Bogalech Fufa

ADDIS ABABA UNIVERSITY
COLLEGE OF HEALTH SCIENCES

SCHOOL OF PUBLIC HEALTH
Assessment of Knowledge, Attitudes and Practices on Cervical Cancer Screening among

Health Service Providers at Marie Stopes International Ethiopia Centers, 2015
By:
Bogalech Fufa
Supervisor:
Dr. MulugetaBetre
A thesis submitted to the School of Graduate Studies of Addis Ababa University in

partial fulfillment of the requirements for the Degree Masters of Public Health
June 2015
Addis Ababa, Ethiopia

ADDIS ABABA UNIVERSITY
COLLEGE OF HEALTH SCIENCES
SCHOOL OF PUBLIC HEALTH
Assessment of Knowledge, Attitudes and Practices on Cervical Cancer Screening among

Health Service Providers at Marie Stopes International Ethiopia Centers, 2015
By:
BogalechFufa
A thesis submitted to the School of Graduate Studies of Addis Ababa University in

partial fulfillment of the requirements for the Degree Master of Public Health in the
School of Public Health, College of the Health Sciences.
Board of Examiners:
1. Dr. MulugetaBetre (Supervisor): ………………………….……
2. ……………………. (Examiner): ………………………………
3. ................................. (Examiner): ………………………….……
June 2015 Addis Ababa, Ethiopia
Acknowledgement
I would like to express my deepest appreciation to my advisor Dr.MulugetaBetrefor his
unreserved assistance, timely comments and relevant guidance from the beginning of the
research proposal to the write-up of the final paper.
i
I would also like to extend my thanks to my co- advisor Teshager Mersha for his invaluable
suggestions from the beginning of the research proposal throughout the thesis work.
In addition I would like to thank Marie Stopes International Ethiopia’s team members who have
participated in this study and the School of Public Health of the Addis Ababa University for the
support provided to me in accomplishing this thesis.
I would like to thank my beloved family, especially mydaughter TatanyaAberraand my son

Abel Aberra for their support in secretarial work and editing the thesis and my husband for his
general support. I am delighted to forward special thanks for their support throughout my days.
Although I would like to thank friends and colleagues for their support to raise my
moralethroughout this work.
Table of Contents
Acknowledgement…………………………………………………………………………………………i
Table of Contents.........................................................................................................................................iii
List of Tables................................................................................................................................................v
List of Tables………………………………………………………………………………………………vi
ii
Abbreviations ........................................................................................................................................ vii
Abstract.......................................................................................................................................................viii
1. Background ......................................................................................................................................... 1
1.1 Introduction ....................................................................................................................................... 1
1.2Problem Statement .............................................................................................................................. 2
1.3The Expected outcome........................................................................................................................ 3
2. Literature Review ................................................................................................................................ 3
2.1Overview of cervical cancer screening.....................................................................................................4
2.2Knowledge of cervical cancer screening ............................................................................................. 5
2.3 Attitude of cervical cancer screening .................................................................................................. 7
2.4Practices of cervical cancer screening ................................................................................................. 8
3. Objective ............................................................................................................................................. 9
4. Methodology ..................................................................................................................................... 10
4.1Study design ..................................................................................................................................... 10
4.2 Study area........................................................................................................................................ 11
4.3Data source and study population ...................................................................................................... 11
4.4Data Collection Instrument ............................................................................................................... 12
4.5Data Collection Process .................................................................................................................... 13
4.6Operational definition ....................................................................................................................... 13
4.7Data entry and analysis procedures ................................................................................................... 15
4.8Data quality management.................................................................................................................. 15
4.9 Ethical Consideration ....................................................................................................................... 16
4.10Dissemination of Results ................................................................................................................ 16
5. Results .............................................................................................................................................. 16
5.1 Background Characteristics of Health Service Providers .................................................................. 16
5.2 Knowledge towards Burden of Cervical Cancer ............................................................................... 19
5.3Knowledge towards Cervical Cancer Risk Factors ............................................................................ 20
5.4Knowledge towards Cervical Cancer Symptom....................................................................................21
5.5Knowledge towards Cervical Cancer screening procedure ................................................................. 22
5.6 Knowledge towards Cervical Cancer Screening Recommended Age of Women ............................... 23
5.7 Knowledge towards Cervical Cancer Screening Recommended Interval........................................... 24
5.8 Attitude of Health Service Providers towards Cervical Cancer Screening……………………………24
5.9 Practice of Health Service Providers towards Cervical Cancer Screening……………………………25
6.Discussion .......................................................................................................................................... 26
iii
6.Strengthand Limitationof Study .......................................................................................................... 32
7.Conclusionand Recommendations ...................................................................................................... 32
7.1Conclusions ...................................................................................................................................... 33
7.2Recommendations ............................................................................................................................ 34
References...................................................................................................................................................35
Apendices ............................................................................................................................................. 38
Annexes 1- Survey questionnaire (English)............................................................................................ 38
Annexes 2. Guide for in- depth Interview with area managers ................................................................ 44
Annexes: 3 Amharic questionnaires ....................................................................................................... 45
Declaration ............................................................................................................................................ 49
List of tables
Table1:Summary of MSIE Regions, Centers and Health Service Providers ............................................ 11

Table 2: Background Characteristics of Health Service Providers .......................................................... 17
iv
Table3: Knowledge towards Burden of Cervical Cancer ........................................................................ 19
List of Figures
Figure1: Knowledge towards Cervical Cancer Risk Factors........................................................20
v
Figure2: Knowledge towards Cervical Cancer Symptoms ................................................................21
Figure3: Knowledge towards Cervical Cancer Screening Procedure ……………………...…...……......22
Figure4: Knowledge towards Cervical Cancer Screening Recommended Age of Women………….…..23
vi
Abbreviations
CSRH Comprehensive Sexual Reproductive Health
ETB Ethiopian Birr
FGAE Family Guidance Association of Ethiopia
FGM Female Genital Mutilation
FMOH Federal Ministry of Ethiopia
HCPs Health Care Providers
HSPsHealth Service Providers
HPV Human papillomavirus
IDI In Depth Interview
KAP Knowledge, Attitude and Practices
LEEP Loop electrosurgical excision procedure
MSIE Marie Stopes International Ethiopia
Pap Papanicolaou
SPSS Statistical Package for Social Sciences
STI Sexually transmitted infections
VIA Visual inspection with acetic acid
VILI Visual inspection with Lugol’s iodine
WHOWorld Health Organization
vii
Abstract
Background and Objective:Cervical Cancer is one of the major non-communicable health
problems, largely preventablewith effective screening programmesandhuman papilloma virus
(HPV) vaccination to prevent, detect and reduce cervical cancer.The burden of cervical cancer is
disproportionately high among the developing countries. The study was conducted to assess
Knowledge, Attitude and Practices (KAP) on Cervical Cancer Screening amongHealth Service
Providers (HSP) at Marie Stopes International Ethiopia Centers in 2015.
Materials and Methods:An exploratorydescriptive cross-sectional study design,both
quantitative and qualitative method was employed. Quantitativedata was collected by means of
self-administered questionnaire from 190 health service providers and qualitative bymeans of an
in-depth interviewfrom five area managers, bothemployed at Marie Stopes International
Ethiopia.
Result:The mean age of the study participants were 34.7 years. 50% of participants considered
cancer of the cervix a public health problem in Ethiopia. They most frequently mentioned
multiple sexual partners 52.6%, sexually transmitted infections (STI) 49.7%, smoking 28.1% and
sexual intercourse at early age 17.5% as major risk factors; and irregular vaginal bleeding 63.8%,
foul smelling vaginal discharge 52.8%, post coital bleeding 39.9% and dyspanurea 38% as major
symptoms of cervical cancer.Pap smear was the most popular screening test mentioned by 62.1%
andvisual inspection with acetic acid (VIA) or Lugol’s iodine (VILI) by 31.1% of respondents.
Participants mentioned recommended women age and screening interval inconsistently. About
66.3% of respondents believed all women should undergo screening for cervical cancer.
However, 53.2% of female respondents didn't feel susceptible to cervical cancer, as well as
65.1% had never been screened. Of the male respondents, only 19.8% had partners/ wives who
had ever been screened.
Conclusions and Recommendations: There is high KAP gap and misconception, towards
cervical cancer screening among HSP. Health service providers need to be targeted first for
cervical cancer screeningbecause of their essential role in the implementation of any future
screening programs and in their educative role with patients. Health service providers need to be
trained to provide health education services and are expectedto be a role model to motivate and
change others attitude and practices.
Key Words: Knowledge,Attitude, Practice, Cervical Cancer, Ethiopia
viii
ix
1. Background
1.1Introduction
Globally Cervical Cancer is one of the major non-communicable public health problems among
female population.Cervical cancer is largely preventable following the introduction of effective
cervical cancer screening programmesin conjunction with human papilloma virus (HPV)
vaccination to prevent, detect and reduce cervical cancer.The burden of cervical cancer is
disproportionately high among the developing countries where 85 % of the estimated 493, 000
new cases and 273, 000 deaths occur in resource-poor countries among women annually.In 2010,
it was estimated that 20.9 million women were at risk of developing cervical cancer in Ethiopia
with an estimated 4,648 and 3,235 annual numbers of new cases and deaths, respectively (1,2).
Low coverage of cervical cancer screening is a serious problem and a major barrier in reducing
the mortality and morbidity in the developing countries. Specifically in Sub-Saharan Africa very
few women are ever screened for cervical cancer. In Ethiopia data compiled by TikurAnbessa
Specialized Hospital from 1996 – 2008 showed 30.3% of all cancers diagnosed in the Hospital
were cervical cancer. The estimated coverage of cytology – based cervical cancer screening in
Ethiopia isvery poor 1.6% in urban settings and 0.4% in rural areas(3).
Mortality caused by cervical cancer in Africa is very high. The reported mortality in Eastern
Africa was 35 deaths per 100,000 women. However, the mortality rates in the developed world
where screening programs run successfully remained below 5 per 100,000 women during the
same year. Survival rate for five years in African countries such as Uganda was only 18%
whereas during the same year it was 72% in the United States of America. On an average in Sub
Saharan Africa the survival rate was 21% comparedto 70% in the United States and 66% in
Europe (4).
However, in low-and middle-income countries (LMICs), only approximately 5% of eligible

women undergo cytology-based screening in a five year period. In virtually all LMICs, cytology-
based services are confined in teaching hospitals or private laboratories in urban areas. The
barriers to scale-up of cervical cytology-based screening programs in Ethiopia include the lack of
trained and skilled professionals, supplies, laboratory infrastructure and equipment. Furthermore,
the absence of a well-organized Surveillance and recall system is a major obstacle to effective
1
implementation: women with abnormal findings may not receive their results, let alone treatment
or follow-up. These are some of the barriers that prevent cytology-based screening programs
from being effective in LMICs (5).
In a bid to implement cervical cancer prevention and control program in Ethiopia, the Federal
Ministry of Health has developed cervical cancer prevention and control guideline.The main goal
of this guideline is to provide healthcare providers, implementing partners and other stakeholders
involved in the prevention and control of cervical cancer in Ethiopia with a standardized Cervical
Cancer Prevention and control health service delivery directive (5). As one of the major actors
on maternal health programs in the country, Marie Stopes International Ethiopia (MSIE) is
providing cervical cancer screening and preventive treatment through its Blue Star health care
network and MSIE centers as well as partnering with large scale farming sites under MSIE led fit
for work project. Currently MSIE is providing screening service using Pap smear technology and
has planned to initiate screening and treatment service using VIA and Cryotherapy (6).
1.2 Problem Statement

Cervical cancer is the most common genital cancer and one of the leading causes of death among
female population. Fortunately, this cancer is preventable by screening for premalignant lesions
but this is rarely provided and hardly utilized.Early diagnosis and prompt treatment of cancer and
precancerous lesions provides the best possible protection against cervical cancer (1). Well
organized programs to detect and treat precancerous abnormalities at the early stages of cancer
prevent up to 80% of cervical cancer in developed countries(1). However, effective cytological
screening programs for detecting carcinoma of cervix have been difficult to implement in
developing world likeEthiopia.
Understanding the level of knowledge, attitudes and practices with regard to cervical cancer
screening among clients, health service providers and different stakeholders will help to address
practical and strategic need of cervical cancer prevention program in Ethiopia. Studies in this
respect seem to be limited in this country which resulted in information gap among practitioners,
researchers and policy makers. Among the exiting literatures few studies were dedicated to
assess the issue in concern taking only clients as study subjects (3, 8).Still very few
existingliteratures in the area of cervical cancer screening were conducted among service
2
providers and clients at a time (1, 9).Therefore as MSIE is one of the actors in providing
comprehensive sexual reproductive health (CSRH) services widely across 5 regions this KAP
studywas conducted among the health service providers to address the information gap.
1.3 The Expected outcome

An identifiedknowledge, attitude and practices gap among health service providers towards
cervical cancer screeningis expected to serve practitioners and policy makers to design evidence
based programs.In addition studies in similar topics which may be conducted in a different scale
and depth can make use of this study as a spring board.
2. Literature Reviewt
This chapter presents related literature on knowledge, attitudes and practices (KAP) about
cervical cancer prevention and control. The section also briefly summarizes key studies
3
oncervical cancer prevention and control that have been undertaken in different parts of the
world.rpart of the uterus.
Cervical cancer is highlighted in the “Political Declaration of the High-level Meeting of the
General Assembly on the Prevention and Control of Non-communicable Diseases” as well as in
the “comprehensive global monitoring framework” under development which includes key
indicators, and a set of global targets for the prevention and control of non-communicable
diseases. (6) Implementation of cervical cancer prevention and control programs contributes to
the attainment of the MDGs through universal access to sexual and reproductive health services
to improve women’s health, to the 2010 UN Secretary-General’s Global Strategy for Women and
Children’s Health and to the 2011 Political Declaration of the UN General Assembly High level
Meeting on Non-communicable Diseases(6).
According to the 2002 World Health Organization report cervical cancer contributes around 12%
of all types of cancers among the women(7).Age-adjusted incidence rate of cervical cancer in
Ethiopia is 35.9 per 100,000 women with 7619 annual number of new cases and 6081 deaths
every year. In Ethiopia Data compiled by TikurAnbessa Specialized Hospital from 1996 – 2008
showed 30.3% of all cancers diagnosed in the Hospital was cervical cancer (3).Though availing
integrated cervical cancer screening services for women at risk will decrease deaths caused by
cervical cancer (10, 11).
2.1Overview of Cervical Cancer Screening

Cervical cancer is potentially preventable, unlike other reproductive organ cancers. Effective
screening programs in conjunction with human papilloma virus (HPV) vaccination can lead to a
significant reduction in the morbidity and mortality associated with this cancer (3, 5). Visual
Inspection with Acetic Acid (VIA) is an evidence-based and affordable alternative approach for
cervical cancer screening in low-resource settings.Visual Inspection with Acetic Acid (VIA)
screening is the simplest method of screening with the lowest cost and relative ease of use. The
approach does not require high technology and has been demonstrated to reduce the deaths of
women in developing countries (16).
Studies have reported VIA sensitivity for detecting precancerous lesions comparable to or greater
than cervical cytology, while requiring fewer resources and feasible to carry out in low level
health facilities (5).
4
Single-visit approach (SVA) using VIA shows promising results in terms of clinical benefits and
cost-effectiveness’s in reducing morbidity and mortality even in resource-poor settings (1).
Given the difficulty of sustaining a high-quality cervical cytology-based screening program, and
the proven effectiveness of the VIA approach, Ethiopia has looked to VIA combined with
cryotherapy for cervical cancer prevention (5).
Screening programs that involve one to two visits to health centers linked with the treatment
appear to be effective, safe and feasible (12).The screening tests for cervical cancer are based on
three assumptions: 1) Primary prevention 2) secondary Prevention and 3) tertiary care. Primary
Prevention includes prevention of infection with Human Papilloma Virus (HPV) either through
behavior change mechanisms, such as abstinence or condom use, or through biological
mechanisms, such as the HPV vaccine. Secondary prevention, which is the main focus of the
guideline, includes screening and treating precancerous lesions with effective outpatient
methods. Tertiary care includes management of invasive cervical cancer (i.e. surgery, radiation
therapy and chemotherapy), as well as palliative care. The first is that prevention is better than
cure and the second is that early detection may allow early treatment as the primary pathologic
process is still reversible. Screening tests are relatively simple procedures that separate healthy
persons from those with a high probability of having the disease (13).
Well-organized programs to detect and treat precancerous abnormalities at the early stages of
cancer prevent up to 80% of cervical cancers deaths in developed countries. However, effective
screening programs have been difficult to implement in low resource settings. This is one reason
why cervical cancer mortality rates are much higher in the developing world(14).So reduction of
the cervical cancer mortality in the developing world is only one of the many priorities
competing for scarce resources (15).
2.2 Knowledge of cervical cancer screening
Studies conducted among health service providers KAP towards cervical cancer screening are
minimal especially in resource poor countries like Ethiopia. However study conducted among
Cameroonian healthcare workers revealed that Knowledge of cervical cancer and prevention by
screening showed several gaps and important misconceptions regarding screening methods (17).
Another study conducted in Tanzania regional Hospital identified less than half of the Nurses
had adequate knowledge regarding cervical cancer, causes and transmission of HPV and age of
5
to be screened; however there is a variation among professionals. Assuming all health
professionals have equal level of awareness with regard to cervical cancer screening is very
misleading. Though this study concluded that need for continuing medical education, creation of
cervical cancer prevention policies and strategies at all levels of the health sector (18).
Similarly a study conducted at Chennai Corporation in India revealed that 85% of female health
care providers (HCPs) were aware of major risk factors and symptoms of Cervical Cancer.95.3%
of HCPs were aware of Pap smear and VIA/ VILI, however only 62.1% and 78.4% knew the
exact purpose of Pap smear and VIA/ VILI respectively (19).
Another study conducted in Niger Delta University shows awareness in cervical cancer
screening was higher amongst female students than female staff in a tertiary institution, but
uptake was generallylow 13% staffs and 11.6% students. There was an association between
awareness and practice of cervical cancer screening amongst respondents. Overall, a greater
proportion of the staff respondents had little or no knowledge aboutcervical cancer screening
(20).
Similar study conducted in Haitian health care workers With regards to their knowledge about
cervical cancer and prevention, 69.2% stated they did not feel they had adequate knowledge.
100% of participants correctly stated that cervical cancer is one of the leading causes of death in
women worldwide. Also, 52.2% correctly stated that cervical cancer is preventable. When asked
whether cervical cancer was curable, 45.5% of the study sample correctly answered that
question. When asked if it is possible to detect pre-cancerous cervical cancer cells, 81.5%
correctly stated that was true. 74.1% of participants also recognized that cervical cancer is not
most common among women in their 20 s. When asked whether cervical cancer can usually be
found at an early stage because of the obvious symptoms such as bleeding and pain, 18.5%
correctly stated that was false. Two-thirds correctly recognized that if cervical cancer is left
untreated it is fatal. When participants were asked whether cervical cancer is caused by a virus
that is spread sexually, 77.8% correctly stated that was true. When asked whether there is a
vaccine that can prevent cervical cancer, one-third stated that was true. Almost all of participants
correctly recognized the purpose for screening is to detect pre-cancerous changes. When asked
whether screening for cervical cancer should begin when a woman is in her twenties, 51.9%
stated this was false.The risk factors for cervical cancer most often chosen by participants were:
6
HIV infection (38.5%), smoking (53.9%), multiple partners (57.7%), and HPV infection (73.1%)
(21).
In some cases clients are in a better position to exercise their health seeking behavior, for
instance most recently conducted study at the selected MSIE Centers and Blue Star Clinics
identified that knowledge on the risk factors, symptoms and prevention methods of cervical
cancer was found to be very limited among clients. However, majority of these clients are aware
of cervical cancer can be treated if diagnosed early. Moreover there was a high level of
willingness among women to get screened for cervical cancer and to pay for screening test and
treatment services (6).
2.3 Attitude of cervical cancer screening

A study conducted in Uganda health workers (physicians, nurses and others) showed that 65% of
female health workers who are eligible for screening did not think they were susceptible to
cervical cancer (22).
Similar study by Chennai Corporation in India female HCPs have better attitude towards cervical
cancer screening than knowledge in all the professions except for health sector Nurses. About
81.3% of HCPs believed that cervical cancer can be detected even before the symptoms appear.
Only 42.1% of female HCPs perceived as not at risk of developing cervical cancer, however
85% of the respondents felt that they should undergo screening for cervical cancer. The most
common reasons for perceiving not at risk include: no symptoms(19%),confidence that they will
not get the disease (19%), no risk factors (14.3%), fear of being diagnosed with the disease
(14.3%), hysterectomy done (23%), and shyness to undergo the procedure (4.8%).Again about
4.8% of the female HCPs who believe that they were at risk did not want to undergo cervical
cancer screening and the reason for this is fear of being diagnosed to have the disease. On the
other hand, 60% of the respondents wanted to undergo screening in spite of their belief that they
are not at risk (19).
Similar study conducted at Surat India Teaching Hospital witnessed that 87% of Nurses who
did not recommend Pap smear to other women, 38.9% gave no response while 35%
believed that women less than 20 years are safe. Some, 11.4% women thought it is a painful
procedure and 6.9% believed it is risky (9).
7
As publicized in different studies, another study conducted in Botswana witnessed that negative
attitude of health service providers and limited access to the doctors were among the major
barriers to cervical cancer screening services (24).
2.4 Practices of cervical cancer screening

Study conducted at Chennai Corporation in India observed that only 18.7% of female HCPs have
ever undergone cervical cancer screening. On the other hand the current health system stresses
regular screening for all women above 30 years irrespective of symptoms, but nearly 19.6% of
the female HCPs have not recommended cervical cancer screening to women who did not show
symptoms (19).
Similarly study conducted in Uganda female health workers (physicians, nurses and others)
found that approx.81% had never been screened (22).
Again a study conducted in Nigeria at Usmanu Danfodiyo University Teaching Hospital Sokoto,
with doctors, nurses, pharmacists, laboratory scientists and medical social workers. It was
assumed that the knowledge of these workers about cervical cancer would be high and they
would have taken the screening tests for themselves. However, the results of the study revealed
that only 4.4% of the respondents had ever undergone the screening tests themselves (23).
Another study conducted at Surat Teaching Hospital concludes that 70% of Nurses never
experienced Pap smear;the most common reasons being mentioned are not thought about it
(28.6%) and no time for it (17.8%) respectively. Even though there is satisfactory knowledge
among nurses about cervical cancer and screening the uptake for screening is minimal(9).
To improve and strengthen cervical cancer screening services WHO has recommended its
member countries to develop and integrate cervical cancer screening into their health systems
depending on the local social, cultural and economic contexts. This will ensure a defined referral
system for diagnosis, treatment and follow up (25).
On the supply side the MSIE based study showed majority of centers didn’t provide Pap smear
and other cervical cancer screening and preventive treatment services yet. However, there are
shortcomings in terms of access to information, reference materials and guidelines on
cervicalcancer screening and treatment. Referral systems and linkages are not established. The
record review revealed poor practice in recording (6).
8
3.Objective
3.1 General Objective
Assess Knowledge, Attitudes and Practices on Cervical Cancer Screening among Health Service
Providers at Marie Stopes International Ethiopia Center, 2015.
3.2 Specific objective

To describe
9
 Understanding of health service providers towards cervical cancer risk factors,
symptom, screening procedure, recommended women age and screeninginterval
 Opinionof health service providers towards cervical cancer screening
 Actions and behavior of health service providers towards cervical cancer screening
4. Methodology
a.Quantitative method
4.1 Study design
An exploratory, descriptive cross-sectional study design, with both quantitative and qualitative
method was employed. Quantitative data was collected by means of self-administered
questionnaire from 190 health service providers and qualitative by an in-depth interview from
five area managers, employed at Marie Stopes International Ethiopia.
10
4.2 Study area
The study was conducted in MSIE centers, across four regions and two city administrations
(Tigray, Amhara, Oromia, SNNPR, Addis Ababa and Dire Dawa)Central area from February
10th to April 30th, 2015.MSIE is a fundamental provider of Comprehensive Sexual Reproductive
Health services in Ethiopia since its inception in 1990. The organization now operates in 23
static Centers, one National Call Center, 10 mobile units, more than 600 Blue Star Clinics and
although community health workers deployed to reach inaccessible and remote rural areas
through voucher program and link them with service delivery outlets. All MSIE centers provide
CSRH services including: short acting, long acting and permanent FP methods, VCT service,
ANC, STI screening and treatment, safe abortion, delivery, postnatal care, PMTCT,
immunization, different laboratory services and likes. The centers are selected as a study sites
because of their potential and eligible client flow and, high number of health service providers.
4.3 Data source and study population

Marie Stopes International Ethiopia has a total of 547 employees which are composed of 357non
health service providers and 190 health service providers. The researcher compiled a list of
employees with the help of MSIE human resource unit .Thus this study was conducted among
all190 health service providers of MSIE.
Table1.Summary of MSIE Regions, Centers and Health Service Providers

Region / No of No of KAP
City administration Town facilities respondents
Tigray Mekele 1 4
Amhara D/Birhan,Dessie,B/Dar and
D/Markos 4 32
11
Oromia Bishotu,Adama,Ambo,
Nekemte,Jimma, and Asella 6 44
SNNRP Hawsa,Hossana,Arbaminch,
Wolayta and Shashemene 5 23
Addis Ababa Arada,Gulele,Kirkos,Choice,

T/Haymanot and Obstetrics 6 83
Dire Dawa Dire Dawa 1 4
Total 23 190
4.4 Data Collection Instrument

Self-administeredquestionnaire was adapted from earlier studies related to cervical cancer and
screening knowledge, attitude, and practices among female health care providersof Chennai
Corporation, 2013.The questions sought to explorerespondent’s knowledge, attitude and
12
practices towards cervical cancer screening. The questionnaire was translated into Amharic using
professional linguists and pre-tested to ensure that it maintained its original meaning.
The questionnaire was divided into 4 major areas that included:-
 Background characteristics
 Knowledge towards cervical cancer which assesses:
 burden of the disease
 risk factors
 symptoms
 screening procedure
 recommended age of women
 recommended screening interval
 Attitude towards cervical cancer screening
 Practicestowards cervical cancer screening
4.5 Data Collection Process
After receiving clearance from Public Health Review and Ethical Clearancecommittee (REC),the
study was conducted using a paperquestionnaire. The researcher trained and oriented3 data
collectors about the purpose of the study, survey questionnaire and how to handle respondents
while in the field. The research tools were pre-tested at family guidance association of Ethiopia
(FGAE).Data collection occurred from February10thto April 30th, 2015 using 190 questionnaires.
The researcher designed data entry screens using SPSSversion 20software application that were
used to translate the paper questionnaire into electronic data for analysis.The researcher checked
the questionnaire simultaneously for completeness and reviewed accuracy of each questionnaire
at least once and corrected any resulting data errors before analysis.
4.6 Operational definition

Operational definitions that help to guide this research includes:-
Knowledge:We considered knowledge about risk of cervical cancer good if a respondent
mentioned at least 3 of the known risk factors (multiple sexual partners, sexually transmitted
infections/STI and smoking).
13
We considered knowledge about symptoms of cervical cancer good if a respondent mentioned at
least 3 of the known symptoms (irregular bleeding, foul smelling vaginal discharge and post
coital bleeding).
We considered knowledge about screening technique of cervical cancer good if a respondent
mentioned at least 2 of the known technique ( pap smear and VIA/VILI).
We considered knowledge about recommended ageof screening for cervical cancer good if a
respondent mentioned at least> 30 years.
We considered knowledge about recommended interval of screening for cervical cancer good if a
respondent mentioned at least every 5years.
Attitude: Attitude was evaluated as perceived susceptibility to cervical cancer and willing to
undergo for screening themselves.
Practice:Practice was evaluated as screening patients for cervical cancerand in case of female
respondents, having ever been screened them and in case of male respondents wives/partners
have ever been screened.
Variables
 Background characteristics: (sex, age, marital status, age at marriage, profession,
in-service year and training)
 Knowledge
 Attitude and
14
 Practices
4.7 Data entry and analysis procedures
The collected quantitative data was entered and analyzed using SPSSversion 20 software
program for total score to calculate frequency, mean and percentage. Similarly, results from
qualitative data summarized by open code application under different themes identified. Data
analyzedusing the technique of triangulation in terms of comparing evidences coming from
different data sources.
4.8 Data quality management
To assure the quality of quantitative data, standardized data collection instrument was developed
and pretested at Family Guidance Association of Ethiopia (FGAE) to ensure for simplicity and
appropriateness.The entered data was checked for completeness at the beginning and middle
stage of the work. Data cleaning was conducted at the end of the data entry.
b. Qualitative Method
4.1 Study design
Case ethnographic study design was usedamong area mangers employed at MSIE across 5 areas
to complement and triangulate the quantitative findings, and data was collected through an in-
depth interview.
4.2 Study population
The study participants were area managers of MSIE who are in charge of leading health related
program across each region.
4.3 Data source and study population
The study was designedto involve all five area managers employed at Marie Stopes International
Ethiopia across five regions.
4.4 Data collection
In-depth interview was conductedamong 5 area managers’ on May 15 and 16, 2015. In-depth
interview was conducted with each participant for 15 to 20 minutes and the developed interview
guide was used. Interview questionsinclude provision of cervical cancer screening at service
delivery points, capacity of providers,and challenges during intervention. The principal
15
investigator was the one to conduct an in-depth interview.Upon the consent of the participant in
an in-depth interview, the researcher made recordings through audio-tapes for ease of
transcribing the qualitative information to be obtained.
4.5 Data analysis
The recorded data with the audio tape were transcribed in Amharic and translated to English.
Analysis was undertaken manually using predetermined themes.
4.9 Ethical Consideration
Prior to data collection, Ethical clearance and approval of study wasobtained from review and
ethical clearance (REC) committee of Addis Ababa University, School of Public Health. Further,
MSIE and respective area managers were informed about purpose and deliverables of research
undertaking. The participants were informed their participation in this study will help for the
success of the study and better improvement of the program. Informed consent was obtained
from each study subjects and participants. Respondents were assured about confidentiality of
responses that would be maintained during and after data collection.
4.10Dissemination of Results
The findings from this study will be disseminated to Addis Ababa University School of Public
Health, MSIEand other organizations who are interested in this issue. Publication and
presentation of the findings at local and international forums will be considered.
5. RESULTS
5.1 Background Characteristics of Health Service Providers
Atotal of 190 Health Service Providers were study participants. The mean age of participants is
34.7 years ± 8.9 SD,ranging from 21 to 58 years.TheywereObstetrician/Gynecologist(6), General
16
practitioners(8), Laboratory technicians (17), Midwifes (25)and Nurses(79).Among the study
participants 57.4% and 63.7% were female and marriedrespectively;their mean age at marriage is
26.8 years ± 4.5 SD ranging from 18 to 42 years. About 39.5% participants have been serving as
a health service provider ranging from1 to 38 years with a mean of 11.3 years ± 7.1 SD.Among
all participants only 7.9% (95% CI: 4.2-12.1%)of providers attended training regarding cervical
cancer.(Table 2)
Table 2: Background Characteristics of Health Service Providers

Variable Number(N=190) Percentage
Sex
Female 109 57.4
17
Variable Number(N=190) Percentage
Male 81 42.6
Age ( in year)
21 – 30 80 42.1
31 - 40 70 36.8
41 - 50 26 13.7
≥ 51 14 7.4
Mean 34.7 years ± 8.9SD
Marital status
Single 61 32.1
Married 121 63.7
Widowed 8 4.2
Age at marriage( in year) (N=139)
15-19 1 0.7
20-24 46 33.1
25-29 58 41.7
>=30 34 24.5
Mean 26.8years ± 4.5SD
Profession
Obstetrician/ Gynecologist 6 3.2
General Practitioner 8 4.2
Laboratory Technician 17 8.9
Midwife 25 13.2
Health Officer 55 28.9
Nurse 79 41.6
In service year
≤4 16 8.4
5-9 75 39.5
10 - 14 45 23.7
≥15 54 28.4
Mean 11.3 years ± 7.1SD
Attended training about
cervical cancer
Yes 15 7.9
No 175 92.1
18
5.2 Knowledge towards Burden of Cervical Cancer
About 77.4% and 50% of respondents considered cervical cancer is at high extent and a public
health problem in Ethiopia respectively. (Table3)
Table3: Knowledge towards Burden of Cervical Cancer
Variable Number Percentage (N=190)

Extent is high in Ethiopia
Yes 147 77.4
No 31 16.3
I don’t know 12 6.3
Public Health Problem in Ethiopia
Yes 95 50
No 69 36.3
Difficult to describe 16 8.4
I don’t know 10 5.3
19
5.3 Knowledge towards Cervical Cancer Risk Factors
The most frequently mentioned risk factor for cervical cancer is multiple sexual partner 52.6%,
Sexually Transmitted Infection (STI) 49.7%, smoking 28.1%, early sexual intercourse
17.5%,HIV infection 10%, HPV 14.6% and others 39.6% of cervical cancer. (Fig 1)
Findings of the in depth interviews (IDIs) indicated most of health services providers don’t have
adequate knowledge about cervical cancer. All respondents believed and agreed lack of trained
human resources is one of the hindering factors in cervical cancer screening services.
As most of participants mentioned multiple sexual partners and Sexually Transmitted Infection
(STI)are mainrisk factors to develop cervical cancer.
One of the area managers said that:
“…..amazingto hear this because we assume ourselves as best sexual reproductive health
provider in the country but on the contrary with this huge number of health service providers
and different professions….”
60.00%
52.6%
49.7%
50.00%
40.00%
39.6%
30.00% 28.1%
20.00% 17.5% 17%

14.6%
11.1% 9.9% 9.4% 9.4%
10.00% 7% 7% 6.4% 4.7%
0.00%
Figure1: Knowledge towards Cervical Cancer Risk Factors
20
5.4Knowledge towards Cervical Cancer Symptoms
The most frequently mentioned vaginal bleeding 63.8%, foul smelling vaginal discharge 52.8%,
post coital bleeding 39.9%, Dyspanurea 38%, abdominal pain 16%, pelvic pain 16.6% and others
12.7% of cervical cancer. (Fig 2)
Findingsof the in depth interviews (IDIs) indicated that most of health services providers don’t
have adequate knowledge about cervical cancer. All respondents believed and agreed lack of
trained human resources is one of the hindering factors in cervical cancer screening services.As
Vaginal bleeding, foul smelling, vaginal discharge are the most frequently mentioned symptoms
of cervical cancer mentioned by study participants.
70.00%
63.8%
60.00%
52.8%
50.00%
39.9%
40.00% 38%
30.00%
20.00% 16.6% 16%

12.7%
10.4% 9.8%
10.00% 8.6% 7.4%
3.1%
0.00%
Figure2: Knowledge towards Cervical Cancer Symptoms
21
5.5 Knowledge towards Cervical Cancer screening procedure
Almost 86.8% of respondents believed that screening can detect cervical cancerbefore symptoms
appear.62.1%, 31.1 % and 4.7% of participants mentioned Pap smear, VIA/VILI and colposcopy
4.7% as cervical cancer screening procedures respectively. However few numbers of respondents
wrongly mentioned punch biopsy 6.8% and Loop electrosurgical excision procedure (LEEP)
2.6% as a cervical cancer screening techniques.
Findings of the in depth interview perceived that Pap smear and VIA/VILI mentioned by most of
health services providers as screening procedureto detect cervical cancer was the most
commonly used cervical cancer screening technique in MSIE centers.( Fig 3)
2.6%
4.7%
6.8%
Pap smear
VIA/VILI
Punch biopsy
31.1% LEEP
62.1%
Colposcopy
Figure3: Knowledge towards Cervical Cancer Screening Procedure
22
5.6Knowledge towards Cervical Cancer Screening Recommended Age of Women
Around 30% of study participants attempted to identifyrecommended age of women for cervical
cancer screening. Those were > 30 years 6.8%,15 to 49years 8.4%,25 to 45years 8.4%,all women
>18years 6.8%. Remarkably70% of respondents didn’t know recommended age of women to be
screened (Fig 4). Findings of the in depth interview observed that HSP did not fully addressed
recommended age of women to be screened.
6.8%
8.4%
8.4% All >18 years

15-49 years
6.8% 25-45 years

> 30 years
I don't know
69.9%
Figure4: Knowledge towards Cervical Cancer Screening Age of Women
23
5.7 Knowledge towards Cervical Cancer Screening Recommended Interval
The most frequently mentioned time interval for early detection and intervention was every one
year 28.4%, every six month 14.2%, every five year 12.1%, every six month to one year 7.4%,
every two year 5.8%, every three year 2.1%, every three to five year 1.6%, every three month
1.6%, one to two months after first screening 1.1% .Remarkably 25.7% of participants didn’t
know cervical cancer screening interval (Fig 5). Findings of the in depth interview revealed that
HSP did not fully addressed recommended screening interval for cervical cancer.
5.8 Attitude of Health Service Providers towards Cervical Cancer Screening
53.2% of female participants didn’t think they were susceptibleto cervical cancer and were not
willing to undergo screening, however 66.3% of respondents believeall women should undergo
screening for cervical cancer. About 7.8% of participants will recommend screening for women
who developed symptoms, 52.2% of respondents recommend screening for women who weren’t
sexually active and 61.7% of respondents believed all clients who visited MSIE centers are
eligible for cervical cancer screening.Approximately71.7% and 82.2% believed that manual
pelvic and speculum exam is important for cervical cancer screening respectively. However
46.8%of female participants were susceptibleto cervical cancer and will undergo for screening
themselves.
All IDI’s respondents explained that all women should undergo screening for cervical cancer at
its early stage for early detection and prevention. Eventually, all respondents mentioned that
cervical cancer can be treated hundred percent if the detection is done at its early stage. However
lack of national cervical cancer prevention and control guideline and focus of msie and donors
were towards core businesses like safe abortion, family planning and safe motherhood which
might affect focus towards cervical cancer.
Some professionals may not be aware of that women are at risk of getting cervical cancer and
they should undergo for regular screening.One of the area managers said that:
“…..I think providers not provide necessary information to clients about cervical cancer
screening availability in our center or other health facility might be due to lack of training,
knowledge and confidence ….”
24
5.9Practice of Health Service Providers towards Cervical Cancer Screening
Among all female respondents only34.9% and 19.8% wives/partners of male respondents have
ever screenedfor cervical cancer. Only 28.9%, 37.4% and 28.4% of respondents ever done pelvic
and speculum examination and cervical cancer screening respectively.
Participants mentioned ,not having symptom, not feeling at risk, not giving attention, not
sexually active, not having awareness about cervical cancer, not eligible, lack of access, fear of
procedure, self-protection from risk factors, not comfortable with speculum and pelvic area
procedure, had Hysterectomy as a reason of not screened for cervical cancer.
All IDIs respondents witnessed that cervical cancer screening uptake is very low, it may not be
nil. The common factors that all IDIs explained for low practices for cervical cancer are giving
no attention,lack of access to the services and lack of trained human resources.
One of the area managers said that:
“….. may be due to high work/ client load at MCH and some busy center, providers not give
attention about cervical cancer seriousness and screening services to themselves and eligible
clients….”
25
6. DISCUSSION
In general, our study identifiedhigh Knowledge, Attitude and Practices gap and misconception,
towards cervical cancer screening among Health Service Providers of Marie Stopes International
Ethiopia, Centers.
Unavailability of systematic screening program the expected practice is to opportunistically
screen eligible women when they come to centers for other sexual reproductive health services or
referred from health facilities. In the opportunistic screening system, the onus is on the health
worker who handles the eligible women to offer screening or refer her to a facility where
screening could be done. The majority of respondents in our study were nurses, who form the
bulk of medical workers in most health facilities.
Though Ethiopia as country has already recognized cervical cancer as one of major public health
problem and shows some promising start up to address the problem like development of
guideline for cervical cancer prevention and control January 2015.
The study has tried to assess participant’s knowledge pertaining to risk factors for cervical
cancer. 52.6% of respondents mentioned multiple sexual partners as one of the risk factor for
cervical cancer. Similarly around 49.7% of the respondents had mentioned Sexually Transmitted
Infection (STI) as one of the risk factor for cervical cancer, another 28.1%, 10% and 14.6% were
mentioned smoking, HIV infection and HPV as risk factor for cervical cancer respectively.
Only small number of participants was aware that HPV infection can lead to cervical cancer.
These results show inadequate knowledge of HPV infection being the cause of cervical cancer in
health professionals in our center. The finding is not consistent with study conducted on
knowledge and awareness about cc and its prevention amongst interns and nursing staff in
tertiary care hospitals in karachi, Pakistanshowed 98% of cervical cancer in our part of the world
is due to HPV infection (30).
The study finding is not consistent with study conductedamong nursing staff in Surat Gujarat
Indiateaching hospital, onknowledge, attitudes and practices about cervical cancer and
screeningat which majority of the respondents have mentioned multiple sexual partners (61.5%)
as one of risk factor for cervical cancer. Similarly according to this study, more than a third of
the respondents mentioned that Human Papilloma Virus infection (38.6%) as one of risk factor
for cervical cancer followed by and heredity (31%) (9).
26
On the other hand study conducted in Haitian health care workers, revealed, that majority of the
respondent have mentioned HPV infection (73.1%) as one of the risk factor for cervical
screening followed multiple partners (57.7%) and smoking (53.9%) respectively (21).
Similar study conducted oncervical cancer knowledge and screening behaviors among female
university graduates of year 2012 attending national graduate orientation program, Bhutan found
that 53% of the respondents agreed that multiple sexual partners increased the risk of getting
cervical cancer and in contrary 53% of the respondents knew sex at an early age as risk factor for
cervical cancer. About 26% of the respondents were aware of the history of cervical cancer
among close family relatives as a risk factor(28).
Another study conducted on Cervical Cancer Screening amongst Nurses in Lagos University
Teaching Hospital, Lagos, Nigeria and found similar result that 54% of the respondents
associated cervical cancer with having multiple sexual partners, however in the contrary 47.5%
linked cervical cancer with having sex at early age, while 52% of the respondents understood
human papillomavirus to be a causative agent in cervical cancer. Again, 18.5% and 19.5% of the
respondents felt that excess alcohol and smoking could cause cervical cancer, respectively.
Almost 85.5% and 95% respondents were aware of the preventability and detectability of
cervical cancer respectively (29).In the contrary study conducted on Knowledge and Awareness
about Cervical Cancer and its Prevention amongst Interns and Nursing Staff in Tertiary Care
Hospitals in Karachi, Pakistan found 61% of the respondents knew that Human Papilloma Virus
(HPV) as the risk factor for cervical cancer (30).
Similarly the study has also tried to assess the study participants’ knowledge towards the sign
and symptom of cervical cancer. Accordingly the most frequently mentioned sign and symptom
was vaginal bleeding 63.8%, foul smelling vaginal discharge 52.8%, post coital bleeding 39.9%,
Dyspanurea 38%. This result is similar with the qualitative findings of the IDIs. The knowledge
level of the study participant on this specific parameter is totally different from a study
conducted on, Knowledge, attitude & practices about cervical cancer and screening among
nursing staff in a teaching hospital, Surat, Gujarat, India, at which majority of the respondents
mentioned foul smelling discharge (73.5%) as one of sign for cervical cancer, followed by post
coital bleeding (45%) and post-menopausal bleeding (44.5%) as signs and symptom of cervical
cancer (9).
27
In the contrary study conducted on knowledge and awareness about cervical cancer and its
Prevention amongst interns and nursing staff in tertiary care hospitals in karachi, pakistanfound
the most common presenting complain reported was lower abdominal pain 42% and per vaginal
bleeding 40%, while few thought discharge 20%, fever 15% and menstrual irregularity could
also be the initial symptoms patients with cervical cancer can present with(30).
Only 7.9% of health service providers had ever attended training towards cervical cancer
screening,similar with the qualitative findings of the IDIs.For countries suffering with high
burden of the disease like Ethiopia, the figure seems very low and showed how the centers are
less equipped to deal with the problem. For instance according to cross-section study conducted
on knowledge, attitude and practice on cervical cancer and screening among female health
workers in India by Chennai corporation, of the total 107 interviewed health workers, about
40% of the participants have ever attained the training (19 ).
50% of study participants believed that cervical cancer a major public health problem in
Ethiopia. But descriptive study on knowledge, attitude and practice on cervical screening among
medical workers of Mulago, Uganda revealed 93% of the respondents know that cancer of the
cervix was a public health concern (21). Similarly the awareness level of the disease burden for
this study participant was found to be low compared to a study conducted on awareness of HPV
transmission and cervical cancer prevention among Cameroonian healthcare worker which is
86%(17).Another study conducted in Haitian health care workers found their level of knowledge
about cervical cancer and prevention is 69.2%, but stated they didn’t feel they had adequate
knowledge.100% of participants correctly stated that cervical cancer is one of the leading causes
of death in women worldwide (21).
Although, the study hastried to assess participant’s knowledge about cervical cancer screening.
Accordingly around 86.8% of participants believed that screening can detect cervical cancer
even before the symptoms appear. And this finding is almost similar with cross-section study
conducted on knowledge, attitude and practice on cervical cancer and screening among female
health workers in India by Chennai Corporation where 81.7% of the respondents believed that
screening can detect cervical cancer even before the symptoms appear (19). Similarly, a study
conducted in Haitian health care workers, revealed that, when asked if it is possible to detect pre-
cancerous cervical cancer cells, 81.5% correctly stated that was true (21).
28
Similar study conducted on Cervical Cancer Screening Amongst Nurses in Lagos University
Teaching Hospital, Lagos, Nigeriaalso found 85.5% were aware of the preventability and
detectability 95% of cervical cancer (29).
Regarding to study participant’s knowledge on different screening methods, 62.1%, 31.1% and
4.7% of them mentioned Pap smear, VIA/ VILI and colposcopy respectively. However few
numbers of respondents wrongly mentioned punch biopsy 6.8% and Loop electrosurgical
excision procedure (LEEP) 2.6% as a cervical cancer screening techniques. The level of
knowledgeof respondents seems low compared to study conducted on cross-sectional study
conducted on knowledge, attitude and practice on cervical cancer and screening among female
health workers in Indi by Chennai Corporation which is 95.3 %(19).
The level of knowledge among female university graduates of year 2012 seems higher compared
toscreening behaviors attending national graduate orientation program, Bhutanwhich is 53%
(28).
In the contrary study conducted on knowledge and awareness about cervical cancer and its
prevention amongst interns and nursing staff in tertiary care hospitals in karachi, pakistan75% of
both interns and nurses mentioned Pap smear as a screening test for cervical cancer. However,
Biopsy 8%, ultrasound 3%, HVS (2%) and Radiological scans 10% were few of the incorrect
responses observed(30).
The most mentioned recommended age of women for cervical cancer screening was 15 to 49
and 25 to 45 years old which actually comprises same figure which was 8.4 %.On the other hand,
6.8 % of the respondents mentioned > 30 years and another 6.8 % of the respondents mentioned
that all women >18years are eligible for screening. Remarkably 69.6% didn’t know age group of
women to be screened, which is complemented by result from IDIs;
one of the area managers said that:
“….. amazing to hear this because we assume ourselves as best sexual reproductive health
provider in the country but on the contrary with this huge number of health service providers
and different professions….”
Unlike this study finding,more than 63.2% of the respondents suggested that screening should
start for women > 30 years of age according to cross-section study conducted on knowledge,
attitude and practice on cervical cancer and screening among female health workers in Indi by
Chennai Corporation (19).
29
Another study conducted on acceptability and correlates of primary and secondary prevention of
cervical cancer among medical students in southwest china implications for cancer
education 32% stated that women should start to undergo screening from the age of 25 (31).
Time interval for cervical screening was also assessed, according to the study finding majority of
the participants most frequently mentioned interval for early detection and treatment was every
one year 28.4% and every five year 12.1% respectively. Howeverevery six month 14.2%, every
six month to one year 7.4%, every two year 5.8%, every three year 2.1%, every three to five year
1.6%, every three month 1.6% and one to two months after first screening 1.1% were mentioned
by the participants. Remarkably 25.7% of participants didn’t know cervical cancer screening
interval.They believed that Pap smear should be done once in one, two, three years or lifetime by
67.5%, 8.5%, 14% and 7.5% respectively. Sixty three percent nurses felt the need of doing Pap
in women above 18 years (9).
Another study conducted on acceptability and correlates of primary and secondary prevention of
cervical cancer among medical students in southwest china implications for cancer
education 49.2% felt women should receive screening every year(31).
Generally 66.3% of participants believed that all women should undergo cervical cancer
screening. Again 58.4% participants believed all clients who visited MSIE are eligible for
screening. Although 7.4% and 49.5% believed that cervical cancer screening is recommended for
a women after she developed a symptom and for sexually inactive women respectively. Similarly
67.9% and 77.9% believed pelvic exam and speculum exam is important for cervical cancer
screening respectively.
As a result of high misconception about cervical cancer and screening, only 46.8% consider
themselves at risk of cervical cancer, similarly 46.8% of respondents consider they will undergo
screening for cervical cancer, however65.1% of female participants have never undergone
cervical cancer screening, which is complemented by result from IDIs;
one of the area managers said that:
“…..I think providers not provide necessary information to clients about cervical cancer
screening availability in our center or other health facility might be due to lack of training,
knowledge and confidence ….”
30
Again another area manager said that:
“….. due to high work load at MCH center, there mightnot give attention about cervical cancer
seriousness and screening services to themselves and eligible clients….”
Similarly study conductedamong nursing staff in Surat Gujarat Indiateaching hospital,

onknowledge, attitudes and practices about cervical cancer and screening reveled 70% nurses
never underwent Pap smear; most common reasons being not thought about it (28.6%) or no time
for it (17.8%). Similar findings of surprisingly low uptake of cervical screening are shared by
authors who have conducted studies on utilization of cervical screening services by health
workers (9).
Similar study conducted in Uganda health workers (physicians, nurses and others), revealed that
65% of female health workers who are eligible for screening did not think they were susceptible
to Cervical Cancer, and 81% had never been screened (22).This low uptake rate is very similar to
other studies conducted among health care workers (25, 26).
Another study conducted in Nigeria at Usmanu Danfodiyo University Teaching Hospital Sokoto,
with doctors, nurses, pharmacists, laboratory scientists and medical social workers supports the
above mentioned issues. Assuming the knowledge of these workers about cervical cancer would
be high and they would have taken the screening tests for themselves. However, the results of the
study revealed that only 4.4% of the respondents had ever undergone the screening tests
themselves (23).
Among the female respondents, the reason for not having screening includes: not having
symptom, not feeling at risk, not giving attention, not sexually active, lack of awareness about
cervical cancer , not eligible, lack of access, fear of procedure, self-protection from risk factors,
not comfortable with speculum and pelvic area procedure, Hysterectomy done. And majority of
the reasons mentioned in this study are similar to study conducted on knowledge, attitudes and
practices on cervical cancer screening among the medical workers of Mulago Hospital, Uganda
(22), and in India at Chennai Corporation among female health workers (19).
31
6. STRENGTH AND LIMITATION OF STUDY
6.1 Strength
 Health professionals focused study in order to motivate role modeling provision
 Practicality and feasibility of self-administered approach
 Volunteering and participation of all MSIE health service providers in the study
 Triangulation of both quantitative and qualitative study methods
6.2 Limitation of the study

 TheKAP survey was conducted among health service providers of MSIE centers. Hence,
the findings do not reflect the level of Knowledge, Attitudes and Practices of health
service providers working in other health institutions
 Semi structured questionnaire wasdifficult to measure KAPof respondents
 Shortage of literatures in similar topics especially for resource poor countries
 As best explanatory method qualitative study with health service providers would
identify important factors
 Misreporting by respondents cannot be ruled out
7. CONCLUSION AND RECOMMENDATIONS

The overall findings of this study came up with high KAP gap and misconception towards
cervical cancer screening.
The information reported here also presents valuable guidance on the improvement of cervical
cancer screening implantation in the healthcare delivery systems of MSIE.
32
7.1 Conclusions
Knowledge towards Cervical Cancer
 The knowledge of providers about cervical cancer with regard to its public health concern
in Ethiopia is not good
 Even if cervical cancer is well-known as one of the health issue in Ethiopia, the readiness
for the available trained human resources is minimal
 The most well-known and leading risk factors for cervical cancer are multiple sexual
partners, Sexually Transmitted Infection (STI), smoking, HIV infection and HPV
 Thewell-known symptoms of cervical cancer are irregular vaginal bleeding, foul smelling
vaginal discharge, post coital bleeding, and dyspanurea
 The most well-known cervical cancer screening techniqueswas Pap smear and VIA/VILI
 Significant number of providers doesn’t know recommended age of women to be
screened andrecommended cervical cancer screening interval
Attitudes towards cervical cancer screening
 There is a strong beliefthat all women should undergo screening for cervical cancer.
 They believed that manual pelvic exam and speculum exam is important for cervical
cancer screening.
 On the contrary, more than half of female respondents believed that they are not at risk of
getting cervical cancer and won’t undergo for screening.
Practices regarding cervical cancer screening
 Onlyone third of participants had ever screened for themselves,less number of

participants ever done manual pelvic exam, speculum examination and cervical cancer
screening.
The common factors for low practices for cervical cancer are not having symptom, feeling not at
risk, not giving attention, lack of access,not sexually active, fear of speculum and pelvic area
procedure and Hysterectomy.
33
7.2 Recommendations
In this study it is evident that there have been activities to be retained, improved and included in
the process of implementation ofcervical cancer screening. Based on the findings of this study
results the following points are recommended.
 Health care practitioners need to be targeted first for cervical cancer screening because
of their essential role in the implementation of any future screening programs and in
their educative role with patients
 HSP need to be trained to provide health education services and will become a role
model to motivate and change others attitudes and practices
 Dissemination of health information on risk factors for cervical cancer like multiple
sexual partners, Sexually Transmitted Infection (STI), smoking, HIV infection and
HPV is very important
 Improve clinical skill of providers in the determination of age group of women to be

screened and cervical cancer screening interval through basic and refreshment training
 Conduct awareness raising campaign on cervical cancer in collaboration with partners.
 All partners should also focus on service expansion to maximize access to the service,
so as to minimize missed opportunities
 Further studies should be done, to understand and identify the cause of HSP, KAP gap
and misconceptions towards cervical cancer screening to find possible interpretation to
change them
34
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24. McFarland DM. Cervical cancer and Pap smear screening in Botswana: Knowledge and
perceptions. IntNurs Rev 2003;50:16775.
25. WHO. Policies and managerial guidelines for national cancer control programs. Rev
PanamSaludPublica. 2002;[PubMed].12(5):366–370.
26. Udigwe GO. Knowledge, attitude and practice of cervical cancer screening (Pap smear)
among female nurses in Nnewi, South Eastern Nigeria. Niger J ClinPract 2006; 9:40‑3.
27. Gharoro EP, Ikeanyi EN. An appraisal of the level of awareness and utilization of the Pap
smear as a cervical cancer screening test among female health workers in a tertiary health
institution. Int J Gynecol Cancer 2006; 16:1063‑8.
28. Tshering D, Pandup Cervical cancer knowledge and screening behaviors among female
university graduates of year 2012 attending national graduate orientation program,
Bhutan. BMC Womens Health. 2014; 14: 44.
29. O. Awodele et al. A Study on Cervical Cancer Screening Amongst Nurses in Lagos
University Teaching Hospital, Lagos, Nigeria. J Cancer Educ. 2011 Sep; 26(3): 497–504.
30. Syed F et al, Knowledge and Awareness about Cervical Cancer and Its Prevention
amongst Interns and Nursing Staff in Tertiary Care Hospitals in Karachi, Pakistan. PLoS
One. 2010; 5(6): e11059.
31. Xiong-Fei P, et al. Acceptability and Correlates of Primary and Secondary Prevention of
Cervical Cancer among Medical Students in Southwest China: Implications for Cancer
Education.PLoS One. 2014; 9(10): e110353.
37
APPENDICES
Annexes 1- Survey questionnaire (English)
Part I- Consent form
Hello, my name is ___________ and I am a student at Addis Ababa University School of

Public Health, currently conducting a research to assess Knowledge, Attitude and Practice on
Cervical Cancer screening among health service providers of MSIE Centers. Thus, I am
requesting your cooperation to fill out the survey question which will take about 15 minutes to
complete. Participation in this survey will be voluntary, and if you don’t want to participate or if
there is any question you don’t want to answer you can skip to the next, or if you choose not to
participate you could withdraw at any time. I assure all information that you provide will remain
strictly private, and confidentiality of responses would be maintained during and after data
collection. Only numbers will be assigned to each copy and no name will be required on the
questionnaire. The numbers would facilitate data entry and analysis, so no one can link your
identity with the registration numbers. Your individual answers will not be discussed with the
staff members. Findings from this research are believed to serve practitioners to design
evidencebased programs. Moreover studies in similar topics which may be conducted in a
different scale and depth can make use this study as a spring board.
I hope you will participate in the survey as your feedbacks are important. Thank you for your
willingness to be my study participant and taking time to fill study questionnaire.
If you need further clarification about the survey, please contact me any time via
+251911417858 or email: [email protected]
38
Section 1: Background characteristicsof health service providers
S.No Questions Response Skip

1 What is your gender? 1.Female
2.Male
2 How old are you?
-----------------------
3 What is your marital 1.Single If you are

status? 2.Married / in union not married
3.Divorced go to
question
4.Widowed
number 5
4 At what age you were
married? -----------------------
5 What is your profession? 1.Gynecologist / Obstetrician

2.General practitioner
3.Health officer
4.Nurse
5.Midwife
6.Laboratory technician
6 What is your total in
service year duration both --------------------------------------
at MSIE and other health
facilities?
7 Have you ever attended

training related to cervical 1.Yes --------------------
cancer? If yes by whom
and when? When ----------------------
2.No
39
Section 2: Knowledge of health service providers towards cervical cancer
S.No Question Response Skip
1 Do you believe Cervical 1.Yes

cancer is a public health 2. No
problem in Ethiopia 3.I don’t know
context?
2 Do you believe level of 1.Yes

cervical cancer is high 2. No
in Ethiopia? 3.Difficult to describe due to few studies
4.I don’t know
3 List predisposing and risk
factors to acquire cervical
cancer?
4 List symptoms of
cervical cancer?
40
Section 3: Knowledge of health service providers towards cervical cancer
screeningprocedures,recommended age and screening intervals
1 Do you believe cervical

cancer screening can 1.Yes
detect cervical cancer 2.No
even before symptoms 3.I don’t know
appear?
2 List types of cervical
cancer screening -----------------------------------
techniques
3 In which groups of
women do you ---------------------------------------
recommend cervical
cancer screening?
4 How frequently would
you recommend cervical ---------------------------------------------
cancer screening? And ---------------------------------------------
why?
41
Section 4: Attitude of health service providers towards cervical cancer screening
1 Do you perceivesusceptibility of 1.Yes If you are male

getting cervical cancer? 2. No go to question
3.I don’t know no.3
2 Will you undergo screening for 1.Yes
cervical cancer? If your answer is no 2. No -------------------------------
write your reason on space provides. 3.I don’t know
3 Do you think all women should 1.Yes------------------------

undergo screening for cervical 2. No------------------------
cancer? Why? 3.I don’t know
4 Do you recommend cervical cancer 1.Yes
screening only when a woman 2. No
developed a symptom? 3.I don’t know
5 Do you recommend cervical cancer
1.Yes
screening for a woman who is not 2. No
sexually active? 3.I don’t know
6 Do you perceiveall women clients

1.Yes ----------------------------
who visited MSIE centers are 2. No ----------------------------
susceptible for Cervical Cancer 3.I don’t know
screening? Why?
7 Do you perceivehaving a pelvic

1.Yes
exam is important for Cervical 2. No
Cancer screening? 3.I don’t know
8 Do you perceive having a speculum

1.Yes
examination is important for 2. No
Cervical Cancer screening? 3.I don’t know
42
Section 5: Practice of health service providers towards cervical cancer screening

1 Have you ever had a 1. Yes If you are male go to question
Cervical Cancer screening? 2.No--------------------- no.2, 3, 4 and 5
If no why?
2 Have your wife or partner 1.Yes If you are female go to

ever had Cervical Cancer 2. No question no.3, 4 and 5
screening? 3.I don’t know
3 Have you ever done pelvic 1.Yes If you are laboratory

exam for Cervical Cancer 2. No----------------------- technician go to question no. 5
screening? If no why?
4 Have you ever done 1.Yes
speculum exam for Cervical 2. No--------------------
Cancer screening?
If no why?
5 Have you ever done Cervical 1.Yes
Cancer screening? 2. No---------------------
If no why?
43
Annexes 2. Guide for in- depth Interview with area managers- Qualitative part of study
Qualitative part
Greetings,……….I am currently doing a research to assess Knowledge, Attitude and Practices

on cervical cancer screening among health service providers of MSIE Centers to fulfill my
thesis. I am here to interview you some issues which enable us to triangulate the quantitative
findings of KAP study from MSIE health service providers. Your response to this interview will
remain confidential and anonymous.
Area of Interviewee: ----------------------------------------------------------------
Position/designation of Interviewee: -------------------------------------------------------
Sex of Interviewee: Male Female
Age (completed years): ---------- Years
No. of years of service in the organization: ------------ Years
Highest level of Educational qualification: ---------------------------
Date of interview: / /2015
Name of interviewer: ---------------------------------------------------
Thank you for your participation in the interview.
1. Would you tell us about your position and experience?
2. How would you describe the service provision towards cervical cancer screening at
MSIEservice delivery points?
3. How do you describe capacity of health service providers at MSIE centers?
4. What are the challenges during service provision?
44
Annexes: 3Amharic questionnaires
ሇማሪስቶፕስኢንተርናሽናልኢትዮጲያየጤናማዕከልአገልግሎትሰጭባሇሙያዎችስሇቅዴመየማህፀንነቀርሳምርመራያሊቸ
ውንእውቀት፣ግንዛቤናየአጠቃቀምሁኔታሇመገምገምየተዘጋጀመጠይቅ
ክፍል 1፡የስምምነትማረጋገጫቅፅ
ጤናይስጥልኝ፣እኔ____________________በአዱስአበባዩኒቨርስቲየህብረተሰብጠናአጠባበቅተማሪነኝ፡፡ይህጥናትናም
ርምርበማሪስቶፕስኢንተርናሽናልኢትዮጲያየጤናማዕከልአገልግሎትሰጭባሇሙያዎችስሇቅዴመየማህፀንነቀርሳምርመራ
ያሊቸውንእውቀት፣ግንዛቤናየአጠቃቀምሁኔታሇመገምገምየተዘጋጀመጠይቅነው፡፡ከዚህጥናትምየሚገኘውውጤትሇባሇሙ
ያዎችበማስረጃየተዯገፈእቅዴሇማቀዴናበዚሁዙሪያተመሳሳይጥናትሇማከናወንሇሚፈልጉአጥኚዎችእንዯመንዯርዯሪያነት
ያገሇግሊልተብሎይታሰባል፡፡
ይህንንበፍቃዯኝነትሊይየተመሰረተመጠይቅሇመሙሊት 15
ዯቂቃየሚፈጅብዎትሲሆንሇመሳተፍካልፈሇጉአይገዯደም፣እንዱሁምመሳተፍከጀመሩበኋሊበማንኛውምጊዜአቋርጠውመ
ውጣትይችሊለ፡፡
ሇጥያቄዎቹየሚሰጥዋቸውመልሶችበሙለሚስጥራዊነታቸውየተጠበቀይሆናል፡፡ስሇዚህስሇማንነትዎእናስሇሚሰጥዋቸው
መልሶችበምስጥርመጠበቅምንምአይነትስጋትአይግባዎ፡፡የእርስዎበዚህጥናትውስጥተሳታፊመሆንሇጥናቱበተሳካሁኔታ
መጠናቀቅብቻሳይሆንሇማህፀንበርነቀርሳቅዴመምርመራዘዳአገልግሎትመሻሻልከፍተኛአስተዋፅኦስሇሚኖረውበዚህጥናት
ውስጥእንዱሳተፉበአክብሮትእጠይቃሇሁ፡፡
ሇተጨማሪመረጃበስልክቁጥር 0911417858 ወይምኢሜይል [email protected]

ሉያገኙኝይችሊለ፡፡በጥናቱሇማሳተፍፈቃዯኛኖት?
እሳተፋሇሁ __________________
አልሳተፍም _________________
ሇመሳተፍፍቃዯኛከሆኑወዯቀጣዮቹጥያቄዎችይሇፉ፡፡ሇመሳተፍፈቃዯኛካልሆኑዯግሞአመስግነውጥያቄውንያ
ቋርጡ፡፡
45
ክፍል 1:የተጠያቂው አጠቃሊይየማህበራዊመረጃየተመሇከተመጠይቅ
ተ ጥያቄዎች መልስ እሇፍ

ራ
ቁ.
1 ጾታዎምንዴነው? 1.ሴት
2.ወንዴ
2 እዴሜዎስንትነው? ____________
3 የጋብቻዎሁኔታምንዴነው? 1. ያሊገባ ካሊገቡናወንዴከሆ
2. ያገባ ኑወዯ 5ኛው
3. የተፋታ ጥያቅይሇፉ፡፡
4. በሞትየተሇየ
4 በስንትአመትሽነውያገባሽው? _____________
5 የሙያዎአይነትምንዴነው? 1. የፅንስናማህፀንእስፔሽያ
ሉስት
2. ጠቅሊሊሀኪም
3. የጤናመኮንን
4. ነርስ
5. አዋሊጅነርስ
6. የሊቦራቶሪቴክኒሽያን
6 በሙያዎትበጠቅሊሊውሇምንያህልጊዜአ _______________
ገልግሇዋል?
7 የማህፀንበርነቀርሳ (Cervical 1. አዎ
cancer) መቼ?__________
ስልጠናሊይተካፈሇውያውቃለ? በማን?___________
__
2. አይ
46
ክፍል 2:የማህፀን በርነቀርሳየእውቀትዯረጃንየሚዲስስመጠይቅ
ተራ ጥያቄዎች መልስ እሇፍ

ቁ.
1 በኢትዮጵያየማህፀንበርነቀርሳ (Cervical cancer)
የሕብረተሰብጠናችግርመሆኑንያውቃለ? …………………………………
ካወቁስየበሽታውንጉዲትበየትኛውዯረጃይመዴቡታል?
………………………………….
2 ሇማህፀንበርነቀርሳየማያጋልጡምክንያቶችንዘርዝር
3 የማህፀንበርነቀርሳበሽታምልክቶችንዘርዝር
ክፍል 3:የማህፀን በርቅዴመካንሰርምርመራአይነቶችንየሚዲስስመጠይቅ
ተ ጥያቅዎች መልስ እሇ
ራ ፍ
ቁ.
1 የCervical cancer _________________
ምርመራማዴረግየበሽታውምልክቶችከመታየታቸውበፊትማ ____
ወቅያስችሊል?
2 የማህፀንበርነቀርሳመመርመሪያዘዳዎችንዘርዝር _________________
____
3 በምንአይነትሁኔታሊይሊለሴቶችየcervical cancer
ምርመራንይመክራለ?
4 የcervical cancer
ምርመራንበየስንትጊዜውማረግጥሩነውይሊለ? ሇምን?
ክፍል 4:የማህፀን በርቅዴመካንሰርምርመራፍሊጎትንእናእምነትንየሚዲስስመጠይቅ
47
ተ ጥያቅዎች መልስ እሇፍ
ራ
ቁ.
1 ሇማህፀንበርካንሰርተጋሊጭነኝብሇውያስባለ? 1. አዎ ወንዴከሆንክወዯጥ
2. አይ ያቄቁጥር 3 እሇፍ
3. አሊውቅም
2 የማህፀንበርካንሰርምርመራማዴረግአሇብኝብሇውያ 1. አዎ
ስባለ? 2. አይ……………
መልሶአይከሆነምክንያቶንባድቦታውሊይይፃፉ፡፡ ……….
3. አሊውቅም
3 ሁለምሴቶችየcervical cancer 1. አዎ……………
ምርመራማዴረግአሇባቸውብሇውይመክራለ? ………..
ሇምን? 2. አይ……………
………...
3. አሊውቅም
4 የcervical cancer 1. አዎ
ምርመራመዯረግያሇበትየበሽታውምልክትከታየበኃ 2. አይ
ሊብቻነውብሇውያስባለ? 3. አሊውቅም
5 ወሲብየማትፈፅምሴትየcervical cancer 1. አዎ
ምርመራማዴረግአሇባትብሇውይመክራለ? 2. አይ
3. አሊውቅም
6 በMSIEክሉኒኮችህክምናያገኙሴቶችበሙለሇcervi 1. አዎ……………
cal cancer ………..
ምርመራእጩናቸውብሇውያስባለ?ሇምን? 2. አይ……………
………...
3. አሊወቅም
7 የማህፅንምርመራ (Pelvic exam)ሇcervical 1. አዎ
cancer ምርመራአስፈሊጊነውብሇውያስባለ? 2. አይ
3. አሊውቅም
8 የማህፀንበርማያመሳሪያ (Speculum 1. አዎ
examination) ሇcervical cancer 2. አይ
ምርመራአስፈሊጊነውብሇውያስባለ? 3. አሊውቅም
ክፍል 5:የማህፀን በርቅዴመካንሰርምርመራማዴረግንየሚዲስስመጠይቅ
ተ ጥያቅዎች መልስ እሇፍ

ራ
ቁ.
1 የcervical cancer 1. አዎ ወንዴከሆንክወዯጥያቄቁጥር
ምርመራአዴርገውያቃለ?ሇምን? 2. አይ…………….. 2፣ 3፣ 4 እና 5 እሇፍ
48
2 ባሇቤትዎ/ጓዯኛዎየcervical 1. አዎ ሴትከሆንሽወዯጥያቄቁጥር
cancer 2. አይ 3፣ 4፣ 5 እሇፊ
ምርመራአዴርገውያውቃለ? 3. አሊውቅም
3 ሇcervical cancer 1. አዎ የሊቦራቶሪባሇሙያከሆኑወዯ
ምርመራሇመጣችሴትየማህፅንም 2. አይ……………… ጥያቄቁጥር 5 ይሇፉ
ርመራ (Pelvic exam) …….
ሰርተውያውቃለ?
መልስዎአይከሆነልምን?
4 ሇcervical cancer 1. አዎ
ምርመራሇመጣችሴትየማህፀንበ 2. አይ………………
ርማያመሳሪያ (Speculum …..
examination)ሰርተውያውቃለ?
መልስዎአይከሆነልምን?
5 የcervical cancer 1. አዎ
ምርመራአገልግሎትሰጥተውያው 2. አይ………………
ቃለ? መልስዎአይከሆነልምን? ..
DECLARATION
I, the undersigned, declare that this is my original work has never been presented in this or any
other university and that all source material used for the thesis has been duly acknowledged.
49
Name: Bogalech Fufa
Signature……………
Place: Addis Ababa
Date of submission: June 12, 2015
This thesis has been submitted for examination with my approval as a University Advisor:
Name: Dr.MulugetaBetre
Signature…………………
Date: June 12, 2015
50

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ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCES

Assessment of Knowledge, Attitudes and Practices on Cervical Cancer Screening among

A thesis submitted to the School of Graduate Studies of Addis Ababa University in

Addis Ababa, Ethiopia

Assessment of Knowledge, Attitudes and Practices on Cervical Cancer Screening among

A thesis submitted to the School of Graduate Studies of Addis Ababa University in

1. Dr. MulugetaBetre (Supervisor): ………………………….……

2. ……………………. (Examiner): ………………………………

3. ................................. (Examiner): ………………………….……

June 2015 Addis Ababa, Ethiopia

I would like to thank my beloved family, especially mydaughter TatanyaAberraand my son

Table1:Summary of MSIE Regions, Centers and Health Service Providers ............................................ 11

Figure1: Knowledge towards Cervical Cancer Risk Factors........................................................20

Key Words: Knowledge,Attitude, Practice, Cervical Cancer, Ethiopia

However, in low-and middle-income countries (LMICs), only approximately 5% of eligible

1.2 Problem Statement

1.3 The Expected outcome

2.1Overview of Cervical Cancer Screening

2.2 Knowledge of cervical cancer screening

2.3 Attitude of cervical cancer screening

2.4 Practices of cervical cancer screening

3.2 Specific objective

4.3 Data source and study population

Table1.Summary of MSIE Regions, Centers and Health Service Providers

Addis Ababa Arada,Gulele,Kirkos,Choice,

4.4 Data Collection Instrument

4.6 Operational definition

4.4 Data collection

5.1 Background Characteristics of Health Service Providers

Table 2: Background Characteristics of Health Service Providers

Table3: Knowledge towards Burden of Cervical Cancer

Variable Number Percentage (N=190)

20.00% 17.5% 17%

Figure1: Knowledge towards Cervical Cancer Risk Factors

20.00% 16.6% 16%

Figure2: Knowledge towards Cervical Cancer Symptoms

Figure3: Knowledge towards Cervical Cancer Screening Procedure

8.4% All >18 years

6.8% 25-45 years

Figure4: Knowledge towards Cervical Cancer Screening Age of Women

one of the area managers said that:

Similarly study conductedamong nursing staff in Surat Gujarat Indiateaching hospital,

6.2 Limitation of the study

 Semi structured questionnaire wasdifficult to measure KAPof respondents

 Shortage of literatures in similar topics especially for resource poor countries

 Misreporting by respondents cannot be ruled out

7. CONCLUSION AND RECOMMENDATIONS

Attitudes towards cervical cancer screening

Practices regarding cervical cancer screening

 Onlyone third of participants had ever screened for themselves,less number of

 Improve clinical skill of providers in the determination of age group of women to be

 Conduct awareness raising campaign on cervical cancer in collaboration with partners.

7. World Health Organization. Cervical Cancer Screening in Developing Countries. World

Hello, my name is ___________ and I am a student at Addis Ababa University School of

S.No Questions Response Skip

3 What is your marital 1.Single If you are

5 What is your profession? 1.Gynecologist / Obstetrician

7 Have you ever attended

1 Do you believe Cervical 1.Yes