Women's Knowledge and Attitude Towards Cervical Cancer Preventive Measures and Associated Factors in South Gondar Zone, Amhara Region, North Central Ethiopia: a Cross-sectional Study

doi:10.21203/rs.3.rs-199361/v1

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Women's Knowledge and Attitude Towards Cervical Cancer Preventive Measures and Associated Factors in South Gondar Zone, Amhara Region, North Central Ethiopia: a Cross-sectional Study

https://doi.org/10.21203/rs.3.rs-199361/v1

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Background: The aim of the current research was to assess women's knowledge and attitudes towards cervical cancer preventions in South Gondar zone.

Methods: A community-based cross-sectional study was carried out in South Gondar zone, Ethiopia. A total of 844 women aged 18 and above have participated in the current study. Binary and multivariable logistic models were used to assess predictors of women’s knowledge and attitude towards cervical cancer.

Results: About 66% of the women had heard about cervical cancer. The percentage of women who heard about cervical cancer was 66%. Regarding the main source of information of respondents, 75.4% were heard from health professionals. Sixty two point four percent of women knew at least one preventive measure and 82.6% of participants knew at least one symptom or sign. Among study participants, 25% and 64% had good knowledge, and favorable attitude towards cervical cancer prevention measures, respectively. Being reside in rural (AOR= .21, 95%CI; .18, .34), not attending formal education (AOR = 0.50, 95% CI: 0.3, 0.75), low income (AOR = .57, 95% CI: .43, .81) and having <4 children ((AOR = .8, 95% CI: .60–.86) were negatively associated with knowledge toward cervical cancer prevention measures

Conclusion: This study found the majority of the respondents had poor knowledge about cervical cancer prevention measures. The majority of the study participants had favorable attitudes regarding cervical cancer prevention. Living in rural areas, not attending any formal education low income and having less than four children was negatively associated with respondents' knowledge towards cervical cancer prevention measures. There is needed to scale up cervical cancer prevention measures and services

Health Economics & Outcomes Research

Health Policy

Cervical cancer

Knowledge

attitude

In Ethiopia, Cervical cancer is the most common cause of hospitalization and death among women, often due to late disease stage at diagnosis. Previous evidence has shown that a lack of awareness and unfavorable attitudes towards cervical cancer are considered as barriers to the prevention of cervical cancer. A community-based cross-sectional study was carried out in South Gondar zone, Ethiopia. A total of 844 women responded to the questionnaire which makes a response rate of 100 %. About 804 (95.7%) of the respondents were orthodox in religion. The majority of them were 367 (43.5%) were housewives. Nearly half (49.9%) of the respondents had a monthly income between 1001- 2000 birr.

About 66% of the women had heard about cervical cancer. The percentage of women who heard about cervical cancer was 66%. Regarding the main source of information of respondents, 75.4% were heard from health professionals. Sixty two point four percent of women knew at least one preventive measure and 82.6% of participants knew at least one symptom or sign. Among study participants, 25% and 64% had good knowledge, and favorable attitude towards cervical cancer prevention measures, respectively.

In conclusion; this study found the majority of the respondents had poor knowledge about cervical cancer prevention measures. The majority of the study participants had favorable attitudes regarding cervical cancer prevention. Living in rural areas, not attending any formal education low income and having less than four children was negatively associated with respondents' knowledge towards cervical cancer prevention measures. There is needed to scale up cervical cancer prevention measures and services so that more women can access them irrespective of where they reside.

Cervical cancer is a type of cancer that occurs in the cells of the cervix; it affects many women worldwide and is caused by Human papillomavirus (HPV) (1, 2). The disease can be prevented via, immunization, early detection and prompt treatment of detecting precancerous lesions (3).

Globally; eighty percent of women are living in low-income countries and it is a major health problem among reproductive cancers worldwide (4, 5). Globally, the governments of different countries give priority to immunization of women against HPV infection as part of early prevention [1]. Having early sexual intercourse leads a woman to be infected with HPV. Patients of cervical cancer may develop symptoms years after being infected (6).

About 28% of Cameroonian women had prior knowledge of cervical cancer (7). A study done in Nigeria revealed that 15% had heard of cervical cancer, overall 40% of the respondents had poor knowledge of cervical cancer (8). A study conducted in Uganda revealed that 55.4% of the women had high knowledge about cervical cancer. With regards to a woman's risk of developing cervical cancer: about 78.4% of respondents stated that a woman might have a risk of developing cervical cancer if women had multiple sexual partners, 88.4% being infected with the HPV, and 73.9% respondents thought early sexual intercourse at a young. Nearly 79.2% of women also assumed that using contraceptives for a long time increased one's risk of developing cancer (9).

Urban residents and higher incomes were associated with the level of knowledge about cervical cancer prevention (9). Study in Kenya suggests that 51% of the respondents were aware of cervical cancer; Health professionals working in health institutions were used as the major source of awareness for women (10). A study in Mizan Tepi revealed that 33.97% of the respondents had poor knowledge and only 25.4% of the respondents had good knowledge. More than half (61%) of women had a positive attitude for the early intervention of cervical cancer via screening (11).

In Ethiopia; Patients came for treatment at the late stage of cervical cancer in that no benefit can be obtained from any treatments. Currently, it becomes a major problem for women, as more of them keep on presenting with cervical cancer at a later stage (12). Knowledge and attitude are important in improving the understanding of factors influencing the involvement of women in preventive activities towards cervical cancer. The objective of the study was to assess knowledge, attitude towards cervical cancer prevention measures of women in South Gondar zone, Ethiopia

The Study Setting and population

A community-based cross-sectional study was conducted from August 20 to September 20 /2019 in three selected districts of South Gondar zone which is located 105 km far from Bahir Dar (the capital city of the Amhara region) and about 666 km northwest from Addis Ababa the capital of Ethiopia. According to the 2007 census result, it has populations of 2,526,813 of this 1,260,880 male and 1265933 were female.

The sample size was determined by using a single population proportion. Considering that the proportion of knowledge towards cervical cancer prevention is 50%. For determining the sample size of this study, 5% level of significance (a = 0.05), 5% margin of error (d = 0.05) and 10% non-responsive rate and design effect of 2 were taken into account. Based on this, the total sample of the study was determined to be 844

Multi-stage sampling was used, three districts in South Gondar zone was selected by lottery method. Out of the three districts, 15 kebeles (the smallest administrative unit in Ethiopia) were selected by using simple random sampling. House to house census was conducted to know the total population of women aged 18 and above in the selected kebeles. Based on the census result, 844 women were allocated proportionally to each district. Finally, individual women age 18 and above were selected using a systematic sampling technique, women were contacted directly door to door in the community. If the woman was not at home during the visit, two additional attempts were done before declaring not available .Face to face interview was administered by a nurse after explaining the objectives when women were free and in a comfortable condition at their home. Data were collected using structured and pre-tested questioners. The questionnaires were first prepared in English, and translated into the local language (Amharic).

The dependent variable was - Knowledge (good vs. Poor), -Attitude (positive vs. negative). The independent variables were age, marital status, education, religion, ethnicity, occupation Condom use with first sex, no of a partner, number of children

Operational definitions: Good Knowledge: respondents who score 50% and above of correct responses of knowledge questions, Poor knowledge, respondents with a score of less than 50% of the correct responses of knowledge questions. Positive attitude: Respondents who scored above the mean and the mean score had a Positive attitude towards prevention for cervical cancer.

Negative attitude: Respondents who scored below the mean score had a negative attitude towards prevention for premalignant cervical cancer.

The data was entered using EP info and analyzed using SPSS version 20 software. Logistic analysis was applied, Odds ratios with 95% confidence intervals were computed to identify the presence of association and statistical significance is p < 0.05.

Ethical clearance was obtained from research evaluation and an ethical review committee of Debre Tabor University College of Health Sciences. Permission letter was also obtained from South Gondar Health department. The participants were informed that participation is made entirely voluntarily and verbal consent was obtained.

A total of 844 women responded to the questionnaire which makes a response rate of 100 %. The mean age of respondents was 30.2 years (Standard Deviation [SD] = 7.3). About 804 (95.7%) of the respondents were orthodox in religion and all (100%) of the respondents were Amhara in ethnicity. Nearly third quartile 618 (73.2%) of the women were married and the majority of them were 367 (43.5%) were housewives. and most (499; 59.1%) had attended formal education and the remaining (345; 40.9%) did not attend any formal education. The majority (618; 73.2%) of the respondents were married, more than half (514; 60.1%) of the respondent lives in rural areas. Nearly half (49.9%) of the respondents had a monthly income between 1001–2000 birr (Table 1).

Table 1

**The socio-demographic characteristics of women in selected districts of south Gondar zone** Amhara region, north-central Ethiopia, 2019(N = 844)
Variables	Frequency
Religion	No	(%)
Orthodox	808	95.7
Muslim	36	4.3
Educational status
Not attend any formal education	345	40.9
Primary	499	59.1
Occupation of the respondent
Housewife	367	43.5
Farmer	166	19.7
Government employee	160	19
Other*	151	17.9
Marital status
Single	146	17.3
Married	618	73.2
Divorced	57	6.8
Widowed	23	2.7
Resident
Rural	514	60.1
Urban	330	30.9
Family average monthly Income
<=1000	150	19.8
1001–2000	378	49.9
> 2000	230	30.3
*Other includes student, daily laborer merchant

Knowledge about cervical cancer prevention measures

About two-thirds (66%) of the study participants replied that they were aware of cervical cancer prevention measures. Health professionals were nearly the third quartile of the women's sources information. About 59 (10.6%) of respondents' were used mass media as a source of information. Regarding the prevention and treatment of cervical cancer 120(14.2%) of respondents reported that primary prevention is crucial, nearly one in ten women were aware of the curability of the disease if it is detected early. Among the respondents, 250 (29.6%) correctly answered a minimum of one prevention measure of the disease.

One hundred fifty (17.8%) respondents knew a minimum of one symptom of cancer. Six (0.7%) women responded that having more than one sexual partner, infected with the human papillomavirus (HPV) 8 (1%), practice early sexual intercourse 54 (6.4%), and cigarette smoking 170 (20%) increased risk of developing cervical cancer. One in hundreds of women was not aware of the risk factors for cervical cancer. Vaccination 25 (3%), delaying sexual intercourse 68 (8%), minimize multiple sexual relationships 40 (4.7%), using condom 28 (3.3%) were mentioned by the women to prevent cervical cancer. Seventy (4%) of the respondents did not mention any prevention methods. Concerning knowledge of the respondent about signs and symptoms of cervical cancer, vaginal bleeding 110(13.1%) and vaginal discharge 40 (4.8%) were known by the women. Overall 212(25.12 %) of the women had good knowledge about cervical cancer prevention measures (Table 2).

Table 2

Knowledge women about cervical cancer and its preventive measures, in Selected districts of South Gondar zone, Amhara region North central Ethiopia, 2019 (N = 844)
	Variables	No	%
1	Have you ever heard about cervical cancer?
	Yes	557	66
	No	287	40
2.	Cervical cancer is curable if detected early
	Yes	89	10.5
	No	755	89.5
3	Early detection of cervical cancer is helpful in its treatment
	Yes	120	14.2
	No	724	85.8
4	Knew at least one risk factor for cervical cancer
	Yes	238	28.2
	No	606	71.8
5	Someone can be vaccinated against cervical cancer
	Yes	80	1
	No	604	99
6	Knew at least one preventive measure for cervical cancer
	Yes	250	29.6
	No	594	70.4
7	Knew at least one symptom of cervical cancer
	Yes	150	17.8
	No	694	82.2
8	Over all Knowledge about cervical cancer prevention measures
	Yes	212	25.12
	No	632	74.88

The attitude of respondents towards cervical cancer prevention measures

Almost half 430(50.1%) of the respondents believed that they were at risk of developing cervical cancer and nearly half 441(48.1%) of the respondents agree that Carcinoma of the cervix is highly prevalent in our country and is a leading cause of deaths amongst all malignancies in Ethiopia. More than half 522 (61.8%) of the participants agree that cervical carcinoma cannot be transmitted from person to person while 38.2% of them agreed it can be transmitted from person to person.

About 607(71.0%) of the respondents agreed that screening helps to prevent cervical cancer. More than half 544 (64.5%) of respondents perceived that screening causes no harm to the patient, whereas, 35.5 % agrees as it is harmful. In general 539(63.8%) of the respondents had a favorable attitude towards cervical cancer prevention measures. About 472(59.9%) of participants thought that screening for premalignant cervical lesions is expensive and 765(90.6%) of the women were agreed that if screening is free and causes no harm to be screened (Table 3)

Table 3

Attitudes of women about cervical cancer and its preventive measures, in Selected districts of South Gondar zone, Amhara region North central Ethiopia,2019 ( N = 844)
No.	Variables	Disagree		Agree
No.	Variables	No	%	No	%
1	Carcinoma of the cervix is highly prevalent in our country and is a leading cause of deaths amongst all malignancies in Ethiopia	447	51.9	441	48.1
2	Any adult woman including you can acquire cervical cancer	403	49.9	431	50.1
3	Carcinoma of the cervix cannot be transmitted from one person to another	322	38.2	522	61.8
4	Screening helps in prevention of carcinoma of the cervix	237	28.1	607	71.9
5	Screening causes no harm to the client	300	35.5	544	64.5
6	Screening for premalignant cervical lesions is not expensive	372	40.1	472	59.9
7	If screening is free and causes no harm, will you screen	79	9.4	765	90.6

Predictors of knowledge of women about cervical cancer prevention measures

Different variables were tested for their association with the knowledge of the women towards cervical cancer prevention measures. Place of Resident, Monthly income, Level of education and Parity of the women were associated with the level of knowledge on cervical cancer in both bivariate and multivariate analysis. One woman was knowledgeable toward cervical cancer prevention measures for every five women who live in rural areas (AOR = 0.21, 95%CI; .18, .34). One woman was knowledgeable toward cervical cancer prevention measures for every two women who were not attending formal education (AOR = 0.50, 95% CI: 0.3, 0.75)

Women having low monthly income (AOR = .57, 95% CI: .43, .81), women having < 4 children ((AOR = .8, 95% CI: .60 –.86) were negatively associated with knowledge toward cervical cancer prevention measures compared to their counterpart .An odds ratio for religion and ethnicity of women was not computed as nearly all women belong to Orthodox Christian and all the women are Amhara in their ethnicity (Table 4)

Table 4

predictors of knowledge of women towards cervical cancer prevention measures in selected districts of South Gondar zone, Amhara region; north central Ethiopia; 2019.
Variables	Knowledge score		COR(95%CI)	AOR(95%CI)
Variables	Good	Poor	COR(95%CI)	AOR(95%CI)
Place of Resident
Rural	80	506	1	1
Urban	132	198	0.24(.21,.5.3)	0.21(.18,.34) **
Level of education
Not attend formal education	67	287	0.56(.2,.8)	0.5(.3,.75)**
Attend formal education	145	354	1	1
Monthly household income
<=2000	152	406	0.6(.4,.82)	0.57(.43,.81)**
> 2000	90	140	1	1
Yes	100	50	3.83(2.1,5.7)	3.6(2.5,4.6)**
No	112	520	1	1
Parity
0–4	172	528	0.87(.5,.93)	0.8(.6,.86)**
> 4	40	107	1	1
** Significantly associated P < 0.05

The current study demonstrated that 60% of the participants had heard about cervical cancer. Previous literature has shown that awareness of cervical cancer was found to be 28 % in Cameroon (7), 15% in Nigeria (8), 51% in Kenya (10), and 93% in Ghana (13). The variation might be due to differences in study populations. .A study in Ghana uses study groups were medical students, non-medical undergraduate students, nurses, and senior university staff might have a better understanding of cervical cancer, whereas the current study includes both rural and urban residents, all of them were not health professionals. Subsequently designing appropriate awareness creation mechanisms is crucial to address all women about cervical cancer prevention measures.

In this study, health professionals were used as the main source of information followed by radio or TV. This implies that health professionals have a key role in educating women.

In this study, ten percent of the women were knowledgeable about the capability of being cured of cervical cancer if it is diagnosed early. This knowledge gap might inhibit women from implementing cervical cancer prevention measures. Hence health promotion, education, and communication about cervical cancer prevention measures are important.

This study, the finding indicates that nearly a third quartile or (75 %) of the respondents had poor knowledge of cervical cancer prevention measures. In contrast to this finding; recent studies showed that in Mizan Tepi University, Ethiopia nearly 34% (11) and Uganda, 44.6% (9) of the respondents had poor knowledge about cervical cancer. University students might have access to different mass-medias that may increase their awareness level towards cervical cancer prevention measures. The current study was conducted at a community level, including the rural areas. Hence the awareness of these women about cervical cancer is minimal; there is a need to educate women on the early warning signs of cervical cancer as failure to recognize the early symptoms and signs contribute to the late presentation common in Ethiopia.

This implies that, in the absence of proper health education strategy in the health system and at a community level, hence tailored health education strategy should be implemented that can help to improve the knowledge of the respondents towards the symptoms of cervical cancer to take measures early.

Concerning the prevention of cervical cancer participants knew that cervical cancer is prevented by avoiding multiple sexual partners (4.7%), avoiding early sexual intercourse (8%), and quitting smoking (10.5%), vaccination (3%), using a condom (3.3%) while in a study done in Sweden 62% respondents reported that cervical cancer can be prevented by early screening and HPV vaccination (14). This disparity could be related to an early screening and availability of the HPV vaccine and services might be provided in all health care systems in developed nations like Sweden to the population at every facility

The current study indicates that overall 63.8% of the respondents had a positive attitude towards cervical cancer prevention measures; a similar magnitude of attitude (61.24%) is reported from recent studies in Mizan Taipei University, Ethiopia (11). In this study, about 32% of participants agreed to be screened for cervical cancer if the cost is free and has no harm health check-up, hence avoiding barriers will help in increasing the number of women participants for screening. Awareness creation activities regarding cervical cancer at a grass root level are crucial

In this study, women residing in rural areas, not attending formal education, low-income, parity less than 4 were negatively associated with good knowledge of women for cervical cancer. This is possible because women who were living in urban may have access for health workers that can give health education for their clients; in addition to this; women who attend any formal education may have the ability to read different leaflet and other printed materials that are a key source of information about cervical cancer and its prevention measures. Women that have more than four children might have proximity to the health facilities that provide antenatal care may provide counseling services toward cervical cancer and its prevention measure. Integrating all health services with cervical cancer services would enhance awareness among women. Hence awareness creation activities should be accessible for women who reside in rural areas that enhance the knowledge of the women about the disease and prevention measures.

Women who belonged to the lower socioeconomic category were less knowledgeable about cervical cancer prevention compared to those from the high status might have different communication, mass media and this could reflect that the awareness might be increased that could increase the demand to use service-related cervical cancer. Lack of standardized questionnaire to measure the knowledge and attitude of the respondents, this might limit the comparability of the findings in different places.

This study found the majority of the respondents had poor knowledge about cervical cancer prevention measures. The majority of the study participants had favorable attitudes regarding cervical cancer prevention. Living in rural areas, not attending any formal education low income and having less than four children was negatively associated with respondents' knowledge towards cervical cancer prevention measures. There is needed to scale up cervical cancer prevention measures and services so that more women can access them irrespective of where they reside. Awareness creation campaigns should be held to provide comprehensive information about cervical cancer prevention and control mechanisms to women in all areas.

HPV: Human Papilloma Virus, KAP: Knowledge, Attitude and Practice, SD: Standard deviation, VIA: Visual Inspection of the Cervix with Acetic Acid, SPSS: Statistical Package for Social Science, WHO: World Health Organization

Ethics Approval and Consent to Participate

This study was approved by the research evaluation and an ethical review committee of Debre Tabor University College of Health Sciences, the use verbal consent was approved by the research evaluation and an ethical review committee since the procedure has no any negative health impact on the study participants and there is no sensitive issues /critical issues with the norm and culture of the community in the study area and finally informed verbal consent was obtained from all respondents.

Consent for Publication

Not Applicable

Availability of Data and Material

The datasets are available from the corresponding author.

Competing Interests

We, the authors declare that we did not have competing interests.

Funding

The authors have no support or funding to report.

Authors' Contributions

TY Contributed to inception, design, analysis, interpretation, drafting of a research manuscript and final approval of the manuscript for publication. TJ Contributed to design, analysis, draft the manuscript and approval of the manuscript for publication. TD Contributed to design, supervise data collection process, analysis, interpretation, drafting of a research manuscript and final approval of the revised manuscript for publication. AM Contributed to the training of data collectors design and drafting of a research manuscript and final approval of the manuscript for publication.

Acknowledgments

We are very grateful to the Debre Tabor University for the approval of the Ethical Clearance. We express our heartfelt thanks to participants for their willingness to participate in the study. Our thanks also extend to the South Gondar health department for their cooperation and assistance during data collection.

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Women's Knowledge and Attitude Towards Cervical Cancer Preventive Measures and Associated Factors in South Gondar Zone, Amhara Region, North Central Ethiopia: a Cross-sectional Study

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