Factors Affecting Cervical Cancer Screening Practice Among Women Attending Gynecology Out - Patient Department at Mettu Karl Referral Hospital, South West,

Introduction : Globally, Cervical cancer is the greatest threat to women's health, which is the fth cause of death accounting for all types of cancer deaths among women. Globally, 528000 new cases each year and the second most common in developing countries around 445,000 new cases develop cervical cancer each year. Cervical screening practice is the recommended for effective methods for prevention and early detection of cervical cancer. To increase the awareness of cervical cancer screening practice health education is pivotal in any prevention program aimed in reducing the overall prevalence of cervical cancer in the community. Objective : To assess cervical cancer screening practice and associated factors


Introduction
Globally, cervical cancer is always the greatest threat to women's health, it is the fth cause of death accounting for all types of cancer deaths among women(1, 2).Globally,528000 new cases cervical cancer each year and the second most common in developing countries around 445,000 new cases develop cervical cancer each year (3,4).
The cervical cancer screening practice is to create access to early detection of cervical cancer and preventative therapy for millions of women worldwide (5). Global studies showed that early detection and treatment can prevent 75 per cent of cancers in developing countries, like other screening tests (3). Early detection through screening and treatment of pre-cancerous lesions remains the best possible protection against cervical cancer (6). Globally evidence shows that utilization of screening for prevention is very poor in developing countries. Unfortunately, it is estimated that one in every three U.S. adults is not getting screened as recommended (7) (5). In the US Screening for cervical cancer, which diagnosed in more than 12,990 women in 2016, can both detect cancer at early stage (8) Prevalence and mortality rates are highest in developing countries; particularly sub-Saharan African nations estimated 528,000 new cases of cervical cancer. Cervical cancer commonly occurs in women aged ranged from 25-65 years (9). It is caused by infection by human papilloma viruses that transmitted from individuals to individuals by sexual intercourse which may infect the areas around the cervix, anus, mouth and throat (8). Of all the cancers, cervical cancer is the only one that has both an effective vaccine and screening program that can prevent disease and death(10). Cervical cancer, which is a malignant neoplasm, can be asymptomatic sometimes in early stages (11). The symptoms that can be seen normally in advanced stages are persistent pelvic pain, unexplained weight loss, unusual bleeding during periods, bleeding and pain after sexual intercourse (12) .
Cervical screening behavior is recommended effective methods for prevention and early detection of cervical cancer (13). However, awareness and knowledge about cervical screening behavior is lacking among lower socioeconomic status and high cost and low awareness were found to be the primary barriers to cervical cancer (14). Cervical cancer screening practice is recommended in Ethiopia, but due to the limited resources, awareness and knowledge is not yet easily available (15).
To increase the awareness of cervical cancer screening practice, health education is pivotal in any prevention program aimed in reducing the overall prevalence of cervical cancer in the community. For health education to be effective and have an impact and good outcomes on cervical screening behavior (8) The incidence of cervical cancer screening practice varies greatly between developing and developed countries, where cervical cancer cases have been considerably abridged since the implementation of effective screening programs in developed countries (16). However, in developing countries, the burden from cervical cancer remains high because of the di culty in implementing cytology-based screening programs (Pap smear, AVI) (17).
There are several barriers to the uptake of cervical cancer screening practice in low and middle-income countries(LMICs), which include low levels of knowledge of cervical cancer, limited awareness of prevention and early detection methods, fear of stigma associated with cancer diagnosis, concerns about spousal disapproval of screening, and concerns about violations of religious and cultural obligations of modesty during screening procedures (6). Even though there is no national Cancer registry in Ethiopia, a survey from federal Ministry of Health and Addis Ababa Cancer registry shows that 64,000 new cases of Cancer occur annually where Cervical and Breast Cancer constitute the signi cant majority of these cases. The problem rose from too little people's awareness about cancer, very limited treatment facilities and too little governments and other stakeholder's intervention (18).
Most of the women in the country visit health institution already with the advanced stage of cervical Cancer when they show up at the Hospitals. Cervical cancer is the leading cause of cancer mortality among Ethiopian women over the age of 30(19). On the other hand, the other study records show that 7600 Ethiopian women are diagnosed annually with cervical cancer and of these, 6000 die of the disease each year. Cervical cancer screening practice has been shown as the most effective way to decrease cancer mortality among all women (12).
In Ethiopia, only 0.6% of all women, 1.6% of urban and 0.4% of rural women aged 18-69yrs screened every 3yrs (20,21).The major factors associated with cervical cancer screening practiceare inadequate knowledge about the disease process, and Pap smear testing and clients negative attitude towards the procedure (14,22). Besides, poor knowledge about cervical cancer, and lack of awareness of available screening methods have been identi ed as the most important factors hindering the use of available cervical cancer screening practice services. Cervical cancer screening practice services are available in some areas of in Ethiopia(23), but screening is mostly conducted only when a woman seeks medical care for other reasons. Sometimes, screening is offered only if the woman presents with symptoms (24). Despite the evidence that universal screening is important, women without symptoms are not routinely screened in many locations in Ethiopia. In Ethiopia methods for screening are different in compared to high-resource countries (25).Gap identi ed in Ethiopia is most of the women have no awareness about cervical cancer screening practice. Little is known about the relative incidence of cervical cancer screening practice (4).
So this study is aimed to assess cervical screening practice among women attending gynecology outpatient department at Mettu Karl referral Hospital, South west, Ethiopia, 2019. Therefore, this study will provide more evidence on the screening behavior of cervical cancer screening practice. The Finding of this study will give an insight to policy makers on cervical cancer screening practice and subsequent planning and implementation of maternal health programs in the Ethiopian communities. It will be used to increase the awareness of women on cervical screening behavior and as base line information for researchers, health professionals, NGOs and as a whole the society to understand about the cervical cancer screening practice.
Early screening for cervical cancer is a key intervention in reduction of maternal deaths. . Health care workers have a signi cant contribution to improve cervical cancer screening practice among women and inexpensive, "screen and treat" approach to cervical cancer prevention. Increasing awareness on cervical cancer screening practice an effective strategy to prevent and cure for women in low-resource countries. Cervical cancer screening practice various factors including cultural, and beliefs about the disease and the health care system were found to affect the treatment seeking behavior for CC. One of the barriers included: stigma associated with disease, limited access to health services, the lack of awareness, and the asymptomatic nature of the disease. Therefore, the purpose of this study is to assess Cervical cancer screening practice and associated factors among women attending gynecology out -patient department at Mettu Karl referral Hospital, South west, Ethiopia, 2019. The study area was governmental hospitals in Ilubabor zone. One of oromia region which is located 600 km away from the capital city, Addis Ababa, Ethiopia. It is bordered on the south by the south nation , nationality and Peoples , on the southwest by the Gambela , on the west by kelem welega zone , on the north by mirab wellega zone , and Benishanigul -gumuz Region, on the northwest by misirak welega zone , and on the east by Jima zone . with an area of 15,135.33 square kilometers.
There are two public hospitals (mettu karl referral hospital and darimu hospital) which are delivering maternal and child health service.

Study design
Institutional based cross sectional study design was used to assess cervical cancer screening practice and associated factors among women attending Gynecology, out -patient department at mettu karl referral hospital.

Sources of Population.
All women's who came to Mettu Karl referral hospital outpatient department for all service during data collection period.

Study populations
All women who visited to Gynecology outpatient departments at Mettu Karl referral Hospital during data collection period. Since the total population is less than 10,000, correction formula is used as follows: For the purpose of this study, the following de nitions will be applied and used within the context in which they are explained:

Inclusion and exclusion criteria
Cervical cancer-means a disease in which cancer cells grow in the cervix. .
Cervical cancer screening practice-means procedure used to detect abnormal cells of the cervix. In this study, screening procedures refer to VIA or a Pap smear Multiple sexual partners: Having lifetime partners greater than two. Multiparty: Having parity greater than two Early initiation of sex: Starting rst sexual intercourse before the age of 18 years Contraceptive use: De ned as use either of the contraceptives: oral contraceptives (pills), inject able, implants, IUCD for more than or equals one month period.
Organizational barriers; Organizational barriers were factors which affected the accessibility of healthcare services to the women.

Data Collection technique
An interviewer administered semi structured questionnaire was adapted by reviewing similar studies (50). Data was collected by 6 trained nurses. Data was collected from the clients after getting verbal consent through informed consent in the health facility. Data was collected using structured interviewer administered questionnaire was prepared in English after reviewing literatures of similar surveys that have been carried out previously then nal modi ed English questionnaire was translated to Amharic. The interview was taken 20 to 30 minute.

Data Quality Assurance
The questionnaires were pre-tested on 5% of the sample size at darimu district Hospital to avoid any confusion during actual data collection period. The data collectors were trained before actual data collection and the principal investigator was supervising the data collector closely. During data collection, both principal investigator and data collectors were check the data for its completeness and missing information at each point. Furthermore the data was coded, checked and cleared during entry.

Data Analysis
After the collection of data, the questionnaire was checked for completeness and consistency.
Then, the data template format was prepared, coded and entered in to Epi Data version 4.2. Then data was exported to SPSS version 21 for analysis. Descriptive analysis was employed to describe the percentages and distributions of the respondents for socio-demographic characteristics. Bivariate and multivariate analysis was used for association of independent variable with dependent variable. Crude and adjusted odds ratios with the corresponding 95% con dence intervals were computed. P-value <0.05 was considered statistically signi cant in this study. Then, the results were presented in the form of tables, graphs and charts Ethical consideration.
Paper of approval and letter for permission was obtained before the beginning of data collection from review board of School of Nursing and Midwifery, College of Health Sciences, Mettu University. Permission letter was provided for Mettu Karl referral hospital. After that participants were explained clearly about the purpose and procedure of data collection, and then con dentiality and privacy were guaranteed. It is also cleared that participation were fully based on the willingness of participants using verbal consent.

Dissemination plan
The result of this study will be disseminated to Mettu University College of health science library and universities included in the study. Possible publication on international reputable peer reviewed journals will be sought and concerned bodies.

Socio-Demographic Characteristics
This study assessed cervical cancer screening practices and associated factors. The total of 320 clients was participated in the study giving a response rate of 99% and most of the respondents(34.9%) were in the age range between 30-39 years, with the mean age of 35.79 with SD±11.46.Regarding to religion, the majority of the participants 169(52.6%) were orthodox Christian and the least covers for catholic 33(10.3%). All the socio demographic characters are presented in the table below (table1).    Table  4). Factors of cervical cancer screening practice Bivariate analysis revealed that sixteen out of thirty two variables showed a significant association with cervical cancer screening practice at a 5% level of significance. For further analysis, all independent variable which fulfilled the minimum requirement for multivariable logistic regression (had significant association at a p <0.25) were entered. The highest risk factors for not good cervical cancer screening practice was found in those individuals with educational level Don't write and read 67 (20.9%), ≥901average monthly income 200(62.3%), age ≥18 at first marriage 211(65.7%),<2 average birth interval 99(62.0%). However, bad cervical cancer screening practice was not statistically different among the above variables (P>0.05).
The study participants those who have age greater than or equal to 50 were fourteen times more likely have bad cervical screening behavior(COR=13.830,95% CI 5.466,34.990) than those who have age 21-29 years. The participants who were use contraceptive had odds of 0.206 times cervical cancer screening practice(COR=0.206,95%CI=0.094 ,0.447) than those who did not use contraceptive.
The participants who were smoking of had 23.9 times cervical cancer screening practice with (COR=0.239;95%CI=0.130,0.438) than not practicing smoking, Women who had history of sexual transmitted diseases of had odds 0.109 times cervical cancer screening practice with (COR=0.109;95%CI=0.56,0.212) compared to those who did not have history of sexually transmitted diseases and Having two or more life time sexual partners of the husband had odds 0.754 times bad cervical cancer screening practice behavior with(COR=0.754;95%CI=0.352,1.6160) compared to those individuals who had one sexual partner.
Those participants who had age ≥50 were about twenty six times more likely with (AOR=26.603 ;95%CI=8.167,86.662),age between 40-49 (AOR=4.152,95%CI=1.630,10.576)were four times more likely and age between 30-39 three times more likely had bad cervical screening behavior compared to those age between 21-29. In this study individuals who had smoking practices were a factor of 0.179 times less likely with (AOR=0.179;95CI=0.087,0.369) had bad cervical cancer screening practice than those who had no smoking practices. Participants who were used contraceptive with a factor of 0.172 times less likely had cervical cancer screening practice with(AOR=0.172; 95%CI=0.070, 0.422) compared to those who were not used any contraceptive. In addition, women's who had STD were more likely had association with cervical cancer screening practice with (AOR=0.169; 95%CI=0.82, 0.347) than who had no STD and respondents who had two or more life time sexual partners of the husband had a factor of one times more likely at risk for cervical cancer screening practice with (AOR=2.973; 95%CI=1.414-6.247) compared to those respondents who had one sexual partner of the husband.
Table5. Results of bivariate and multivariate analysis for Cervical cancer screening practice and associated factors among women attending gynecology out -patient department at MK referral Hospital, South west, Ethiopia, 2019.

Discussion
The broad purpose of this research was to better understand cervical cancer screening practice and associated factors among women attending Gynecology, out -patient department at MK referral hospital. Among the total of study participant 320, the current study found that the participation rate in screening for cervical cancer is about 29.9%. However, this nding is higher than 9.6% in Gamo Gofa (26) , 18.8% in studies carried out in Nepal (27),19.8% in Mekele (28) and less than another study conducted in Uganda 48% (51,23,51,53) (29). This may partly be due to difference in socio-demographic characteristic of the subjects of the studies and sample size difference. According to the current study, the main reason of not taking cervical cancer screening practice service is lack of health education.
Factors associated with cervical cancer screening practice were also assessed. This study reveals that women's age, contraceptive usage, intending smoking, presence of STD and multiple sexual partner of the husband were found to be associated factor for cervical cancer screening practice.

Limitations
As the respondents had to remember when they had performed cervical cancer screening, there might have been recall bias.
Being a cross sectional study; it cannot show cause-effect relationship between the variables studied.

Conclusion And Recommendations
According to this nding, the overall rate of those participants who had awareness on cervical cancer screening practice were about 29.9%. Maternal age, using smoking, using contraceptives, presence of sexually transited disease, and having multiple sexual partner of the husband are predominantly stated factors associated with cervical screening.

Ilubabor Zone health birau
Focus preventive health measures for cervical cancer screening practice and its prevention.
Should provide awareness campaigns targeting illiterate groups can be conducted in community so that they become motivated towards cervical cancer screening Should provide educational interventions to improve uptake of cervical screening with time and to increase selfe cacy and perceived focus of control about cervical cancer.
Should done on awareness creation and sensitization of health workers on cervical cancer screening practice and sustaining national screening programs widely.
MK Hospital health professionals who are assigned to cervical cancer screening clinics and community health workers Health workers need to be marked at rst since they have role in any potential screening activities in order to achieve screening coverage in the community.
Conduct health education programs to the women eligible for screening attending gynecological clinic regarding prevention of cervical cancer and importance of cervical cancer screening.
Should provide women with choice from whom they want to be screened

Ministry of Health together with other stakeholders
To embark on intensive awareness creation campaigns on cervical cancer to complement health education in health facilities.
Ethiopian Cancer Association and other health groups should reading materials as well as different campaign for awareness creation.    Description of women's contraceptive usage among women attending gynecology OPD and MCH at MK referral hospital, 2019