Demand for and predictors of cervical cancer screening among adult Women in Tigray, north Ethiopia

Abstract

Background: Cervical cancer is a reproductive organ cancer occurred in the transformation zone of the external opening of the cervix. Evidences indicate that cervical cancer is the second cause of morbidity and mortality in developing countries including Ethiopia. Though, the endeavor of the government to strengthen cervical cancer screening in Ethiopia, the service provision and screening coverage remains low. Factors at community, individual, infrastructure and professional levels may challenge the demand for cervical cancer screening. Therefore, different analysis of possible predictors and challenges and health education intervention on the hypothesized predictors of demand for cervical cancer screening might have influence on strengthening the cervical cancer screening services demand. Objectives This study was designed to detect different level predictors and challenges of demand for cervical cancer screening and outline the impact of health education intervention on demand of women for cervical cancer screening in Tigray, Northern Ethiopia. Methods The study included a cross sectional, matched case control and descriptive qualitative study designs to determine different levels of predictors and challenges of demand for cervical cancer screening; from January to April 2018; and a cluster randomized controlled trial design was used to evaluate the impact of health education intervention on demand of women for cervical cancer screening from April to December, 2018 in 30 districts.

Participants involved in the cross-sectional and randomized trial studies were selected randomly; while purposive sampling was used for the qualitative study to select the key informants and clients for in-depth interview. In the cluster randomized controlled trial, data were collected at two time points, in the first contact, and at six months post health education intervention follow up as second contact. Potential confounders biases and errors were controlled using stratification, matching, intra-class correlation coefficient at design stage, and variable adjustment and ITT in the analysis. The cluster variation was assessed using multi-level mixed effect models, and the impact of the intervention was evaluated using difference in differences model to estimate the true effect size. Thematic analysis was used to describe the qualitative data. Results: At baseline, the percentage of demand for cervical cancer screening was 480 (48%). The intra class correlation indicated that 18.9% of the total variance in demand was attributable to the differences across the cluster districts (p-value of < 0.0001). Variables considered in the community level were mean family size, mean score of community awareness, households to HEW ratio, health professionals to population ratio per thousands, population to health institutions ratio, and literacy average across clusters. Multi-variable analyses revealed that predictors like secondary education (AOR = 5.27, 95% CI 2.12, 13.04) tertiary education (AOR=7.95, 95% CI 2.67, 23.62), having monthly income of 2001-4000 (AOR = 3.23, 95% CI (1.01, 10.36)), those who knew their husbands had two or more lifetime sexual partner (AOR = 2.27, 95% CI (1.14, 4.50)), being knowledgeable on cervical cancer (AOR =3.28, 95% CI 1.66, 6.46), having supportive attitude of participants on cervical cancer screening (AOR = 11.34, 95% CI 5.57, 23.08) and community awareness mean score (AOR = 1.25, 95% CI 1.05, 1.48) were significantly associated with screening practice. The predictors of cervical cancer screening utilization were also complemented by the qualitative approach. Though most clients mentioned that the service accessibility and affordability is good, some said that it is a challenge. Moreover, participants did not hide that there was long waiting time, crowded clients and service was started later after registration. Key informants were also assured that the presence of challenges for cervical cancer screening service provision; including low community awareness, absence of cervical cancer screening service structure, loss to follow up, shortage of trained professionals, staff turnover and poor sustainability of supplies. This finding implies that an increase in awareness of the community on cervical cancer and mitigate challenges might improve the low screening coverage in Ethiopia. Hence, it informs the importance of health education interventional study. Comparing the intervention group with control group at baseline, the overall demand of participants for cervical cancer screening was 39.14% in the intervention and 42.3% in the control group; with no significant difference (p value = 0.397). However, following the intervention, the proportion of overall demand was increased to 86.2% in the intervention and 52.4% in control group with significant difference in differences of 36.9% (p value = 0.000). There are no differences observed when demand is analyzed using PP & ITT. Conclusions: The proportion of demand for cervical cancer screening among participants in the baseline data was low. Variables like having secondary and tertiary education, monthly income, the knowledge and attitude on cervical cancer and awareness of the women on their husband’s increased number of lifetime partner were positively associated with demand for cervical cancer screening. Distance of the service area, the cost of the service, duration of service provision, the approach of the providers and screening environment were among the challenges repeatedly mentioned that hamper screening for cervical cancer. Moreover, poor knowledge of the community on cervical cancer, low screening supplies and trained professionals, professional turnover, poor referral system, and lack of infrastructure were among the challenges mentioned for cervical cancer screening, The provision of health education intervention on cervical cancer improves the demand of adult women for cervical cancer screening compared to the control groups. Recommendation For professionals: It would be better if health professionals work on health education and motivation of the community for cervical cancer screening utilization and priority should be given for those who are in reproductive age of women that are at high risk. For policy makers and program planer: it is important to establish decentralized screening services and plan to train sufficient health professionals for the accessibility of the services by all the community