Knowledge on cervical cancer, attitude toward its screening, and associated factors among reproductive age women in Metu Town, Ilu Aba Bor, South West Ethiopia, 2018: community‐based cross‐sectional study

Abstract Background Cervical cancer is one of the major public health problems worldwide. Lack of awareness and unavailability of screening services are the major factors that contribute to the problem of cervical cancer in Ethiopia. The community‐based study conducted regarding the knowledge and attitude toward cervical cancer among women of reproductive age group is not enough to indicate the problem. Aim To assess the knowledge on cervical cancer, attitude toward its screening, and associated factors among women of reproductive age. Methods A community‐based cross‐sectional study with a mixed approach method was conducted from April to May 2018. The sample size calculated for this study was 420. A systematic random sampling technique was used to select study participants. A binary logistic regression model was used to determine the association between the covariate and the dependent variable. Result Of all participants, 31% have good knowledge of cervical cancer, and 57.8% have a positive attitude toward cervical cancer screening. In a multivariable analysis, educational status, occupation, visiting health facilities, and parity were significantly associated with knowledge and attitude toward cervical cancer screening. Conclusion This study suggests increasing women's awareness, health education on cervical cancer in the community, and health institutions should be strengthened. Patient and public contribution Female health workers were involved in the data collection process. Educated women and women who are community health leaders were involved as Interviewees for the qualitative part of the study. However, they have no direct contributions to authorship.


| INTRODUCTION
Cervical cancer is an abnormal growth of cells in the lining of the cervix.
The most common cause of cervical cancer is the human papillomavirus (HPV) infection. Cervical cancer is one of the major public health problems of women worldwide. 1,2 Globally, cervical cancer is the leading cause of cancer death in sub-Saharan Africa, Latin America, and many Asian countries. 3 It is the fourth most common cancer with an estimation of 570,000 cases and 311,000 deaths in 2018 and the most diagnosed cancer and the leading cause of death in 42 countries. Regionally, the highest incidence of cervical cancer is seen in Africa, with an increased rate in southern, Eastern, and Western Africa, respectively. 4 The incidence of cervical cancer varies among countries of the world. The incidence and death rate in East Africa and West Africa is five times higher than in North Africa. 5,6 The incidence is increasing in African countries. However, knowledge and awareness about cervical cancer are very poor and mortality due to cervical cancer is high. In addition to this weak health system, lack of health care infrastructure, lack of screening service, and lack of trained health care workers exacerbate the cervical cancer problem. 4,7 The majority of women report that they want to be screened, that is positive attitude, for cervical cancer; however, they complain about lack of screening services. [8][9][10][11] In Ethiopia, cervical cancer is the second most common cancer in women.
According to the estimation of 2012, annually 7,095 cervical cancer cases are diagnosed and 4,732 cervical cancer death is occurred in Ethiopia. 12 Based on 2013 data from the Addis Ababa cancer registry, cervical cancer accounts for about 14.3% of all cancer cases. 13 A higher proportion of cervical cancer is recorded in Addis Ababa, Oromia, and Amhara regions (32.98%, 30.11%, and 19.72%, respectively). 14 In Ethiopia, lack of awareness, competing health interests (like Malaria, TB, HIV, etc.), unavailability of cervical cancer screening services, and treatment are the major factors that contribute to the problem of cervical cancer. Recently, few studies showed that lack of awareness is the major factor that influences the knowledge concerning cervical cancer and its screening. 15 Also, there is a gap of information on factors associated with the knowledge and attitude of women toward cervical cancer.
The objective of this study was to assess the knowledge and attitude of women on cervical cancer and what factors can influence this knowledge in Mettu town, Ethiopia. The findings of this study provide additional information about the level of knowledge and attitude among women in the community on cervical cancer that can help program planners and health educators to design targeted and tailored strategies to increase cervical cancer knowledge and potentially increase cervical cancer screening uptake in Ethiopian.

| Study design and setting
A community-based cross-sectional study design with mixed approach (Quantitative and Qualitative) methods was used to assess knowledge about cervical cancer and attitude toward its screening among women of reproductive age in Mettu town Ilu Aba Bor Zone, Oromia Region, Ethiopia from April to May 2018. The town is the capital of the Ilu Aba Bor Zone, which is located 600 km away from Addis Ababa and located in the southwestern part of the Oromia region. Administratively, Mettu town is subdivided into three Kebeles (unpublished Mettu town administration reportort of 2017). A kebele is the smallest administrative unit in Ethiopia Data S1.

| Study participants
The source population was women of reproductive age (15 to 49) years in Mettu town and the study population was all sampled women of reproductive age who live in the selected house holds.

| Quantitative part
The required sample size for the quantitative study was estimated by using single population formula (n = (Z α/2) 2 P (1 − P)/d 2 ) based on the following assumptions; the proportion of good knowledge of cervical cancer (53.7 %) from the study conducted in Hossana town 16 and at 95% Confidence level, 5% margin of error and 10% non-response rate.
Thus, the final sample size was 420. A systemic random sampling method was used to selects households and women for interviews.

| Qualitative part
A purposive sampling technique was used. A total of 15 key informants were selected by the authors based on their age, educational level, and responsibilities, and experience. Thus, educated women (secondary and above), women above 25 years of age, employed women, and women who are community health leaders were selected.

| Data collection tools and procedures
A pre-tested structured interviewer-administered questionnaire was used to collect the quantitative data from the study participants. The questionnaire was designed based on the study objectives and adapted from related different survey tools and literature. 10,[16][17][18] It was first prepared in English and was translated to the local language (Afan Oromo) and back-translated to English to check for its consistency. All data collectors and supervisors were well trained on the data collection procedure. Day-to-day supervision was carried out for the entire length of the data collection.For the qualitative part, an indepth interview (IDI) with a semi-structured interview was conducted.
Selected key informants were asked about cervical cancer, its risk factors, its prevention as well as their attitude toward cervical cancer screening.

| Data processing and analysis
For the quantitative part, the collected data were checked, coded, and entered into Epi-Data version 3.1 and then exported to SPSS 20 for analysis. Frequencies and cross-tabulations were used to summarize descriptive statistics. The associated factors were assessed by the Binary logistic regression model. Odds Ratio estimated with 95% CI to show the strength of association and Pvalue < .05 was used to declare statistical significance.For the qualitative study, explanatory sequential mixed methods were used.
Each IDI was tape-recorded and note taken. The data, which were recorded with the audiotape, were transcribed verbatim, translated, and coded. After transcribing, similar themes of the qualitative information were arranged by using thematic analysis and were triangulated or explored with the quantitative finding.

| Study variables
Knowledge of cervical cancer and attitude toward cervical cancer screening are dependent variables. Whereas, socio-demographic factors (age, education of a mother, education of husband, marital status, occupation of a mother, occupation of husband), health servicerelated factors (ever visit health institution, use modern contraceptive, ever had HIV test, history of STI), obstetrics factors (parity, history of abortion), and socioeconomic factors (monthly income) are independent variables.

| Measurement
Knowledge: Ten questions regarding knowledge about the cause (risk factors), symptoms, treatment options, and prevention methods of cervical cancer were taken. Those score above and equal to 5(≥50%) was considered as good knowledge and those score below 5(<50%) was considered as poor knowledge. 19,20 Attitude: Was assessed by eight questions on a Likert scale of five scores. These five scores are Strongly Disagree, Disagree, Neutral, Agree, and Strongly Agree. The mean score was calculated to use as a cut point. 21 3 | RESULTS (32.2%) and 88(21.5%), respectively.Nearly two-thirds (65.4%) of the participants were Oromo followed by Amhara (21%) and

| Health service-related and obstetrics factors
More than three-fourth (79.5%) of the respondents were ever used modern contraceptives in their lifetimes. More than three-fourth (79.3%) of the respondents were ever visited health facilities for any service at least once ( Table 2).

| Factors associated with knowledge of cervical cancer
The bivariate analysis showed that socio-demographic factors, obstetric, and health service-related factors were seen by bi-variable logistic regression analysis. Age, marital status, educational status, occupation,  21 This result is inconsistent with the study conducted in the Republic of democratic Congo and Dessie Town. The difference might be due to the nature of the population and socio-cultural difference. 23,26 In this study, educational status and parity were significantly associated with attitude toward cervical cancer screening. This study is consistent with a study conducted in China, India, and Gondor Town, Northwest Ethiopia, and Dessie Town. 17,19,22,23 This is possible since educated women know the advantage of screening. Parity is also associated with a positive attitude in this study.

| CONCLUSION
This study underlines that overall knowledge about cervical cancer is low. Also, 57.8% of the participants have a positive attitude toward cervical cancer screening. The result of this study showed that educational status, occupation, visiting health facilities, and parity are factors associated with knowledge about cervical cancer. Increasing women's awareness, health education on cervical cancer should be strengthened.

ACKNOWLEDGMENT
We would like to extend our heart full gratitude to the Mettu University, Department of Public Health for giving ethical clearance for this study.
Our special thanks also go to the data collectors, supervisors, and all study participants for their time and willingness to participate in the study.