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

Objective. In Ethiopia, the age-adjusted incidence rate of cervical cancer is high, 35.9 per 100,000 women. Despite this fact, cervical cancer screening coverage in Ethiopia is very low. The objective of this study is to assess the magnitude and factors affecting the practices of cervical cancer screening among female nurse in Mekelle Town, Tigray, Northern Ethiopia, 2014.Methods. This study used a cross-sectional design. Bivariate and multivariate logistic regression was used to evaluate factors associated with cervical cancer screening practice. Results. A total of 225 female nurses participated in the study.Themagnitude of cervical cancer screening practice among these nurses was 10.7%, within the past five years of the survey. Attitude and work place of the respondents were significantly associated with a history of cervical cancer screening practices with an adjusted odds ratio (AOR) of 3.023, 95% CI (1.134–8.059), and 3.424, 95% CI (1.080–10.853), respectively. Conclusion. The study showed that the magnitude of the cervical screening practice is very low among nurse health professionals. Negative attitude andworkplacewere identified to be the predictors of decision for cervical cancer test.


Introduction
Carcinoma of the cervix (cervical cancer) is a malignant neoplasm of the cervical area [1].Vaginal bleeding, contact bleeding, or (rarely) a vaginal mass may indicate the presence of malignancy and symptoms may appear after the cancer is in its advanced stages.Cervical cancer is preventable and, in most cases, curable, if identified in its early stages [1].Breast and cervical cancer are the most frequently occurring types of reproductive cancers in women worldwide [2].Cervical cancer is caused by persistent infection with certain types of Human Papilloma Virus (HPV) and it is the second most common cancer in women with 529,000 new cases each year worldwide.Eighty percent of the cases occur in low-resource countries like Africa, Latin America, and Southeast Asia [3].
Cervical cancer screening is looking for precursors, cervical intraepithelial neoplasia, before a person has any symptom and if abnormal tissues or cancer is found early, it may be easier to treat or cure.To prevent this disease, cervical cancer screening programs are introduced worldwide and the introduction of Papanicolaou (Pap) test led to significant reduction in mortality and morbidity in developed countries [4].
In 1945, American Cancer Society endorsed the use of the cervical smear as an effective cancer prevention test for carcinoma of the uterine cervix [5].The screening techniques often used are Pap smear test, visual inspection of the acetic acid-painted cervix (VIA), and HPV DNA test.Screening programs in Africa are however often rudimentary or nonexistent and the same is true in Ethiopia [6,7].Marked decreases in cervical cancer incidence and deaths have been achieved by systematic population-based cytology screening programs in developed nations, from as early as the 1960s [8].
Health workers, especially nurses, are often considered as "role models" in health related issues.Nurses play a major role in enlightening the public on the availability and need for cervical cancer screening services.They are informed individuals who are expected to have more information and knowledge about several health related issues and also act as role models in uptake of preventive services, but studies have documented otherwise [9].
In Ethiopia, records showed that nearly 22 million Ethiopian women are over the age of 15, approximately 7,600 are diagnosed with cervical cancer and roughly 6,000 women die of the disease each year [3].These figures are probably significantly lower than the actual number of cases and it is projected that the number of new cases will almost double by 2025 [3].Cervical cancer is fatal if diagnosed in advanced stages.It is treatable in early stages.But, even when the disease is not fatal, the consequences are severe and often lead to physical, psychological, and sexual problems [10].
In developed countries, the proportions of women who are screened by Pap test vary from 68 to 84% [11].However, in developing countries, screening coverage is still low, ranging from 2.0% to 20.2% in urban areas and from 0.4% to 14.0% in rural areas [12].Different studies showed that very few women in sub-Saharan Africa and other developing countries are ever screened for cervical cancer and low levels of awareness and poor knowledge of cervical cancer coupled with unavailability and inaccessibility of cervical cancer screening services are responsible for the very small number of women being screened [10].Previous research findings indicated that the magnitude of cervical cancer screening in Ethiopia is very low, which is 0.6% [7].

Methods
The study was conducted in public health institutions, which includes health centers and all levels of hospitals in Mekelle Town, Northern Ethiopia.This study used a cross-sectional study design and sample size was determined using the formula for a single population proportion, taking a prevalence estimate of 34.6% from a previous research conducted in Nigeria [4].Assuming 95% confidence interval and margin error of 5% ( = 0.05), the total sample size was calculated as 242, including 10% nonresponse rate.
Data were collected using a semistructured questionnaire, which contains both open-ended and closed-ended questions.It was piloted on 5% ( = 13) female nurses to check the consistency and understandability of the questions and slight modification was made based on frequent data quality checks.For example, when investigators realized that many female nurses who work in the health centers have lack of knowledge on the site of the screening service, "I do not know the place of the service" was added as a response to the question "why do not you get a screening for cervical cancer?" The dependent variable in this study was self-reported history of ever being screened for cervical cancer within the past five years.The independent variables were sociodemographic factors (age, ethnicity, marital status, parity, and level of education), knowledge, attitude, work place, service year, cost, access, and distance of the screening service.
The data were entered and analyzed using SPSS version 20.Bivariate and multivariate logistic regression analysis was run after checking for multicollinearity test between the independent variables.Using multivariate logistic regression analysis, 95% CI and adjusted odds ratios (AORs), where confounding variables are controlled, were computed in order to identify any statistically significant associations between independent factors and history of cervical cancer test.The level of statistical significance was set at  < 0.05.

Knowledge and Attitude Measurement.
The understanding of the respondents (knowledge) about carcinoma of the cervix with respect to the questionnaire on symptoms, risk factors, screening, prevention, and treatment methods was measured using Nahida's KAP (knowledge, attitude, and practice) study, as follows: (i) 80-100%: good knowledge; (ii) 60-79%: moderate knowledge; (iii) <60%: poor knowledge.
The belief and feeling of the respondents (attitude) about cervical cancer and its screening practice, prevention, cost, severity, susceptibility, and treatment were measured using Likert scale system, which ranges from score 5 (strongly agree) to score 1 (strongly disagree).The responses were summed up and a total score was obtained for each respondent.The mean score was calculated and those who scored equal to or greater than the mean were categorized as having a positive attitude and those who scored below the mean were categorized as having a negative attitude towards cervical cancer screening.Ethical clearance was obtained from the Institutional Review Board of Mekelle University, College of Health Sciences.This study was approved by the Institutional Review Board of Mekelle University, College of Health Sciences.
Written consent was obtained from all participants and they were informed that participation is voluntary and they can withdraw any time during conducting the study.

Sociodemographic Characteristics.
The response rate of female nurses in public health institutions in this study was 93%.The data showed that the median age of respondents was 28 years old, with the majority (63.6%) of respondents in the range of 20-29 years.As seen in  2).As shown in Table 2, from a total of 225 female nurses, 171 (76.4%) know at least one preventive measure of cervical cancer.On the other hand, only 43.1% of the study participants knew that the preventive measure for cervical cancer is avoidance of predisposing factors.From a total of 225 respondents, 144 (63.1%) have positive attitudes towards cervical cancer screening, based on Likert scale system (Table 3).1).

Factors Associated with a History of Self-Reported Cervical Cancer Screening Practice. Logistic regression analysis
showed that attitude (AOR = 3.023, 95% CI: 1.134, 8.059) and work place (AOR = 3.424, 95% CI: 1.080-10.853)were found to be significantly associated with the practice of cervical cancer screening (Table 4).The odds of getting screened for cervical cancer in female nurses who work at outpatient department are 3 times more as compared to female nurses who work in other wards.Similarly, the odds of getting screened for cervical cancer in nurses having a positive attitude are 3.4 times as compared to female nurses who have negative attitudes.

Discussion
In this study, the practice of cervical cancer screening was 10.7%, which is almost similar to studies conducted in Nigeria (10%), India (8%), and Ghana (11.6%) [4,13,14].However, this is quite different as compared to studies from Sri Lanka (17.2%) [15], Brazil (94.7%) [16], and Japan (24%) [17].This This study revealed that attitude (AOR = 3.023, 95% CI: 1.134-8.059)and work place (AOR = 3.424, 95% CI: 1.080-10.853)were found to be significant factors for cervical cancer screening practice.However, attitude and work place of the respondents were not significantly associated with the practice of cervical cancer screening in studies done in Nigeria [4], Japan [18], Brazil [16], Ghana [14], and Japan [17].This might be due to the fact that cervical cancer screening centers in Ethiopia are very few and are available only in secondary and tertiary hospitals, where most of these services are in outpatient departments [19].During the data collection, Pap smear test was exclusively performed for all women only in one tertiary hospital (Ayder referral hospital) and one higher health center (Family Guidance Ethiopia, Mekelle Branch).In addition, cervical cancer screening service was available for women with HIV/AIDS in three additional hospitals in the region.
As evidenced by different literatures, including ours, high level of awareness and knowledge of cervical cancer demonstrated by health professionals did not translate to proper utilization of the screening services [4,18,20].This study has demonstrated that women negative attitudes could deter them from up taking cervical cancer screening [21].This negative attitude could be due to the lack of trust and confidence, where these clients may partially know the service providers.This partial acquaintance can be a source of shy, fright, and anxiety to use the service.However, it should be noted that a combination of different factors plays a significant role in women, preventing for cervical cancer screening [21].On the other hand, studies in highresource settings have found that providing self-sampling kits to women who do not attend regular cytological screening increase their participation [22].
It has been shown that health care provider recommendations are strong predictors of cervical cancer screening for the general population [20,23].These health professionals, who had not tested for themselves, may not initiate and recommend others for screening.The main factor reported for not getting screened was carelessness.The overall poor attitude and carelessness of these female nurses may greatly hamper the screening program.A meta-analysis research conducted by Julinawati et al. showed that women developed positive attitude towards cervical cancer screening only after experiencing significant clinical symptoms, including yellowish discharge or bleeding from the vagina [21].The result of this study can be considered as an indication of the magnitude of the cervical cancer screening practice in the general population.

Conclusion and Recommendation
Even though health professionals are expected to be role models in all aspects of health service utilization, the study showed that the magnitude of cervical screening practice is very low among nurse health professionals.Attitude and assignment of work place in the public health institutions were found to be the predictors of cervical cancer test.Let alone the general population, the current screening program is not effective even in reaching female health professionals.Integration of cervical cancer screening into routine reproductive health services should be considered.Efforts should be put in place to influence the attitude and perception of women through public health education.There is a need for sensitization of nurses and other health professionals about cervical cancer and the importance of screening.In addition, appropriate environment should be designed for cervical cancer test.

Figure 1 :
Figure 1: Reasons of not being screened for cervical cancer among female nurses at Public Health Institutions in Mekelle City, Tigray, Ethiopia, June 2014.

Table 1 :
Distribution of female nurses by sociodemographic characteristics in Mekelle City, Tigray, Ethiopia, June 2014.

Table 2 :
Distribution of responses of female nurses on knowledge questions about cervical cancer at Public Health Institutions in Mekelle City, Tigray, Ethiopia, June 2014.

Table 3 :
Responses of female nurses on attitude questions at Public Health Institutions in Mekelle Town, Tigray, Ethiopia, June 2014.

Table 4 :
Factors associated with the practices of cervical cancer screening among female nurses at Public Health Institutions in Mekelle City, Tigray, June 2014.