Introduction

Cervical cancer is an important public health problem invariably caused by persistent infection with high-risk human papilloma virus. Despite being largely preventable through vaccination against high-risk human papillomavirus (HPV) and regular screening programs, cervical cancer remains a global health challenge [1–5]. The incidence and mortality varied widely and geographically and globally around 604, 127 new cases and 341,831 deaths reported in 2020. In sub-Saharan Africa, 34.8 per 100,000 and 22.5 per 100,000 new cases and deaths occurring annually from the disease compared with 6.6 and 2.5 per 100,000 new cases and deaths in North America [1,2,6,7]. The drastic differences are mainly explained by lack of access to HPV vaccination, regular screening, and the high burden of HIV infection in this region [1,3–7]. The problem is still overwhelming due to scarcity of resources, deficiency of health care system, making cervical cancer screening opportunistic rather than being organized and largely relying on visual inspection with acetic acid (VIA). The low rates of cervical cancer screening for few African countries were revealed by various studies; Uganda 7%, Nigeria 8.3%, Kenya 6%, and Ethiopia 2%, respectively [8–13]).

Ethiopia has a population of 36.9 million women with ages ≥15years and who are potentially at risk of cervical cancer. Around 9.8 million women are of ages between 30–49 years who happens to be the targeted audiences for regular screening. Annually, around 7,619 new cases and 6081 deaths were reported in Ethiopia in 2020 [8,14,15]. VIA as single-visit approach combined with access to cryotherapy was piloted and introduced in Ethiopia by the Federal Ministry of Health (FMOH) in collaboration with Pathfinder International Ethiopia. This later integrated into a comprehensive care package for people living with HIV/AIDS and availing the service in 25 healthcare facilities in the country [16]. Ethiopia has adopted the new World Health Organization (WHO) cervical cancer prevention and control guideline and has implemented an arranged screening to women of ages between 30–49 years, which can be expanded to 25–59 years on specific indications (being HIV positive or immune compromised state, have never been screened between 30–49years, population risk, resource availability). Nationally, 33% of the public health facilities including Addis Ababa provide a free cervical cancer screening as of 2018. In Addis Ababa, the capital city of the country, all public health centers and hospitals have been providing cervical cancer screening services as of 2020 [17]. However, the coverage of cervical cancer screening in the country remains very low, ranging from 2.0–20.2% and 0.4–14.0% in the urban and rural areas, respectively [1,9,14,16,18].

Health workers are the trusted source of medical information and their attitudes and practices towards diseases of public health importance, like cervical cancer, are very critical if the country must make progress towards the prevention of such diseases [19, 20]. As shown in various studies, Female Health Workers (FHWs) have a high level of knowledge and positive attitude towards cervical cancer screening (CCS). However, CCS uptake remained very low [14,18,21,22]. Healthcare providers in hospitals and health centers constitute the most visible front-line personnel providing health education to patients and the general population. In addition, female healthcare providers play an integral role in educating and awareness creation of women in the prevention of diseases. They can also influence cervical cancer screening adherence and health promotion, and act as a role model to the women in the community [23, 24].

There were many studies done on cervical cancer screening across different parts of the country with varying study population and design with the main outcome of interest being the knowledge, attitude, and practice (KAP). The healthcare providers who work at the public health institutions in Ethiopia encounter invariably all of the clients who are coming for cervical cancer screening. We have undertaken this study to address the screening service utilization as the main outcome factor and the factors influencing the uptake among female healthcare providers with different health-related disciplines and academic level and who were working at the primary and tertiary health care levels (health centers and hospitals), in Addis Ababa, and to make the study more manageable and feasible, the study was delimited to government health institutions.

Methods

Results

Sociodemographic characteristics of the study participants

A total of 432 participants of age 25–59 years were included in the final analysis. Of the total study participants, 276 (63.9%) were working at the health centers and 249 (57.6%) were of age below 30 years. Three hundred seventy-two (86%) were non-physician, of which, clinical nurses and midwives together account for 301 (69.7%). Similarly, of the total participants 199 (46.1%) had work experience of five years or less. The household monthly income of most participants was between 5,000–10, 000birr for 248 (57.4%) followed by 10,000–50,000birr for 126 (29.2%), respectively (1USD=54.7442birr) (Table 1).

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Table 1. The sociodemographic characteristics of the participants, July 2023.

https://doi.org/10.1371/journal.pone.0321662.t001

Knowledge of the study participants on cervical cancer screening

Based on the predetermined criteria, only 234 (54.2%) of the total participants were considered to have good knowledge about cervical cancer screening. On further analysis of knowledge related characteristics, 387(89.6%) of the participants knew the etiology of cervical cancer. Most study participants described having multiple sexual partners, and early age at sexual experience as risk factor for cervical cancer, 366 (84.7%) and 307 (71.1%), respectively. However, cigarette smoking as risk factor was reported by less than half of the participants, 194 (44.9%). Vaccination followed by screening were the two most frequently mentioned preventive methods among the participants in this study, 365 (84.5%) and 296 (68.5%), respectively. Among the participants who had the information about screening modality for premalignant lesion; Pap smear/cytology was the most frequently reported and HPV DNA test was the least reported, 333(82.4%) and 149 (36.9%), respectively. Nearly half, 234 (54.2%), of the participants stated the correct World Health Organization (WHO) recommended age, that is 30–49 years, for the cervical cancer screening. Interestingly, 406 (94.0%) of the study participants knew that premalignant lesion and cervical cancer can be treatable (Table 2).

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Table 2. The knowledge related characteristics of the study participants about cervical cancer and its screening (n=432), July 2023.

https://doi.org/10.1371/journal.pone.0321662.t002

Among the total participants, 272 (63%) were reported to have favorable attitude towards cervical cancer screening. Nonetheless, the screening service uptake among the total study participants and the target age groups (age ≥30years) were 84/432 (19.4%) and 57/183 (31.2%), respectively.

Table 3 and 4 below describe the screening service utilization by the participants overall knowledge and professional designation. Among the participants who were enrolled in the current study, the clinical nurses and the specialist physicians have utilized the screening services more than the rest of the professionals, 22.2% and 20.8%, respectively. However, when comparison was made among the total participants who utilized the screening services, 64.3% were clinical nurses followed by 13.1% midwife nurses.

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Table 3. Subgroup analysis of screening service utilization among the participants by their profession, July 2023.

https://doi.org/10.1371/journal.pone.0321662.t003

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Table 4. Level of knowledge and screening service utilization, July 2023.

https://doi.org/10.1371/journal.pone.0321662.t004

The screening service uptake of the participants having good knowledge compared to those described as not knowledgeable was 25.2% and 12.6%, respectively. When observed among the total participants who utilized the screening services, 70.2% were knowledgeable participants (Table 4).

In this study, 84/432 (19.4%, [95%CI 19.36–19.44]) of the total participants and 57/183 (31.2% [95%CI 31.16–31.64]) among the targeted age groups were screened at least once for cervical cancer. Among those who utilized the screening service; the motivating factors were awareness about the screening methods and physician recommendation, 41(48.8%), 22 (26.2%), respectively. Ten (11.9%) were screened due to the fear persuaded by having cervical cancer patient/relative. Sixty-three (75%) of the screened participants obtained the screening service only once in the past ten years, and 66 (78.6%) were screened within the past 3–5 years. Majority, 62 (73.8%) were screened by visual inspection with acetic acid (VIA), while 20 (23.8%) obtained the pap smear test.

As shown in S3 Fig, among the total participants who were not ever screened (n=348), the two most common reasons were assumption of feeling of healthy/ low risk perception 117 (33.6%) followed by lack of attention 96 (27.6%). Similarly, the lack of attention followed by the feeling of healthy were the two most common reasons for not being screened among the targeted age groups (Table 5).

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Table 5. The reasons for those not using screening services among targeted age group (≥30 years (n = 183), July 2023.

https://doi.org/10.1371/journal.pone.0321662.t005

Factors affecting cervical cancer screening utilization among the study participants, July 2023

As depicted in Table 6, some variables showed significant associations with the cervical cancer service utilization on bivariable model only, while other variables showed consistent association both on bivariable and multivariable regression models. Compared with their counter parts; working at health center COR 95% CI, 1.9 (1.11–3.26), having positive attitude COR 95% CI,1.7 (1.02–2.91), knowledge of cryotherapy as treatment method COR 95% CI, 3.6 (1.62–5.78), assertion that behavioral change COR 95% CI, 2.2 (1.32–3.62), treatment of precancerous lesion prevents cervical cancer COR 95% CI, 1.7 (1.00–2.78), knowledge of HPV DNA as screening method COR 95% CI, 1.7 (1.04–2.77), and knowledge of screening frequency COR 95% CI, 2.8 (1.62–4.99) have shown statistically significant association only on bivariable model. On multivariable logistic regression analysis; participant age ≥30 years (AOR=1.6, 95%CI1.15–3.37), being married (AOR=6.1, 95%CI 2.42–15.06), (AOR=3.7, 95%CI1.01–12.12), and working in cervical cancer screening units showed an independent association with the screening service utilization. Participants work experience ≥5 years was also shown to have statistically significant association with screening service utilization; 6–10years (AOR=3.8, 95% CI 1.52–9.12), 11–15years (AOR= 13.2, 95% CI 4.03–43.33), and >15 years (AOR=5.4, 95% CI 1.09–26.36), respectively. Similarly, the study participants knowledge of the etiology (AOR=1.6, 95%CI=1.01–12.12), cigarette smoking as risk factor (AOR=4.1, 95%CI1.68–9.76), and VIA as screening method (AOR=14.2, 95%CI3.77–53.32) have shown an independent association with screening service utilization.

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Table 6. The bivariable and multivariable logistic regression analysis of the independent variables with cervical cancer screening utilization, July 2023.

https://doi.org/10.1371/journal.pone.0321662.t006

Discussion

This study was conducted to assess the cervical cancer screening utilization and the factors affecting it among female healthcare workers in the public health institutions of AA, Ethiopia. Encouraging healthcare workers was reported as a significant predictor of the screening uptake on top of implementing structured screening program in place [26]. The 19.4% prevalence of cervical cancer screening utilization among the total participants reported in our study is consistent with studies done in Nigeria, Iraq, India, and Kenya with the screening service utilization rates; 20.8%, 18.5%, 25%, 20%, and 25%, respectively [25,27–30]. The similarity could be explained partly by the fact that all the stated studies are from developing countries where cervical cancer screening is by and enlarge opportunistic and not well organized. The reported screening service utilization in the current study is higher compared to the previous reports from Ethiopia; The pooled national prevalence reported from two studies (8.1%, 14.8%), Southern Ethiopia (11.4%), Northern and Northwest Ethiopia (10.7%). This difference could possibly be explained by the difference in the study design and population; 1. The national pooled prevalence was obtained from systematic review and metanalysis of 44 and 25 studies, 2. The population from the Southern Ethiopia were not health professionals, and 3. The Northern Ethiopia study participants were only nurses, and those from the Northwest Ethiopia were recruited only from the hospitals [18,31–34]. As clearly depicted in the study participants section, our participants were recruited from the capital city of the country and comprised of the female healthcare providers from all health disciplines working at the tertiary and primary levels of the healthcare system of the country (referral hospitals and health centers).

The prevalence of screening utilization among the participants in the targeted age group (age ≥30 years) of 31.2% in our study is slightly higher compared to the previous study conducted in AA which was 25% [11]. This disparity could be possibly explained by the difference in the study population; the outcome in the previous study was a knowledge, attitude, and practice (KAP) and the study population were community health extension workers. Contrary to the above, the service utilization of 31.2% in our targeted study participants is lower than the report from Japan (54.7%), United States (71%), and Cameroon (43.48%). This variation could be due to the age difference in the study population; the participants age range for the Japanese, United states, and Camerron women was 20–30, 45–65, and 25–65 years, respectively. In addition, the availability of well-established screening system in place, the difference in the socioeconomic status and health literacy could explain the observed differences for participants being from high income countries like Japan and the United States. [32,35,36].

The odds of screening utilization in our study which was 2.3 times higher in women with good knowledge is comparable to the earlier studies from Ethiopia and Nigeria, where awareness and knowledge about cervical cancer was shown to have significant association with the screening service uptake [22,32,33].

The reported screening service utilization by nurses in our study, 22.3% and 64.3%, within the nursing profession and among the total screening service utilizers, was comparable to the report from the Nigerian study where the proportion of nurses was 22.7% [31]. The possible explanation for the larger proportion of service utilization by nurses in our study includes; 1. The nurses make the larger proportion among the healthcare workers who obtained the Federal Ministry of Health lead training on cervical cancer prevention, screening, and treatment, 2. They are the ones largely allocated to the screening unit, and essentially deliver the screening services, which gave them the opportunity for better awareness and service utilization.

The reported odds of the screening services utilization in our participants which was 3.7 times higher among women working in cervical cancer screening unit is in agreement with the 2020 systematic review and metanalysis report from Ethiopia, and the cross-sectional study done in Mekele town, Northern Ethiopia, where place of work was shown to have significant association with the screening service utilization [32,33,37].

The finding in our study that participants knowledge of the etiology of cervical cancer was associated with slightly higher screening service utilization with an odds of 1.6 is comparable to the study done in Mekele town, Northern Ethiopia [37]. Similarly, the odds of screening service utilization 4.1 and 14.2 for participants who knew cigarette smoking as risk factor and visual inspection with acetic acid (VIA) as screening method in our study is consistent with the systematic review and metanalysis report from Nigeria, where awareness about the screening methods was the positive facilitator of the screening utilization. Likewise, the odds of screening service uptake was reported to be 3.2 among participants with good knowledge about the screening methods in the previous studies from Ethiopia [22,32,33]. The independent association of the positive attitude with screening service uptake in the previous study from Ethiopia was only demonstrated on the crudes odds ratio (COR) in current study, and this could partly be explained by the difference in the design of the studies [33].

This study has specifically addressed the screening service utilization of all female healthcare workers in the public health facilities in the capital city of the country, where organized cervical cancer screening services being implemented. The participants being from the various health-related disciplines and who were working both at the primary and tertiary healthcare systems of the country were some of the strengths of this study. Since Addis Ababa is the capital city of the country and Ethiopia is a country with diverse ethnic and cultural differences, one can’t simply generalize the results of the findings to all female healthcare workers practicing across all corners of the country. Too few observations (samples) in the regression model should be interpreted carefully as this might make it difficult to accurately estimate relationships between variables and potentially leading to misleading conclusions.

Conclusion

The screening service uptake among total participants and the targeted age groups was far below the WHO cervical cancer elimination strategy for developing countries. The low screening service uptake was alarming since the study participants were female health workers who were expected to be role models to their community. Compounding the low screening service utilization by the health care workers was the lack of readiness to utilize the screening service even in the near future and there were some participants in our study who had never ever heard at all about cervical cancer screening.

Therefore, we urge the Addis Ababa Health Bureau and the Federal Ministry of Health of Ethiopia to consider this finding as an input in the future planning of cervical cancer prevention and control strategies. Particular attention needs to be paid to female healthcare workers in an effort to improve the cervical cancer screening uptake at the national level.

We further recommend a qualitative study to explore some masked behaviors of the female health care workers regarding the meagre screening uptake.

Supporting information

Acknowledgments

We thank the Department of Obstetrics and Gynecology in the School of Medicine for allowing us to undertake this study. The female health workers who participated in this study deserve due recognition for their time and interest. Special thanks go to Girma Taye, (PHD, Head of Epidemiology and Biostatistics, CHS, AAU), and Mr. Mohamed Legas (MSc in reproductive health) for assisting us in statistical analysis. We are indebted to Lukman Yusuf, Professor Emeritus of Obstetrics and Gynecology for assisting us in editorial and grammatical work of the manuscript.