Cervical cancer screening uptake among women who visited Gondar public health facilities was one in eight after a personal invitation. Feeling healthy was the most common reason for VIA screening test refusal. Higher educational status, previous recommendation by health providers, higher knowledge status, higher perceived susceptibility, lower perceived barrier, higher perceived severity, shorter cues to action, and higher perceived self-efficacy were significantly associated with actual screening uptake.
This study found higher cervical cancer screening uptake by study participants (16.4%) compared to the national cervical cancer screening coverage (2.9%)(10). Also, the study finding was consistent with other studies (no uptake after invitation), in which cervical cancer screening uptake was 16.4% among women in a survey conducted in Kenya in 2018 (27) and 17.5% among women seeking services at a health facility Kisumu, Kenya, in 2015 (28).
Although cervical cancer screening uptake in this study was not that high, it was higher than the previous uptake study of 10% in Gondar Hospital in 2018 without invitation (12), 10.6% in Addis Ababa in 2018 (15), 8% in Nigeria in 2016 (29), 6% in Kenya in 2013 (30), and 4.8% in Uganda in 2016 (31). This small difference might be due to differences in population characteristics and study settings or facilities. The uptake report from these studies was not after invitation; it was based on retrospective assessment, and some studies were from an HIV clinic alone. For instance, the previously conducted study in Gondar focused on HIV-positive women who visited the referral hospital compared to the current study, which included women irrespective of HIV status attending health facilities and hospitals together (possible now due to service availability at lower-level facilities). Thus, increased uptake observed in the current study might be because of recent placement of VIA screening to the health centre level in the town, which is closer to the participants than where it had been only at the hospital level. Also, eligible women were actively invited and offered VIA screening in the current study compared to the previous studies. This might have helped women to easily identify and access the service and utilise it accordingly. Current cervical cancer prevention promotion programmes are spread throughout the country and there are sensitisation implementation activities, which may have led to higher uptake in our study.
However, the current finding is lower than the self-reported lifetime screening uptake of 23.4% among women in the Gondar University Referral Hospital in 2017 (18), 20.9% in Debre Markos, Ethiopia, in 2017 (14), 46% in Kenya in 2017 (32), 40.7% in Bahrain in 2018 (33), and 26% in Saudi Arabia in 2019 (34). The difference might be due to a difference in the way cervical cancer screening uptake was measured. All the above-mentioned studies used lifetime self-reported experience as a measure for screening uptake (21-23) compared with uptake being measured at one time point in the current study.
The most common reasons for cervical cancer screening refusal were feeling healthy (86%), coming to visit the facility for other reasons (77.5%), lack of time (45%), fear of the test result (18%), and embarrassment (17%). This was consistent with the study done in Butajira, Ethiopia, documenting a lack of time to undergo screening, self-assertion of being healthy, and fear of screening as the main reasons for cervical cancer screening test refusal(9). This highlights that women might not undergo the screening service simply because they do not understand why the screening test is needed and who is eligible for the service. Therefore, screening programmes should consider potentially hindering factors for screening uptake.
This study found that among socio-demographic characteristics, educational status had an independent association with cervical cancer screening uptake. This is consistent with studies in Gondar where higher education level also increased the odds of uptake (12); similar findings were reported in Kenya (28). This means that women who are not educated have limited access to cervical cancer screening programmes (17). To increase cervical cancer screening uptake, better ways to attract women without formal education have to be found. In the multivariable model, there was no independent statistical association between other socio-demographic factors and uptake of screening.
In this study, the history of previous recommendation by a health professional for screening was significantly associated with cervical cancer screening uptake. This is consistent with findings from Uganda (31). This implies that to increase uptake of cervical cancer screening by eligible women, health workers can recommend screening to eligible women whenever they encounter them at health facilities. This may have a lagged effect, even if the women do not immediately adhere to the recommendation.
Knowledge status among study participants (382, 82.3%) was poor in Gondar public health facilities based on the mean score computed from 17 items assessing the risk factors, symptoms, treatment, and prevention methods of cervical cancer used by other studies, and it had a strong independent statistical association with cervical cancer screening uptake (AOR=8.4, 95% CI [3.33, 21.21]). This is consistent with studies in developing countries in general where knowledge of cervical cancer and screening is poor. A similar finding was reported in Gondar Hospital that comprehensive knowledge was poor (79.8%) and was a strong predictor variable for screening uptake in that study (AOR=3.02, 95% CI [2.31, 7.15]) (18). The finding is also in line with a systematic review and meta-analysis conducted among HIV-positive women in Ethiopia in 2020 that showed women who had good knowledge of cervical cancer were more likely to be screened for cervical cancer than their counterparts (35).
The perception of the women based on HBM constructs regarding cervical cancer and screening was found to have an impact on cervical cancer screening uptake. In this study, perceived higher susceptibility of cervical cancer was statistically associated with cervical cancer screening uptake (AOR=6.5, 95% CI [2.72, 15.51]). This finding is similar to a study in Mekelle, Ethiopia, in 2015 (20), in which perceived susceptibility was significantly associated with lifetime cervical cancer screening uptake (AOR=2.2, 95% CI [1.30, 3.78]). It is also similar to a study in Botswana in 2017 (36), in which perceived susceptibility was significantly associated with screening uptake (AOR= 1.8, 95% CI [1.094–3.067]).
About half of the participants in this study had a low perceived barrier (235, 50.6%). In multivariable logistic regression, a low perceived barrier by study participants had a strong statistical association with cervical cancer screening uptake (AOR=6.4, 95% CI [2.30, 17.80]). This is in line with a 2015 study in Mekelle, Ethiopia, in which perceived barriers were significantly associated with cervical cancer screening uptake (AOR = 2.256, 95% CI [1.447–3.517]) (20). It is important, therefore, to remove perceived barriers, such as the belief that cervical cancer screening would be painful and embarrassing.
This study also revealed that perceived severity of cervical cancer among study participants in Gondar town public health facilities was common (76.6%) and significantly associated with cervical cancer screening uptake (AOR=3.4, 95% CI [1.019, 11.851]). This is consistent with a study in Kenya in which those who perceived cervical cancer as a serious disease had higher screening uptake than those who did not (28). This implies that although more women perceived cervical cancer as severe, few of them utilised the screening service. Therefore, programmes to explain severity will not change much, since many women already believe that cervical cancer is severe. This highlights the need to consider additional ways that can have immediate effect on the decision to accept the service.
This study also revealed cues to action were also significantly associated with cervical cancer screening uptake. This is consistent with a study in Kenya in 2014 (28). In terms of self-efficacy, one in four study participants had high self-efficacy regarding cervical cancer screening and had a strong statistical association with cervical cancer screening uptake. This is consistent with a study in Nigeria that reported that the confidence of women regarding screening resulted in increased screening uptake(37). It is therefore necessary to educate and empower women as often as possible to boost their confidence. Doing so will help them to make decisions to utilise the already freely available cervical cancer screening service in health facilities.
Strengths and limitations
This study reflects a real-life practice and effect of the “see and treat” approach currently implemented by the Ethiopian government: women visiting a health centre for routine services were invited and uptake was measured. We postulate that this magnitude of uptake during a single visit is representative for the strategy without additional campaigns or incentives. There is no clear uptake target for this situation, and the impact on the overall screening uptake over one year is not clear. Additional sensitisation over some time may still increase the uptake. Since the study was facility-based and used consecutive sampling techniques to select the study participants in Gondar, generalisability to the whole of Ethiopia is probably difficult.