The purpose of this meta-analysis was to assess the association between knowledge and utilization of cervical cancer screening services among women in Ethiopia.
Cervical cancer screening is
Lack of knowledge and poor attitude towards the disease and risk factors can affect screening practice and the development of preventive behavior for cervical cancer. (3)
Compliance with screening has previously been suggested to be associated with women's knowledge. (4) Ample knowledge is important to spot the premalignant lesions
To prevent this disease, cervical cancer screening programs are introduced worldwide
Across the three intervention periods, the media publicity appeared to generate an additional 6.7 percent increase screening in areas with a high proportion of women of non-English-speaking-background compared with changes in screening with a low proportion of women of non-English-speaking background. (7)
The age-adjusted incidence of cervical cancer in Ethiopia is 26.4 per 100,000 women, which is second only to breast cancer. Roughly 4,732 women die of cervical cancer each year, the highest cancer-related mortality rate (10.9 per 100,000) among Ethiopian women. (9)
In Ethiopia, the coverage of cervical cancer screening is only 1%. Among all women, 42.7% had heard of cervical cancer screening and 144 (27.7%) women had adequate knowledge of cervical cancer screening. In total, a quarter (25%) of eligible women had an experience of cervical cancer screening (10)
Almost half 210(49.6%) of them had good overall knowledge about cervical cancer, only 9(2.1%) of them were ever screened. This study identified that those women whose ages were 50 or more were 21 times more likely to have good knowledge than those who were young. (11)
Materials and methods
Electronic databases were searched from 2010 to 2020.on reference manager software and quality assessments of the included studies were performed by assessing the risk of bias.
A meta-analysis was applied to investigate the effect of knowledge about cervical cancer screening on the utilization of cervical cancer screening services.
Primary concepts of 'cervical cancer screening', 'knowledge about cervical cancer screening service ', 'pap smear ', 'utilization', and 'Ethiopia ' were expanded to generate additional keywords for the search. Using the following search strategies; 'Cervical+ cancer+ screening+ utilization+ Ethiopia;- 'Cervical+ pap smear + screening+ utilization+ Ethiopia;- 'Cervical+ knowledge about cervical cancer screening service + utilization+ Ethiopia;- 'Knowledge about cervical cancer screening service+ Ethiopia;- 'cervical + utilization+ Ethiopia.
Figure 1 shows the selection process of the articles retrieved. The initial database search returned 1998 published English-language studies after removing unrelated titles. The abstracts were read
Figure 1 Study flow diagram.
In this meta-analysis, the utilization of cervical cancer screening was assessed by self-reported action towards screening for premalignant cervical lesions
The knowledge of cervical cancer screening was assessed by their response to whether they heard about cervical cancer screening or not if they heard about cervical cancer screening they are considered as having good knowledge about cervical cancer screening and otherwise considered as having poor knowledge about cervical cancer screening.
By design, this study is secondary data analysis. Using Review Manager Version 5.3 software (12), we determined pooled odds ratios and associated 95% confidence intervals
We applied the random effects analytic model to account for inter survey variation and to provide a more conservative effect than a fixed model would have provided. The I2 statistics were used to assess the variability among the included studies and above 50% was considered as significant.
Table 1 provides information on the research methods, year, and the focus of the included studies. The 12 studies were published between 2014 and 2019
Author / year
Tittle / study design
Berhanu T 2019
Knowledge of Cervical Cancer and Its Screening Practice among Health
Extension Workers in Addis Ababa, Ethiopia/Across sectional, interview
Knowledge about cervical cancer screening and its practice among female health care workers in
Factors Affecting the Practices of Cervical Cancer Screening
among Female Nurses at Public Health Institutions in Mekelle
Town, Northern Ethiopia, 2014: A Cross-Sectional Study
Geremew B 2018
Comprehensive knowledge on cervical cancer, attitude towards its screening and associated factors among women aged 30–49 years in Finote Selam town,
Knowledge, attitude and practice towards cervical cancer among women in Finote Selam city administration, West Gojjam Zone, Amhara Region, North West Ethiopia, 2017/a commu-
Kress M C 2015
Knowledge, attitudes, and practices regarding cervical cancer and screening among
Michael E 2018
Cervical cancer screening utilization and its associated factors among
women aged 30 years and above in Woliso town, South West Showa
Zone, Oromia region, Ethiopia/Community based Cross
Assessment of Knowledge, Attitude and
Muluneh A 2019
Predictors of cervical cancer screening service utilization among commercial sex workers in Northwest Ethiopia: a case
Seyoum T 2016
Solomon K 2019
Predictors of cervical cancer screening practice among HIV positive women attending adult anti-retroviral treatment clinics in Bishoftu town, Ethiopia: the application of a health belief model/
Teame M 2018
Factors affecting utilization of cervical cancer screening services among women attending public hospitals in Tigray region, Ethiopia, 2018; Case
47.16% (2218), women reported knowing cervical cancer screening service, 26.25% (1235) were utilized for cervical cancer screening service. Among those who utilize cervical cancer screening service, 757 (16.09 %) and 478 (10.16%) were in the age of <20 years and age of >20 years, respectively. In all studies, the proportion of utilization of cervical cancer screening services among women was 1235 (26.25%).
The odds ratios for all studies revealed no statistically significant association of utilization of cervical cancer screening service with knowing cervical cancer screening service relative to not knowing cervical cancer screening service.
However, the meta-analysis demonstrates a statistically significant difference between the two age categories
The funnel plot for the subgroups of age > 20 years and age < 20 years indicate that all of the relevant trials that have been conducted were identified.
Visual inspection of the funnel plots (figure) in the above meta-analysis suggests symmetry for age > 20 years and age < 20 years; therefore, it seems that all of the relevant studies that had been conducted were included in the meta-analysis.
The subgroup analysis compares the effect of knowledge about cervical cancer screening service, good knowledge about cervical cancer screening service
The results of the subgroup analysis suggest that there is a statistically signiﬁcant subgroup effect (P < 0.00001), meaning that age signiﬁcantly modiﬁes the eﬀect of good knowledge about cervical cancer screening service in comparison to poor knowledge about cervical cancer screening service.
However, a visual inspection of the forest plot conﬁrms that heterogeneity is lower within the subgroups than across all studies, and so the subgroup analysis explains heterogeneity in the overall analysis subgroup eﬀect is qualitative.
Considering the covariate distribution, 6 studies included in the age > 20 years subgroup, and 6 studies contribute data to the age < 20 years subgroup.
However, there is substantial unexplained heterogeneity between the studies within each of these subgroups (age > 20 years: I2 = 88% age < 20 years: I2 = 78% ). Therefore, the validity of the knowledge effect estimate for each subgroup is uncertain, as individual study results are inconsistent. The importance of this subgroup analysis is high.
We conducted this review intending to obtain an overall effect of knowledge on cervical cancer screening and current gaps in research and knowledge. According to this study, the pooled odds ratios across the studies using the Mantel-Haenszel (MH) statistic was 1.17 (95% CI 0.40, to 3.41)
Several studies conducted in Ethiopia by different scholar
This result was incomparable with the results of studies conducted in different parts of Ethiopia
Mostly, meta-analysis heavily depends on published studies
Association of the utilization of cervical cancer screening service
The subgroup analysis compares the effect of knowledge about cervical cancer screening service
The funnel plot for the subgroups of age > 20 years and age < 20 years
Our findings suggest that knowledge of cervical cancer screening service is not directly related to the likelihood that they practice cervical cancer screening and age signiﬁcantly modiﬁes the eﬀect of good knowledge about cervical cancer screening service in comparison to poor knowledge about cervical cancer screening service.
Knowledge about cervical cancer screening service has considerable advantages in age > 20 years
All data are included in the paper.
Conflicts of Interest: The authors declare that they have no conflicts of interest.
Tesfaye Tegegne was responsible for conceptualization, project administration, software, supervision, and development of the original drafting of the manuscript.
Tesfaye Tegegne, Eleni Tesfaye, Abiyu Ayalew Assefa, and MekibibKassa have were participated in quality assessment of articles, methodology, validation, and screening of research papers
- All authors contributed with data analysis, critically revised the paper, and agreed to be accountable for their contribution.
We would like to thank all the primary authors of the included articles
Ethics approval and consent to participate
Competing of interest
The authors have declared that there is no competing interest
Consent for publication
Not any funding received for this work
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