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KNOWLEDGE AND UTILIZATION OF CERVICAL CANCER SCREENING SERVICE AMONG WOMEN IN ETHIOPIA: META ANALYSIS

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Abstract 

The purpose of this meta-analysis was to assess the association between knowledge and utilization of cervical cancer screening services among women in Ethiopia. 

Previous tests of the association of knowledge and utilization of cervical cancer screening services have yielded inconsistent results. Using data from 12 studies, from different regions of Ethiopia, we performed a meta-analysis with a specific focus on women's utilization of cervical cancer screening services

We applied the random-effects analytic model and calculated a pooled odds ratio. 47.16% (2218) Women who know cervical cancer screening service 11.41% (537) engaged in the utilization of cervical cancer screening services. 

The proportion of utilization of cervical cancer screening service among women aged >20 years was 18.22% in 6 of the 12 studies. The overall proportion of utilization of cervical cancer screening was 24.21% and 28.08% among having knowledge of cervical cancer screening service and not having knowledge cervical cancer screening service, respectively.

Our findings suggest that knowledge of cervical cancer screening service is not directly related to the likelihood that they practice cervical cancer screening. The relationship between age and utilization of cervical cancer screening should be explored further.

 

 

 

 

 

 

 

 INTRODUCTION 

Cervical cancer screening is a key to detect pre-cervical cancer earlier. Still,, but it is almost not utilized in all developing countries, and most cases were diagnosed at the late stage of cervical cancer. (1) It causes hundreds of thousands of death among women annually worldwide. When a woman is screened for cervical cancer at least once in her life between the ages of 30 and 40, the risk of getting cervical cancer can be decreased by 25-36%. Despite this advantage, the coverage of cervical cancer screening is limited in low and middle-income countries, including Ethiopia. (2)

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, and the understanding should be spread among common people to increase the awareness towards screening and preventing the disease conditions as soon as possible. (5)

To prevent this disease, cervical cancer screening programs are introduced worldwide, and the introduction of the Papanicolaou (Pap) test led to a significant reduction in mortality and morbidity in developed countries. (6)

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)

Eighty-nine 89 women were interviewed at Baragwanath Hospital. Only 4 of these had heard of or had had a cervical smear. This indicates that education about cervical carcinoma and cervical smears needs to be more extensive. (8)

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 

Data

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.

Study selection

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, and studies that did not meet the inclusion criteria were excluded. After removing duplicates, this resulted in 1083 studies investigating cervical cancer screening. After the full article examination, 12 studies met the inclusion criteria. The rest were excluded for reasons being, studies not in Ethiopia and studies not examining knowledge about cervical cancer screening service and utilization of cervical cancer screening service.

 

 

 

 

 

Figure 1 Study flow diagram.

 

 

 

 

Measures 

In this meta-analysis, the utilization of cervical cancer screening was assessed by self-reported action towards screening for premalignant cervical lesions. Tthose ever screened for cervical cancer were considered as having a good practice of cervical cancer screening and otherwise considered as having poor practice.

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.

Analysis

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 with describing to describe the relationship between utilization of cervical cancer screening and knowledge of cervical cancer screening. We calculated pooled odds ratios across the studies using the Mantel-Haenszel (MH) statistic (the DerSimonian-Laird method or random effect model). Using the I2 statistic [100% × (chi-square− degree of freedom)/chi square] (13), we assessed the nature and extent of heterogeneity across the surveys. 

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.

 

 

 RESULTS

 Study characteristics 

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, and they comprised of the population from a different region in Ethiopia. Two studies were conducted in the Tigray region, another three in the Amhara region, the two studies from the Oromia region, and four studies from the Southern region and one study from Addis Ababa city.

Table 1.

 

Author / year 

Sample size 

Tittle / study design

Berhanu T 2019

286

Knowledge of Cervical Cancer and Its Screening Practice among Health

Extension Workers in Addis Ababa, Ethiopia/Across sectional, interview- based survey.

Dulla D2017

225

Knowledge about cervical cancer screening and its practice among female health care workers in Ssouthern Eethiopia: a cross-sectional study/Institution-based cross sectional study.

Gebre M2014

225

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

1135

Comprehensive knowledge on cervical cancer, attitude towards its screening and associated factors among women aged 30–49 years in Finote Selam town, Nnorthwest Ethiopia/A community based cross-sectional study.

Kassa S2017

735

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-

nity-based cross-sectional study design.

 

 

 

 

 

Kress M C 2015

218

Knowledge, attitudes, and practices regarding cervical cancer and screening among Eethiopian health care workers/self-administered, anonymous, multiple-choice surveys

Michael E 2018

148

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- sectional study

Mulatu K2016

209

Assessment of Knowledge, Attitude and practice on Cervical Cancer Screening among Female Students of Mizan Tepi University, Ethiopia, 2016/Descriptive cross- sectional

study design

Muluneh A 2019

219

Predictors of cervical cancer screening service utilization among commercial sex workers in Northwest Ethiopia: a case-control

Study

Seyoum T 2016

281

utilization of Cervical Cancer Screening and Associated Factors among Female Health Workers in Governmental Health Institution of Arba Minch Town and Zuria District, GamoGofa Zone, Arba Minch, Ethiopia, 2016 /facility- based  cross- sectional study

Solomon K 2019

475

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/ facility- based cross-sectional study

Teame M 2018

 

548

Factors affecting utilization of cervical cancer screening services among women attending public hospitals in Tigray region, Ethiopia, 2018; Case- control study/Hospital- based unmatched case- control study

 

 

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 age of <20 years and the age of >20 years. A subgroup analysis demonstrated that the odds ratio for the age of >20 years was higher than that for the age of <20 years (OR = 5.17; 95% CI: 1.75–15.32 and OR = 0.23; 95% CI: 0.13–0.42) respectively. In other words, knowledge about cervical cancer screening service discrepancy was stronger for the age of >20 years than for the age of <20 years, with the age of >20 years much more likely to the utilization of cervical cancer screening service. 

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, and poor knowledge about cervical cancer screening service on the outcome of utilization of cervical cancer screening service. The subgroup analysis was conducted to investigate whether age modifies the effect of knowledge about cervical cancer screening services on the utilization of cervical cancer screening services.

 

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. Good knowledge about cervical cancer screening service is favored over poor knowledge about cervical cancer screening service for age > 20 years, while poor knowledge about cervical cancer screening service is favored over good knowledge about cervical cancer screening service for age < 20 years; therefore, the subgroup effect is qualitative. There is a relatively smaller amount of heterogeneity between results from the studies within the age < 20 years (78%). 

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. 

A sufficient number of studies (6) and\participants (2080 and 2623) were included in each subgroup, so the covariate distribution is not concerning for this subgroup analysis. 

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. 

 

 

 

 

 

Discussion

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), which indicated that no significant association between knowledge of cervical cancer screening and cervical cancer screening utilization.

Several studies conducted in Ethiopia by different scholars also failed to show any association between knowledge of cervical cancer screening and the practice of cervical cancer screening (6, 14). Similarly, a study which is done in Botswana (15) showed that knowledge of cervical cancer and its prevention has no association with cervical cancer screening utilization. Furthermore, this finding goes in line with the concept stated ion books of health education and behavioral science which emphasizesing that knowledge does not always translate into behavior change (16). This might be due to factors like accessibility, acceptability, affordability, quality of screening, and treatment services.

This result was incomparable with the results of studies conducted in different parts of Ethiopia, which reported that knowledge about cervical cancer and its screening was related to the utilization of cervical cancer screening (17-19). Similarly, studies conducted in Uganda (20), Tanzania (21), Hong Kong (22), Malaysia (23), and Myanmar elucidate that knowing cervical cancer screening was associated with participation in cervical cancer screenings. Yet, the association between knowledge and behavior change is not always clear (16, 17) this variation might be due to the difference in the study population, sampling, study design , and theoretical framework.

Mostly, meta-analysis heavily depends on published studies, which are more likely to report significant results; studies having non-significant association would be would be systematically avoided. However, in this analysis, the problem of publication bias would be less significant as the focus of the analysis is a contemporary issue of scientific argument by which reporting any direction of association would be practically interesting to researchers and publishers.

 

Association of the utilization of cervical cancer screening services with knowing cervical cancer screening service relative to not knowing cervical cancer screening services table.

 

 

 

 

 

 

 

 

 

 

The subgroup analysis compares the effect of knowledge about cervical cancer screening services on the outcome of the utilization of cervical cancer screening services.

 

 

 

 

 

 

 

 

 

The funnel plot for the subgroups of age > 20 years and age < 20 years 

 

 

 

 

 

Conclusion

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. However, this advantage is not seen in age < 20 years. It would be beneficial for more studies to be conducted in these areas to confirm the subgroup effect.

Data Availability: 

All data are included in the paper.

 

Conflicts of Interest: The authors declare that they have no conflicts of interest. 

 

Authors' Contributions: 

  • Klaeab Tesfaye Tegegne was responsible for conceptualization, project administration, software, supervision, and development of the original drafting of the manuscript.
  • Klaeab 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.

Acknowledgments 

We would like to thank all the primary authors of the included articles

Declaration 

Ethics approval and consent to participate

Not applicable

Competing of interest 

The authors have declared that there is no competing interest 

Consent for publication 

Not applicable

Funding 

Not any funding received for this work

References

1. Seyoum T, Yesuf A, Kejela G, Gebremeskel F. Utilization of cervical cancer screening and associated factors among female health Workers in Governmental Health Institution of Arba Minch town and Zuria District, GamoGofa zone, Arba Minch, Ethiopia, 2016. Arch Cancer Res. 2017;5(4):165.

2. Nigussie T, Admassu B, Nigussie A. Cervical cancer screening service utilization and associated factors among age-eligible women in Jimma town using the health belief model, South West Ethiopia. BMC women's health. 2019;19(1):127.

3. Aweke YH, Ayanto SY, Ersado TL. Knowledge, attitude and practice for cervical cancer prevention and control among women of childbearing age in Hossana Town, Hadiya zone, Southern Ethiopia: Community-based cross-sectional study. Plos One. 2017;12(7).

4. Ideström M, Milsom I, Andersson‐Ellström A. Knowledge and attitudes about the Pap‐smear screening program: a population‐based study of women aged 20–59 years. ActaobstetriciaetgynecologicaScandinavica. 2002;81(10):962-7.

5. Mulatu K, Motma A, Seid M, Tadesse M. Assessment of knowledge, attitude and practice on cervical cancer screening among female students of Mizan Tepi University, Ethiopia, 2016. Cancer BiolTherOncol. 2017;1(1):1-5.

6. Gebreegziabher M, Asefa NG, Berhe S. 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. Journal of Cancer Research. 2016;2016.

7. Mitchell H, Hirst S, Mitchell JA, Staples M, Torcello N. Effect of ethnic media on cervical cancer screening rates. Australian and New Zealand journal of public health. 1997;21(3):265-7.

8. Emdon S, Gerard U, Jones R. Knowledge about and utilization of facilities for cervical smears among black women in Johannesburg. South African medical journal= Suid-Afrikaansetydskrifvirgeneeskunde. 1984;65(8):289-90.

9. Kress CM, Sharling L, Owen-Smith AA, Desalegn D, Blumberg HM, Goedken J. Knowledge, attitudes, and practices regarding cervical cancer and screening among Ethiopian health care workers. International journal of women's health. 2015;7:765.

10. Getachew S, Getachew E, Gizaw M, Ayele W, Addissie A, Kantelhardt EJ. Cervical cancer screening knowledge and barriers among women in Addis Ababa, Ethiopia.PloS one. 2019;14(5).

11. Bulto G, Demmissie D, Daka K. Knowledge about Cervical Cancer, Screening Practices and Associated Factors among Women Living with HIV in Public Hospitals of West Shoa Zone, Central Ethiopia. J Women's Health Care. 2019;8.

12. Guyatt G, Oxman A, Santesso N, Helfand M, Vist G, Kunz R. The Cochrane collaboration. Review Manager (reman). Pain. 2009;9(1):205-13.

13. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses.BMJ. 2003;327(7414):557-60.

14. Solomon K. Predictors of cervical cancer screening practice among HIV-positive women attending adult antiretroviral clinics, Bishoftu, Ethiopia: the application of the health belief model: Addis Ababa University; 2018.

15. Tapera R, Manyala E, Erick P, Maswabi TM, Tumoyagae T, Letsholo B, et al. Knowledge and attitudes towards cervical cancer screening amongst University of Botswana female students. Asian Pacific journal of cancer prevention: APJCP. 2017;18(9):2445.

16. Erku DA, Netere AK, Mersha AG, Abebe SA, Mekuria AB, Belachew SA. Comprehensive knowledge and uptake of cervical cancer screening is low among women living with HIV/AIDS in Northwest Ethiopia. Gynecologic oncology research and practice. 2017;4(1):20.

17. 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 the health belief model. PloS one. 2016;11(3).

18. Heyiwd, bekabiltt, Ebo gg. Knowledge, attitude and practice of cervical cancer screening among women aged 15-49 years in Bishoftu town, east shewa zone, Oromia region, Ethiopia, 2016. Ethiopian journal of reproductive health. 2018;10(2):10-.

19. Wanyenze RK, Bwanika JB, Beyeza-Kashesya J, Mugerwa S, Arinaitwe J, Matovu JK, et al. Uptake and correlates of cervical cancer screening among HIV-infected women attending HIV care in Uganda. Global health action. 2017;10(1):1380361.

20. Beran T, Lyimo FS. Demographic, knowledge, attitudinal, and accessibility factors associated with uptake of cervical cancer screening among women in a rural district of Tanzania: three public policy implications. 2012.

21. Leung SS, Leung I. Cervical cancer screening: knowledge, health perception and attendance rate among Hong Kong Chinese women. International journal of women's health. 2010;2:221.

22. Nwabichie CC, Manaf RA, Ismail SB. Factors affecting uptake of cervical cancer screening among African women in Klang Valley, Malaysia. Asian Pacific journal of cancer prevention: APJCP. 2018;19(3):825.

23. Nandar CS, Laosee O. Determinants of cervical cancer screening among migrants in the northern district of Yangon, Myanmar. Journal of Public Health and Development. 2015;13(2):3-