Original research: Usage of cervical cancer screening services among HIV-positive women in Southern Ethiopia: a multicentre cross-sectional study (2024)

Strengths and limitations of this study

• A valid and reliable data collection tool was used in a setting capable of providing cervical cancer screening and antiretroviral treatment.

• We did not assess factors like the attitude of HIV-positive women towards cervical cancer screening services and viral load.

• The study was also based on participant self-report through interviews, which might result in recall bias.

• The perceived barrier construct of the health belief model we used focuses only on the cognitive domain, which may fail to identify other barriers.

Study area and period

The study was conducted in the public health facilities of Wolaita Sodo town, located 329 km SouthWest of Addis Ababa, the capital city of Ethiopia. According to the Wolaita zone health office report, in Wolaita Sodo town there is 1 teaching referral hospital, 1 non-governmental-owned general hospital, 3 health centres, and 34 private health institutions. The cervical cancer screening services are provided at the Wolaita Sodo University Teaching Referral Hospital (WSUTRH) and Sodo Health Centre. The study was conducted from 1 July 2020 to 30 September 2020.

Study design and participants

A multicentre cross-sectional study was conducted among systematically selected adult (≥18 years) HIV-positive women on ART in the public health facilities of Wolaita Sodo town, Southern Ethiopia. Critically ill adult HIV-positive women on ART were excluded from the study.

Sample size determination and sampling technique

The sample size was determined by applying a double population proportion formula using Epi Info V. 7.2.3.1 software, with the assumptions of a 95% confidence level, 80% power, and a 1:1 ratio of cervical cancer non-screened to screened HIV-positive women. The factor that provides the largest sample size was used to detect a statistically significant difference. Accordingly, women with perceived barriers were 90% less likely to use cervical cancer screening services, with an OR of 4.64.¹⁹ With these assumptions, the sample size was 386, and after adding a 10% non-response rate, the final sample size was 429.

The average number of HIV-positive women visiting adult ART clinics during the 3 months of data collection was estimated by considering the number of women visiting adult ART clinics in the past 3 months. A systematic sampling technique was used to recruit the study participants; accordingly, every second woman (870/429=2) was taken based on their order of arrival for follow-up service, and the first woman was selected by using a lottery method (online supplemental figure).

Variables

The outcome variable of interest was the usage of cervical cancer screening services, and the independent variables were socio-demographic factors, medical and reproductive characteristics, knowledge about cervical cancer and its screening, source of information about cervical cancer and its screening, cervical cancer screening practice and perception based on constructs of the HBM.

Operational definitions

Cervical cancer screening usage: When an HIV-positive woman self-reports that she was screened for cervical cancer within the past 5 years.^{20 21} Perceived susceptibility: There were five Likert scale items with a minimum score of 5 and a maximum score of 25. Those who scored greater or equal and less than the median score were categorised as having ‘high’ or ‘low’ perceived susceptibility, respectively.^{20 21}

Perceived barriers: There were 11 Likert scale items with a minimum score of 11 and a maximum score of 55. Those who scored greater or equal and less than the median score were categorised as having ‘high’ or ‘low’ perceived barriers, respectively.^{20 21} Perceived benefit: There were 6 Likert scale items with a minimum score of 6 and a maximum score of 30. Those who scored greater or equal and less than the median score were categorised as having ‘high’ or ‘low’ perceived benefits, respectively.^{20 21}

Perceived severity: There were nine Likert scale items with a minimum score of 9 and a maximum score of 45. Those who scored greater or equal and less than the median score were categorised as having ‘high’ or ‘low’ perceived severity, respectively.^{20 21} Perceived self-efficacy: There were four Likert scale items with a minimum score of 4 and a maximum score of 20. Those who scored greater or equal and less than the median score were categorised as having ‘high’ or ‘low’ perceived self-efficacy, respectively.^{20 21}

Cues to action: There were three ‘yes’ or ‘no’ questions with a minimum score of 3 and a maximum score of 6. Those who scored greater or equal and less than the median score were categorised as having ‘high’ or ‘low’ cues to action, respectively.^{20 21} Knowledge: Knowledge of cervical cancer and its screening was measured using six knowledge-based questions, and each question has one correct answer. One point was given for each correct response and zero points for each incorrect response. The scores were summed and the median was calculated; those women who scored above the median were categorised as women with good knowledge, and those women who scored less than the median were categorised as women with poor knowledge.^{20 21}

Data collection tools and process

A pretested, structured interviewer-administered questionnaire was developed after reviewing previous similar studies^{17 22–25} (online supplemental file) and organised according to the objective of the study. Patients’ ART follow-up charts were reviewed to review the clinical parameters, such as the current WHO clinical staging of HIV and cluster of differentiation 4 count. The HBM constructs were adopted from the principles of 1993 Champion’s revised HBM Scale.^{20 21}

The questionnaire was prepared in English and then translated into the local language, Amharic, and retranslated back to English to maintain consistency by professional language translators. The reliability of the measurement tool was checked by calculating Cronbach’s alpha coefficient to measure the internal consistency of the knowledge assessment and the Likert scale items of HBM constructs. Accordingly, the tool was reliable and appropriate for data collection. Four experienced bachelor’s degree-holding nurses and two senior supervisors working in the ART clinics of the health facilities were involved in the data collection process.

Data management and analysis

The collected data was coded and checked for consistency and completeness up to the end of each data collection period. Epi-data software V.3.2.0 was used for data entry, and the entered data was exported to Stata V.15 for Windows. Descriptive statistics of numerical variables were presented in medians with an IQR, and categorical variables were presented using frequency and percentages. The bivariate analysis was done to check the existence of a crude association and to select candidate variables; those variables that had a p value<0.25 were included in the final model.²⁶

Confounding was checked, and a percentage change in the regression coefficients (β) less than 20% reveals an absence of confounding. Interaction for the main effect model was also checked, and the partial likelihood ratio test result with a p value>0.05 and a variance inflation factor less than 10 indicated the non-existence of multicollinearity among the independent variables.

The multivariable binary logistic regression model was used to identify the independent factors associated with the cervical cancer screening service. The summary measures of the estimated crude OR and adjusted OR (AOR) with a 95% CI were presented, and a p value<0.05 was used to declare statistical significance. The goodness of fit of the model was assessed using the Hosmer and Lemeshow goodness of fit test. Finally, the results were presented in statements, tables and figures.

Socio-demographic characteristics

A total of 429 HIV-positive women who were on ART in the WSUTRH and Sodo Health Centre ART clinics were approached. Among these, 12 women did not respond; ultimately, 417 HIV-positive women participated, making the response rate 97.2%. The median age of HIV-positive women was 31 years with an IQR of 28–36 years; 364 (87.29%) were urban residents, according to the WHO clinical stage of HIV; 362 (86.81%) of them were on stage 1; and 212 (50.84%) HIV-positive women started ART within the last 4 years (table 1).

Knowledge related to cervical cancer

Regarding the overall knowledge of the study participants, 192 (46.04%) had good knowledge regarding cervical cancer. Concerning the signs and symptoms of cervical cancer, the most common symptoms mentioned by the study participants were vagin*l bleeding and foul-smelling vagin*l discharge, reported by 146 (35.01%) and 60 (14.39%) HIV-positive women, respectively. The most commonly mentioned risk factor for cervical cancer was having multiple sexual partners, as reported by 203 (48.68%) HIV-positive women (table 2).

Information about cervical cancer and its screening practices

Three hundred and thirty-six (80.58%) HIV-positive women have heard about cervical cancer, and of those who had ever heard about cervical cancer, 283 (82.03%) of them heard from their healthcare providers, 42 (12.17%) heard from the media and 20 (5.8%) of them heard from their close relatives, families and friends. Three hundred and thirty-seven (80.82%) HIV-positive women heard about the presence of cervical cancer screening; among these, 278 (82.49%) of them heard from healthcare providers, 42 (12.46%) from the media and 17 (5.04%) from their close relatives, families and friends for the last time.

During the past 5 years, 116 (27.82%; 95% CI: 24.2% to 33.1%) HIV-positive women on ART were screened for cervical cancer, and 301 (72.18%) were not screened for cervical cancer. Among those screened, healthcare provider’s recommendations, relatives’ or friends’ recommendations and media recommendations were the most common reasons that made women be screened for cervical cancer, reported by 89 (76.72%), 11 (9.48%) and 10 (8.62%) women, respectively. Concerning the last screening time, 67 (57.76%), 30 (25.86%) and 19 (16.38%) HIV-positive women were screened within the past 1, 3 and 5 years, respectively. Among those who were not screened for cervical cancer, women’s feeling of being healthy was the most common reason mentioned by 156 (51.83%) HIV-positive women (figure 1).

Perception of cervical cancer and its screening

The mean and SD scores of the constructs of the HBM show that the perceived susceptibility scores were 15.5±3.7, the perceived severity score was 29.8±7.7, the perceived benefit score was 21.1±5.6, the perceived barrier score was 31.2±6.3, the self-efficacy score was 11±3.4 and the cues for action score was 1.1±1.2, respectively (table 3).

Factors associated with the usage of cervical cancer screening services

After controlling for the effect of other variables, married HIV-positive women were 75% less likely to receive cervical cancer screening services (AOR=0.25; 95% CI: 0.07 to 0.93). Similarly, women who had a high perceived barrier were 66% less likely to use cervical cancer screening services than women with a low perceived barrier (AOR=0.34; 95% CI: 0.12 to 0.98).

Whereas, government employees were almost four times more likely to use cervical cancer screening services as compared with non-government employees (AOR=3.85; 95% CI: 1.31 to 11.3). HIV-positive women who had started sexual intercourse before being 20 years old were two times more likely to use cervical cancer screening services as compared with their counterparts who started after 20 years (AOR=2.39; 95% CI: 1.09 to 5.26). Women who had a history of modern contraceptive use were three times more likely to use cervical cancer screening than those who had not used any modern contraceptives (AOR=2.43; 95% CI: 1.05 to 5.65).

Women with high self-efficacy were four times more likely to use cervical cancer screening services than those with low self-efficacy (AOR=4.42; 95% CI: 1.79 to 10.89). Similarly, HIV-positive women with high perceived benefits were 12 times more likely to use the cervical cancer screening service than those who had low perceived benefits (AOR=12.23; 95% CI: 2.22 to 67.35) (table 4).

Reviewer comments:

Author'smanuscript:

Twitter: @HagosZenawi

Contributors: AHM and BDK contributed to the study’s conception. AHM, ZHG and BL designed the study, performed the analyses and wrote the first version of the manuscript. ZHG, MAA and NGG contributed to the statistical analyses. All authors read and commented on the manuscript and approved the final version of it. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. ZHG has full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Patient consent for publication

Not applicable.

Ethics approval

Ethical approval was obtained from the Institutional Health Research Ethics Review Committee of Wolaita Sodo University (CHSM/ERC/149). Written informed consent was taken from each participant, and the data collected from the women and medical records were handled with strong confidentiality, neither the case records nor the collected data were used for any other purpose. All the collected patient information was stored anonymously, and the study was conducted following the 1964 Declaration of Helsinki. Participants gave informed consent to participate in the study before taking part.

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