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Background
Cancer of the cervix is the second most common cancer among women worldwide, with about over 660 000 new cases and approximately ninety-four percent of the 350 000 cervical cancer-related death happened in low- and middle-income countries. Effective screening initiatives are particularly crucial in preventing cervical cancer in women. Therefore, the purpose of this systematic literature review was to investigate the pooled prevalence of Ethiopian female healthcare professionals' cervical cancer screening utilization.
Methods
Published articles were searched from different major international databases (PubMed, Cochrane Library, Scopus, Web of Science, Since Direct, Google Scholar). Direct Google searches were used for additional sources mainly for gray and preprint studies. This review included studies that reported either the use of cervical cancer screening or cervical cancer screening predictors in Ethiopia. All published and unpublished studies through May/2024 and reported in the English language were retrieved to assess eligibility for inclusion in this review. The Newcastle-Ottawa Scale quality assessment tool was used to assess the quality of the included studies and Egger's test was used to assess the publication bias.
Results
In order to calculate the pooled prevalence of cervical cancer screening, 2,919 female healthcare professionals participated in the review. Articles were published from 2015 to 2024. The pooled Utilization of cervical cancer screening in Ethiopia, as determined by a meta-analysis of ten articles was 13.59% (95% CI: 7.53, 19.65).
Conclusion and recommendation
The estimated/pooled cervical cancer screening utilization was found to be lower than the World Health Organization recommendations as the estimator revealed in the meta-analysis. The low utilization of Cervical Cancer (CCa)screening practice despite they are healthcare professionals is a significant concern that can impact the broader efforts to combat cervical cancer. Based on the this reviews the authors recommend regular monitoring and evaluation of the CCa screening habits of healthcare professionals and the effectiveness of implemented interventions. It is necessary to explore the factors that enable or hinder CCa screening and address the issue through qualitative or mixed-method studies.
cervical cancer screeningutilizationhealthcare professionalssystematic reviewmeta-analysisEthiopiansection-at-acceptanceMaternal HealthIntroduction
Cervical Cancer(CCa) is the second most common cancer among women worldwide, with over 660 000 new cases and approximately ninety-four percent of the 350 000 cervical cancer-related death happened in low- and middle-income nations (1, 2). In low- and middle-income countries (LMICs), including Ethiopia, cervical cancer is the commonest cancer affecting reproductive organs and also the leading cause of death from cancer among women. Studies 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 (2, 3).
Comprehensive cervical cancer control methods, such as primary prevention (HPV vaccination), secondary prevention (screening and treatment of pre-cancerous lesions), tertiary prevention (diagnosis and treatment of invasive cervical cancer), and palliative care, can therefore be used to prevent it (4, 5). These precautions haven't, however, been applied consistently throughout and among nations. Only forty-four percent of women in LMICs were screened for CCa, with Sub-Saharan African women having the lowest prevalence (5). In high-income countries, the percentage of women who were screened for the disease is greater than 60%. While in Ethiopia the proportion of CCa screening was very low (15.79%) as reported in 2021 (6, 7).
Effective screening initiatives are particularly crucial in preventing CCa in women who have not had a vaccination (7). In conjunction with prompt and effective treatment of precancerous lesions, the World Health Organization (WHO) recommends screening women aged 30–49 years through visual inspection with acetic acid (VIA) in low-resource settings, a Papanicolaou test (cervical cytology) every 3–5 years, or HPV testing every 5 years (7, 8).
Ethiopia's first cancer prevention and control strategy was released in 2015 (9). VIA and cryotherapy, which were determined to be practical and suitable screening and treatment modalities, have been used in a “screen-and-treat” approach (10). CCa screening utilization is still low (11–15) even after this approach has been put into practice. This can be attributed to a number of factors, including low knowledge (16), negative attitude (17), inadequate diagnostic facilities (18), an unstructured referral system (19), poor infrastructure (20), and being young women (21). Women belonging to the lower social class, life style practiced by women such as sexual and hygienic behavior, increased parity, smoking, early initiation of sexual intercourse, multiple sexual partners among couples, that can expose to Human papilloma virus (HPV) which is a major cause of cervical cancer have been identified as a risk factor in other studies (22–24). HPV with different variants like type 16, 18, 31, 33, and 45 are mostly related with invasive carcinoma of the cervix. Thus, infection with HPV will alter the nature of cervical cell that can be detected early if there is adequate screening technique (24, 25).
The crucial issue is that all individuals and couples should have access to comprehensive, high-quality reproductive healthcare and services, including the prevention of CCa, and that using these services is essential to the socioeconomic advancement and general well-being of all Ethiopian citizens, particularly women. If a woman has CCa and is diagnosed and treated promptly, screening can save her life. In order to save lives and lessen the suffering that many women with CCa endure, it is essential that all medical professionals to advocate for this service. Therefore, the purpose of this systematic literature review was to investigate Ethiopian female healthcare professionals' use of cervical cancer screening.
MethodsData sources and search strategies
The aim of this systematic literature review and meta-analysis was to estimate the pooled uptake of CCa screening utilization among female healthcare professionals in Ethiopia. The findings of this review have been reported according to the recommendation of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA-P) 2009 statement checklist (26). Published articles were searched from different major international databases (PubMed, Cochrane Library, Scopus, Web of Science, Science Direct, Google Scholar), and direct Google hand searches were used for additional sources mainly for gray and preprint studies. The Population, Exposure, Comparison and Outcome (PECO) search formula was used to retrieve the articles. All original published and unpublished studies done to determine the prevalence of CCa screening utilization in Ethiopia were extracted to be included in this study. The outcome of interest was the pooled prevalence of uptake of CCa screening among female healthcare professionals. For each of the selected components of PECO, electronic databases were searched using the key words search and the medical subject heading (MeSH) terms. The keywords include “uptake, utilization, cervical cancer, screening, healthcare professional and Ethiopia”. The search terms were combined by the Boolean operators “OR” and “AND”. The specific searching detail in PubMed was putted as ((cervical cancer screening) AND (practice)) OR (utilization)) OR (uptake)) OR (experience)) OR (exposure)) AND (healthcare provider)) OR (healthcare worker)) OR (healthcare professional)) OR (healthcare personnel)) OR (health worker)) AND (Ethiopia)).
Eligibility criteria and study selection
This review included studies that reported either the use of CCa screening or CCa screening among female health care professionals in Ethiopia. All published and unpublished studies conducted in female health care professionals through first May, 2024 and reported in English language were retrieved to assess eligibility for inclusion in this review. However, this review excluded studies that were case reports, surveillance data (demographic health survey), and abstracts of conferences, articles without full access and the main outcome of interest not reported. The article selection underwent several steps. Two reviewers evaluated the retrieved articles for inclusion using their title, abstract and full text review. Disagreement during the selection process between the reviewers were resolved by consensus after detail discussion. Full texts of selected articles were then evaluated using the eligibility criteria. During the encounter of duplication, only the full-text article was retained.
Quality assessment and data collection
The Newcastle-Ottawa Scale (NOS) quality assessment tool was used to assess the quality of the included studies. The tool contains three components; selection of the study groups, comparability of the study groups, and ascertainment of exposure or outcome (27). The tool's core component, which was rated on a five-star scale, focused mostly on each primary study's methodological quality. The tool's other component, which was rated between two stars, focused mostly on how comparable each study was. The tool's final component, which was rated from three stars, was used to assess each original study's statistical analysis and findings. Three category criteria totaling a maximum of nine points were included in the NOS. Each study's quality was evaluated using one of the following scoring algorithms: studies with a score of greater than or equal to seven were deemed “good,” those with a score of four to six were deemed “moderate,” and those with a score of less than or equal to three were deemed “poor.” This systematic review result is more valid now because only primary studies of medium to good quality have been included. Using a defined data extraction format, the two reviewers (MA and AW) independently evaluated the publications for overall study quality and extracted data. Primary author, publication year, study region, sample size, prevalence, and the chosen predictors of cervical cancer screening use were all included in the data extraction format.
Publication bias and statistical analysis
Using the Egger's (28) and Begg's (29) tests with a p-value of less than 0.05, the publication bias was evaluated. The heterogeneity between studies was evaluated using the I2 statistic and there was no heterogeneity within the included articles. Microsoft Excel was used to extract the data, which were then exported to Stata version 11 for analysis.
ResultsStudy identification and characteristics of included studies
Both published and unpublished research on the usage of CCa screening among female health care professionals in Ethiopia were included in this systematic review and meta-analysis. A total of 540 research articles were found throughout the assessment procedure. After thorough assessment 410 publications were checked based on their titles and abstracts and 130 duplicate data were removed. After that, the eligibility of 19 full-text papers was assessed based on the inclusion and exclusion criteria. Consequently, three studies were excluded because they failed to provide the expected results (14, 30, 31), one due to low quality (32), and five because the research population was different (16, 33–36). Ten studies were included in the final quantitative meta-analysis (Figure 1).
PRISMA flow diagram of cervical cancer screening uptake in Ethiopia.
Characteristics of the included studies
All the studies included in this review were cross-sectional, and all ten studies were facility-based cross-sectional studies (FBCS). In order to calculate the pooled prevalence of CCa screening, a total of 10 original articles which comprise 2, 919 female health care professionals were included. All the Original articles included in this study were published from 2015 to last May 2024 despite there were no publication year limitation during filtering related studies. From the studies included in this review, the largest sample size was 442 healthcare professionals (37), while the smallest sample size was 164 from a study conducted in other area of Amhara (38).
The studies were distributed as follows: two were conducted in Addis Ababa, three in Amhara, one each in Oromia, Tigray, Sidama, Central Ethiopia region, and one in three different areas of Ethiopia (Addis Ababa, Adama and Bahir Dar). From the total articles included in this review 70% of them were applied simple random sampling (SRS) technique (Table 1).
Characteristics of studies included in meta-analysis, Ethiopia.
Authors
Publication year
Study area
CCa screening practice (%)
Design
Sample size
Sampling technique
Gebrie et al. (39)
2015
Addis Ababa
8.5
FBCS
275
SRS
Tesfaye et al. (40)
2024
Addis Ababa
18.5
FBCS
293
SRS
Aytenew et al. (38)
2024
Amhara
28.1
FBCS
164
SRS
Kress et al. (41)
2015
Ethiopia
17
FBCS
217
Purposive
Jemal et al. (42)
2023
Central Ethiopia
19.6
FBCS
241
SRS
Gebreegziabher et al (43)
2016
Tigray
10.7
FBCS
242
Purposive
Abebaw et al. (37)
2022
Amhara
8.7
FBCS
442
SRS
Melese et al. (44)
2023
Oromia
14.7
FBCS
266
SRS
Dulla et al. (45)
2017
Sidama
11.4
FBCS
367
SRS
Amare et al. (46)
2022
Amhara
14
FBCS
412
Purposive
FBCS, facility-based cross-sectional; SRS, simple random sampling.
Meta-analysis of cervical cancer screening uptake in Ethiopia
The highest CCa screening uptake was seen in South Gondar hospitals in Amhara region at 28.1% (38). In contrast, the lowest was 8.5% in a study done at Addis Ababa (39) and 8.7% in a study done in the Amhara region (37). The aggregated national level of CCa screening utilization, as determined by a meta-analysis of ten articles, was 13.59% (95% CI: 7.53, 19.65) (Figure 2).
Pooled prevalence cervical cancer screening utilization among healthcare professionals in Ethiopia.
Publication bias was assessed using egger's test (Figure 3) and Funnel plot by prevalence of cervical cancer screening practice shows symmetrical distribution (Figure 4).
Publication bias analysis using Egger's publication bias plot.
Publication bias by prevalence of cervical cancer screening practice.
Discussion
In Ethiopia, the use of CCa screening programs is not widely established. Nevertheless, the WHO advises that screening tests for CCa be a part of carefully thought out and executed initiatives in every nation's health care strategy. This systematic review aimed to provide a comprehensive estimate of the pooled prevalence of CCa screening uptake among female healthcare professionals in Ethiopia. Consequently, 13.59% (95% CI: 7.53, 19.65) was the pooled national level of CCa screening usage.
The result of the review was consistent with 12.87% in Sub-Saharan Africa (47), 12.70% in India (48), 17% in Nepal (49),19.4% in Kenya (50), 13.46%, 8.11%, and 14.79% in Ethiopia (6, 51, 52). The review results, indicating a prevalence of CCa screening utilization among female healthcare professionals, align with several regional studies, suggesting a consistent trend across various developing regions.
The current review result was lower than 41.0% in Africa (53), 21.4% in China (54), 26.2% in Saudi Arabia (55), and 24.2% in Nigeria (56). This disparity might be due to the demographic characteristics, study settings, and the quality of medical services and screening initiatives. The possible reason might also be the low-risk perception of the healthcare professionals and fear of positive results. The explanation for this could be healthcare professionals not to have been trained to conduct CCa screening were less likely to have positive attitude towards CCa prevention activities (57).
The findings of this literature review also showed that highest CCa screening uptake was seen in South Gondar hospitals in Amhara region and the lowest was in study done at Addis Ababa. The reason might be the difference in the period of study. As the study period difference increases, the interplay of different factors also increase and the practice too (38, 39). Regional variation in the burden of CCa screening in Ethiopia might be explained by the difference in maternal health care service utilization that could be explained by in the difference in spousal support, cultural and linguistic diversity across the regions and societal stigmatization. Additionally, attitude of health care staff may vary by region or other factors may contribute to the difference such as age, educational level, etc. Furthermore, Ethiopia presents varied picture with prevalence across different studies. These variations within the same country might reflect regional disparities, differences in study methodologies, or temporal changes in factors influencing prevalence of practice.
Overall, the review's findings show both parallels and discrepancies with the stated prevalence in a number of comparable regions. These differences highlight how crucial it is to take local factors and context into account when tackling health issues. Furthermore, they contend that although there may be broad patterns, localized factors have a major influence on prevalence rates and ought to be the center of customized interventions and policies.
Limitation of the review
This systematic review and meta-analysis on CCa screening utilization among female healthcare professionals in Ethiopia has its own limitations. Firstly, it includes only ten studies from six regions, which may affect the representativeness of the findings and limit the generalizability of the conclusions to a national level. The absence of studies from other regions leaves potential regional disparities unaddressed. Secondly, the review relies exclusively on quantitative data, without incorporating qualitative studies that could offer deeper insights into the factors facilitating or hindering CCa screening. As a result, while the review provides valuable quantitative estimates, the lack of qualitative analysis restricts a comprehensive understanding of the underlying factors influencing screening behaviors. These limitations underscore the need for further research to provide more representative and holistic insights.
Conclusion and recommendations
Cervical cancer is the leading cause of cancer deaths in women in the developing world. Despite, new technologies have been developed to allow for more rapid, cost-effective, and sensitive cervical cancer screening, the utilization of these technologies and services remain minimum. The cervical cancer screening rate was determined to be lower than the WHO recommendations based on this literature review. The low utilization of CCa screening among female healthcare professionals is a significant concern that can impact the broader efforts to combat cervical cancer. Despite their medical knowledge and access to healthcare resources, many healthcare professionals are not engaging in regular screening practices. This underutilization not only jeopardizes the health of the healthcare professionals but also sets a poor example for patients and the community, potentially undermining public health campaigns aimed at increasing screening rates. Based on the this reviews the authors recommend regularly monitor the screening rates among healthcare professionals and evaluate the effectiveness of implemented interventions. Conducting qualitative study to find out underlying reasons for deigning interventions in order to improve utilization and adjust interventions accordingly is also crucial. Through the identification and synthesis of findings from accessible primary studies, this study offers evidence to support policy and program activities and also help the stakeholders and policy makers to consider holistic approaches to address different segments of the eligible population.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author/s.
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Abbreviations
CCa, cervical cancer; CI, confidence interval; FBCS, facility based cross-sectional; HPV, human papillomavirus; LMIC, low- and middle-income countries; MeSH, medical search heading; NOS, newcastle-ottawa scale; OR, odds ratio; PECO, population exposure comparation outcome; SRS, simple random sampling; VIA, visual inspection with acetic acid; WHO, World Health Organization.
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