (9.62–23.64)16.49 (9.2029.54) **
      Know someone who screened for cervical cancer
      No1246131
      Yes57614.62 (3.07–6.96)5.46 (2.5311.79) **
      Perceived barrier
      Low1333223.03 (2.11–4.35)2.58 (1.434.65) **
      High483521
      Wealth status
      Lowest181561
      Second281391.75 (0.92–3.29)1.23 (0.49–3.04)
      Middle351651.84 (1.00–3.38)1.49 (0.61–3.64)
      Fourth51984.51 (2.49–8.17)3.31 (1.139.70) **
      Highest491163,67 (2.03–6.61)2.22 (0.76–6.51)
      Knowledge status
      Poor582951
      Good1233791.65 (1.17–2.34)3.8 (2.216.56) **
      AOR- Adjusted Odds Ratio, COR- Crude Odds Ratio, 1-reference category, * *p < 0.05.

      4. Discussion

      This study was conducted to assess cervical cancer screening utilization among women 30–65 years in Girar Jarsoo district north shoa, Oromia region Ethiopia. Accordingly, the prevalence of cervical cancer screening utilization was found to be 21.2% with (95% CI: 18.5–23.9).
      In this study, the prevalence of cervical cancer screening utilization was 21.2%. This finding was in line with studies done in Mekele, northern Ethiopia (19.8%)
      • Bayu H.
      • Berhe Y.
      • Mulat A.
      • Alemu A.
      Cervical cancer screening service uptake and associated factors among age eligible women in Mekelle zone, Northern Ethiopia, 2015: a community based study using health belief model.
      and Lagos, Nigeria (18.5%).
      • Ndejjo R.
      • Mukama T.
      • Musabyimana A.
      • Musoke D.
      Uptake of cervical cancer screening and associated factors among women in rural Uganda: a cross sectional study.
      However, this finding was lower than studies done in Japan (54.7%),
      • Kaneko N.
      Factors associated with cervical cancer screening among young unmarried Japanese women: results from an internet-based survey.
      United states (71%),
      • Harper D.M.
      • Plegue M.
      • Harmes K.M.
      • Jimbo M.
      • SheinfeldGorin S.
      Three large scale surveys highlight the complexity of cervical cancer under-screening among women 45–65 years of age in the United States.
      Cameroon (43.48%).
      • Donatus L.
      • Nina F.K.
      • Sama D.J.
      • et al.
      Assessing the uptake of cervical cancer screening among women aged 25-65 years in Kumbo West Health District, Cameroon.
      This inconsistency might be the difference in age of the participant. In our study, participants’ age was 30–65 years whereas, a study in Japan was among 20–30 years; United States includes 45–65 years and Cameroon includes 25–65 years. Another inconsistency might be socio-demographic factors; people living in Japan and United States have a high quality of life as compared to our study participants, implying that they might give more weight to their health which provides a high chance to be screened for cervical cancer. Evidence showed that people living in USA and Japan have a high quality of life as compared with all countries. On the other hand, cervical cancer screening service was initiated few years back plus organized and continuous health awareness and health education programs are not well established in Ethiopia.
      On the contrary, the magnitude of this study was higher than the studies done in Kenya (11%)
      • Orang’O E.O.
      • Wachira J.
      • Asirwa F.C.
      • et al.
      Factors associated with uptake of visual inspection with acetic acid (VIA) for cervical cancer screening in western Kenya.
      and Lagos, Nigeria (13.3%).
      • Oluwole E.O.
      • Mohammed A.S.
      • Akinyinka M.R.
      • Salako O.
      Cervical cancer awareness and screening uptake among rural women in Lagos, Nigeria.
      The result of the current study is also higher than the studies conducted elsewhere in Ethiopia including, Finote Selam (7.3%),
      • Kasa A.S.
      • Tesfaye T.D.
      • Temesgen W.A.
      Knowledge, attitude and practice towards cervical cancer among women in Finote Selam city administration, west Gojjam zone, Amhara region, north west Ethiopia.
      and Jimma town (15.5%).
      • Nigussie T.
      • Admassu B.
      • Nigussie A.
      Cervical cancer screening service utilization and associated factors among age-eligible women in Jimma town using health belief model, South West Ethiopia.
      This discrepancy might be due to the difference in the measurement of the outcome of interest. In our study, the outcome variable cervical cancer screening utilization is measured if a woman had at least one cervical cancer screening history throughout her lifetime whereas, above mentioned articles were used a maximum of five years. The other discrepancy might be also the difference in the age of study participants and study period. Moreover, currently cervical cancer screening become a routine procedure for patients came with gynecologic problem and the screening centers become expanded which might improve service utilization.
      This study revealed that women who reported their HIV status were one of the significant factors for the utilization of cervical cancer screening utilization. Women who reported their HIV status positive were 16.49 times more likely to utilize cervical cancer screening compared to women who reported their HIV status negative. This finding was similar to the study conducted in western Kenya.
      • Orang’O E.O.
      • Wachira J.
      • Asirwa F.C.
      • et al.
      Factors associated with uptake of visual inspection with acetic acid (VIA) for cervical cancer screening in western Kenya.
      The possible reason might be HIV-positive women had frequent contact with health care professionals in such a way that they might request to have a test for cervical cancer, and also, they might have more gynecological examination and investigations for co-morbid disease when they are seriously ill.
      The wealth status of study participants was also found to be a significant predictor of cervical cancer screening utilization. Women who were in the fourth quintile were 3.31 times more likely to utilize cervical screening when compared with women who were in the lowest quintile. This finding was consistent with studies done in Japan
      • Kaneko N.
      Factors associated with cervical cancer screening among young unmarried Japanese women: results from an internet-based survey.
      and northern Peru.
      • Winkler J.
      • Bingham A.
      • Coffey P.
      • Penn Handwerker W.
      Women's participation in a cervical cancer screening program in northern Peru.
      This might be women who had high financial resources could access health services easily, get access to education and different media outlets and they know the consequence of not being screened for cervical cancer. A study showed that accessibility of financial resources enables access to health-care services.
      • Utilization H.-C.
      Health-Care Utilization as a Proxy in Disability Determination.
      Knowing someone screened for cervical cancer was also another significant predictor for cervical cancer screening utilization. Women who know someone screened for cervical cancer were 5.46 times more likely to utilize cervical cancer screening when compared with women who didn't know someone screened for cervical cancer. This study was supported by studies done in Uganda and Jimma town Ethiopia.
      • Nigussie T.
      • Admassu B.
      • Nigussie A.
      Cervical cancer screening service utilization and associated factors among age-eligible women in Jimma town using health belief model, South West Ethiopia.
      ,
      • Ndejjo R.
      • Mukama T.
      • Musabyimana A.
      • Musoke D.
      Uptake of cervical cancer screening and associated factors among women in rural Uganda: a cross sectional study.
      The possible explanation might be when unscreened women discuss with screened women, they might get access to information about services given in the health facilities including, how screening will be done, side effects, time the procedure takes, and reduces fear. It in turn helps to discuss with their families about the issue and can convince them easily.
      Knowledge about cervical cancer screening was other significant predictors of cervical cancer screening utilization. Women who had good knowledge about cervical cancer screening were 3.8 times more likely to utilize cervical cancer screening compared to women who had poor knowledge. This study finding was consistent with studies done in Jimma,
      • Nigussie T.
      • Admassu B.
      • Nigussie A.
      Cervical cancer screening service utilization and associated factors among age-eligible women in Jimma town using health belief model, South West Ethiopia.
      Dire Dawa,
      • Belay Y.
      • Dheresa M.
      • Sema A.
      • Desalew A.
      • Assefa N.
      Cervical cancer screening utilization and associated factors among women aged 30 to 49 Years in Dire Dawa, Eastern Ethiopia.
      Debre Markos
      • Shiferaw S.
      • Addissie A.
      • Gizaw M.
      • et al.
      Knowledge about cervical cancer and barriers toward cervical cancer screening among HIV-positive women attending public health centers in Addis Ababa city, Ethiopia.
      and Mekele town, Ethiopia.
      • Bayu H.
      • Berhe Y.
      • Mulat A.
      • Alemu A.
      Cervical cancer screening service uptake and associated factors among age eligible women in Mekelle zone, Northern Ethiopia, 2015: a community based study using health belief model.
      The possible explanation might be women who had good knowledge were aware of cervical cancer screening which in turn increases the odds of screening utilization and clear rumors and go for screening without hesitation. In addition, the paucity of information on where and when the service is provided would negatively affect the uptake of service utilization.
      Another important factor that significantly determines cervical cancer screening utilization was found to be perceived barriers of study participants. The odds of cervical cancer screening utilization were 2.58 times higher for women who had low perceived barriers to cervical cancer screening as compared to women who had high perceived barriers. This finding was supported by a study done in Mekele, Ethiopia.
      • Bayu H.
      • Berhe Y.
      • Mulat A.
      • Alemu A.
      Cervical cancer screening service uptake and associated factors among age eligible women in Mekelle zone, Northern Ethiopia, 2015: a community based study using health belief model.
      It is fact that the presence of high perceived barriers for a specific health problem affects healthcare-seeking behaviors of individuals. On the other hand, solving the above-mentioned barriers would increase cervical cancer screening utilization. It could also have been explained by low perceived barriers means improved social, personal, and facility barriers and a high chance to undergo cervical cancer screening.

      4.1 Limitation of the study

      Recall and social desirability biases might have been introduced. However, the study participants had been informed that their participation is important for the study, the information is unspecified, and kept confidential for the study purpose only.

      5. Conclusion

      Less than one-fourth (21.2%) of study participants were utilized cervical cancer screening. The top common reasons for not utilized of cervical cancer screening were feeling healthy and didn't know about the service. Factors like, women reported their HIV status positive, knowing someone ever screened for cervical cancer, being in the fourth quintile of wealth index, good knowledge about cervical cancer screening, and low perceived barriers to cervical cancer screening were significantly associated with cervical cancer screening utilization. Hence, health education should be given for the community to screen and disclose their HIV status, increase knowledge about cervical cancer screening utilization, and reduce perceived barriers are crucial points.

      Declarations

      Ethics approval and consent to participate.
      The study was conducted under the Ethiopian Health Research Ethics Guideline and the declaration of Helsinki. Ethical clearance was obtained from the Institutional Ethical Review Board (IRB) of the University of Gondar (Reference number: SMIDW/18/2013 E.C). A formal letter of cooperation was written to each selected kebele administrative from Girar Jarsoo district health bureau. Written informed consent was obtained from each study participants after informing the objective of the study. Any participant who was not willing to participate in the study was not forced, no personal identifications was included in the datasheet and all data taken from the participants were kept strictly confidential and used only for the study purpose.

      Consent for publication

      Not applicable.

      Data availability

      The authors declare that the data regarding this manuscript can be accessed as per the request of any interested body.

      Funding

      No fund was received for this work.

      Authors’ contributions

      AAA: wrote the proposal, participated in data collection, AAA, ZME and MBA analyzed the data, drafted the paper and prepared the manuscript, approved the proposal with few revisions, participated in data analysis and revised subsequent drafts of the paper. All the authors read and approved the final manuscript.

      Declaration of competing interest

      The authors declare that they have no competing interests.

      Acknowledgment

      We are very grateful to the University of Gondar for the approval of the ethical clearance. We would also like to extend our gratitude to Girar Jarsoo District health office for providing the desired information and supportive letter to undertake the study. We would also like to thank the study participants, data collectors, and supervisor.

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