Utilization of cervical cancer screening and associated factors among women in Debremarkos town, Amhara region, Northwest Ethiopia: Community based cross-sectional study.

INTRODUCTION: Cervical cancer is the most common type of malignancy among all malignancies for women worldwide with 266 000 deaths every year. Even though there is a proven importance of cervical cancer screening, the death of women due to cervical cancer in Ethiopia is high. We, therefore, did this study to investigate the utilization of cancer screening and its associated factors among women in Debremarkos town, Amhara region, Ethiopia.
METHODS: A community-based cross-sectional study was conducted among women from 30-49 years in Debremarkos town, from July 1 to August 30, 2018. A multistage sampling procedure was used to select 822 women in the study. We used EPI info version 7 for data entry and SPSS version 24 software for cleaning and analysis. Bivariable and multivariable logistic regression analyses were performed to identify factors associated with the utilization of cervical cancer screening. Variables with a p-value of less than 0.05 were taken as significant variables. RESULT: The study revealed that 44 (5.4%) of women have been screened for cervical cancer. Women's age [AOR:3.126(1.246,7.845)], marital status (AOR:3.41(1.299,8.972)], educational status(secondary education level [AOR: 4.578(95% CI: 1.19, 17.65)] and College and above education level [AOR:7.27,95%CI: 2.07,25.513)]), started sexual intercourse for the first time below 16 years[AOR:3.021(1.84,4.97)], history of multiple sexual partners [AOR:2.51(1.040, 6.06)], history of sexually transmitted disease [AOR:4.04(1.68, 9.72),], knowledge on cervical cancer screening [AOR:4.02(2.07,7.77)] and attitude towards cervical cancer screening [AOR:3.23(2.52,4.12)] were significant factors for utilization of cervical cancer screening.
CONCLUSION: This study showed the magnitude of the utilization of cervical cancer screening is very low. Women's age, marital status, educational status, age at first sex history of multiple sexual partners and sexually transmitted disease, knowledge and attitude were important factors of screening. Therefore, intervention programs that are aimed at improving cervical cancer screening practice among women should focus on the identified factors.

Introduction

Cervical cancer is the most common malignancy among all malignancies for women worldwide [1]. In 2012, about 266, 000 deaths occurred due to cervical cancer worldwide and 90% of cases occurred in Low and Middle-Income Countries (LMICs); the highest was occurred in Sub Saharan Africa (SSA) where cervical cancer is the leading killer among women[2]. In Ethiopia,7095 cases and 4732 death of cervical cancer occur every year [3].

Cervical cancer screening has been proven to be a very effective prevention strategy for cervical cancer [1, 4, 5]. The United States Preventive Services Task Force (USPSTF), the American Cancer Society (ACS) World Health Organization (WHO) guidelines state screening for cervical cancer once within lifetime reduces significantly the risk of mortality from cervical cancer and incidence of advanced cervical cancer [6-8]. The WHO recommended age for cervical cancer screening should be limited to women the age of 30 to 50 years since there is evidence on younger age women with a milder degree of lesion spontaneously recover to normal [5, 9, 10].

Ethiopia adopted the WHO guideline and advised women to start cervical cancer screening at age of 30–49 years at least one to three years interval with the approach of seeing and treat through Visual Inspection under Acetic acid (VIA) as screening strategy and cryo-therapy as a treatment method[1, 4, 5, 11].

Despite the importance of screening, a high incidence of cervical cancer is still a big problem and a major cause of morbidity and mortality of women in LMICs especially in SSA [12, 13] and the lowest cervical cancer screening rate found in Ethiopia which accounts below 1% [14].

Therefore, the main aim of this research was to identify factors affecting cervical screening utilization and recommend ways to increase screening utilization by the community.

Methods

Study area and period

This study was conducted in Debremarkos town, Amhara region, Northwest Ethiopia from July 1 to August 30, 2018. Debremarkos town is the capital city of East Gojjam Zone that is found in the Amhara region, North West Ethiopia, which is located at 300 km from Addis Ababa, the capital city of Ethiopia and 265 km from Bihar Dar, the capital city of Amhara region. There are one referral hospital, three health centers and five non-governmental clinics that give different reproductive health services in the town. Only the government referral hospital gives cervical cancer screening services.

Study design

A community-based cross-sectional study design was employed.

Study participants

The source population was all women age 30–49 years old who were residents of Debremarkos town. The study population was women age 30–49 years old who were residents of Debremarkos town during the study period in the selected kebeles. We excluded women who are not permanent residents of the town (less than six months) and those who were critically ill during the data collection period.

Sample size

The sample size for prevalence was determined based on a single population proportion formula assumption. The expected proportion of cervical cancer utilization (19.8%) from the previous study in Ethiopia at Mekelle town[15]and a 3.5%confidence limit (margin of error) was used.

With considering design effect 1.5 since it had two stages and the sample size was calculated as498*1.5 = 747then the non-response rate was also considered to be 10%and 747*0.10 = 75.Then the final sample size was747+75 = 822.

Sampling techniques

A multistage sampling technique was used and firstly all the kebeles found in the Debremarkos town were listed in a frame. Then three out of the seven kebeles were selected by the lottery method. Again the list of households found and coded in each kebele. The size of households consisting of eligible population to be selected from each kebele was determined proportionally based on the size of the study units and the kth value was computed for each selected kebele. The woman of the selected household was interviewed and if there was more than one woman in the household, the lottery method has been used to select only one. In the case of absenteeism, after three repeated visits the next eligible woman was included in the study.

Study variables

Dependent variable

Utilization of cervical cancer screening

Independent variables

Socio-Demographic Characteristics, Reproductive and behavioral characteristics, and knowledge and attitude on cervical cancer and its screening.

Operational definitions

Utilization of cervical cancer screening

Refers to the proportion of persons eligible to be screened within a population who have been screened within 3 years for cervical cancer[15].

Multiple sexual partners

Those women who have ever had penetrative sexual intercourse with more than one partner in their life serially or at the same time [16].

Cigarette smoking

The active smoking or ever had a smoking history of women one or more manufactured or hand-rolled tobacco cigarettes per day which excludes passive smokers [17].

Knowledgeable

Women who answered knowledge questions score of mean value or above were considered as knowledgeable.

Favorable attitude

Women who answered attitude questions a score of mean value or above were considered to have a favorable attitude.

Data collection and data quality control

To assure the data quality, data were collected with face to face interviews by three trained BSc Midwives after one-day data collection training was given to them together with three MSc holder supervisors. The questionnaire was structured and pre-tested which was first prepared in English and translated to local (Amharic) language and then again translated back to English. A pretest was conducted on 42 women of the sample size in other than the study area and the necessary correction on the tool was employed accordingly.

Data processing and analysis

Epi Info version 7 software was used for data entry and SPSS version 24 for used for analysis. Bivariate logistic regression was employed to identify an association between independent and dependent variables. Variables having a P-value of less than 0.2 in the bivariate logistic regression analysis were fitted into the multivariable logistic regression model. The 95% confidence interval of odds ratio was computed and variable having P-value less than 0.05 in the multivariable logistic regression analysis was considered as statistically significant.

Ethical clearance

Ethical clearance was obtained from the Ethical Review Committee of the Department of Midwifery, under the delegation of the institutional review board of the University of Gondar. Ethical clearance and formal letters were also obtained from the University Gondar School of Midwifery and were submitted to Debremarkos health office and permission was obtained. Finally, written informed consent was also obtained from each study participant.

Results

Socio-demographic characteristics of the respondents

All 822 study participants responded to the questionnaire, giving a response rate of 100%. The mean age of the study participants was 36.81 years (36.81 ±5.14 SD). The majorities of women were Amhara 809 (98.4%), Christian religion 789 (96%) and married 768(64.8%). Two hundred thirty-one (28.1%) of the women have not attended formal education (Table 1).

Table 1

Sociodemographic characteristics of women (n = 822) age 30–49 in Debremarkos town, Northwest Ethiopia, 2018.

Variable	Frequency	Percent
Age of women
30–39	592	72
40–49	230	28
Marital status
Married	638	77.6
Others*	184	22.4
Religion
Christian	789	96
Muslim	33	4
Educational status
No formal education	231	28.1
Primary education	180	21.9
Secondary education	212	25.8
College and above	199	24.2
Ethnicity
Amhara	809	98.4
Others**	13	1.6
Occupation
Housewife	149	18.1
Self-employee (doing own small business)	309	37.6
Private employee(salaried in the nongovernmental sector)	192	23.4
Government employee	172	20.9
Household income ***
<900	166	20.2
900–1600	201	24.5
1601–2699	293	35.6
> = 2700	162	19.7

*Single, divorced and widowed,

**Oromo and Gurage,

***in Ethiopian Birr

Reproductive and behavioral characteristics

Two hundred one (24.5%) study participants first had sexual intercourse at age 16 and below. Women who had a history of multiple sexual partners (MSPs) within three years were 461 (56.1%). And 129 (15.7%) had a history of sexually transmitted disease (STD). Six hundred eighty-nine (83.8%) of the study participants had used modern family planning method at least for one year. Six hundred sixty-three (80.7%) got birth at least once. Around ninety-seven (11.8%) of respondents had a family history of cervical cancer and 17 (2.1%) of the respondents had also smoking history (Table 2).

Table 2

Reproductive characteristics of women (n = 822) age 30–49 in Debremarkos town, Northwest Ethiopia, 2018.

Variable	Frequency	Percent
Age started sexual intercourse (in years)	201	24.5
< = 16
>16	621	75.5
Multiple sexual partner
No	461	56.1
Yes	361	43.9
History of smoking
No	805	97.9
Yes	17	2.1
History of STD
No	693	84.3
Yes	129	15.7
Ever use a modern FP method
No	133	16.2
Yes	689	83.8
Duration of modern FP method use
1–4 years	530	76.9
> = 5 years	159	23.1
Family history of cervical cancer
No	725	88.2
Yes	97	11.8
Ever had got pregnant
No	127	15.5
Yes	695	84.5
Gravidity
1–5	529	76.1
>5	166	23.9
Ever had given birth
No	159	19.3
Yes	663	80.7
Parity
1–5	558	84.2
>5	105	15.8

Knowledge, attitude and utilization of cervical cancer screening

More than half of the respondents (59%) were knowledgeable about cervical cancer screening (Table 3). More than half of the respondents (57.4%) had a favorable attitude towards cervical cancer screening (Table 4). Forty-four (5.4%) of the study population have been utilized cervical cancer screenings a minimum of once within the last three years with [95% CI: 3.8, 7.1](Table 5).

Table 3

Knowledge about cervical cancer screening among women (n = 822) in Debremarkos town, Northwest Ethiopia, 2018.

Variable		Frequency	Percent
Ever heard about cervical cancer
No		130	15.8
Yes		692	84.2
Ever heard about cervical cancer screening
No		130	15.8
Yes		692	84.2
All eligible women can have cervical cancer screening without complication
No		327	39.8
Yes		495	60.2
Knew health institutions that give cervical cancer screening service
No		388	47.2
Yes		434	52.8
Knew symptoms of cervical cancer
No		740	90.0
Yes		82	10.0
Bleeding during sexual intercourse may be one of the signs of cervical cancer
No		740	90.0
Yes		82	10.0
Cervical cancer is a killer disease
No		281	34.2
Yes		541	65.8
Is cervical cancer preventable disease
No		379	46.1
Yes		443	53.9
Is cervical cancer curable disease
No		366	44.5
Yes		456	55.5
May have cervical cancer without any sign and symptom			s
No		480	58.4
Yes		342	41.6
Overall knowledge
	Knowledgeable	485	59
	Not Knowledgeable	337	41

Table 4

Attitude towards cervical cancer screening among women (n = 822) in Debremarkos town, Northwest Ethiopia, 2018.

Variables		Level of agreement
		Agree		Disagree		Indifferent
		Number	Percent	Number	Percent	Number	Percent
Any reproductive age woman is susceptible to develop cervical cancer		390	47.4	225	27.4	207	25.2
Like any women, you are susceptible to develop cervical cancer		372	45.3	248	30.2	202	24.6
Cervical Cancer can be transmitted genetically		111	13.5	454	55.2	257	31.3
Cervical cancer may be dangerous		481	58.9	180	22	156	19.1
Precancerous cervical screening may be beneficial to health		481	58.9	180	22	156	19.1
Cervical cancer screening is painful		436	53.4	153	18.6	233	28.3
Overall attitude		Frequency			Percent
	Favorable attitude	474			57.4
	Unfavorable attitude	348			42.6

Table 5

Utilization of cervical cancer screening among women (n = 822) in Debremarkos town, Northwest Ethiopia, 2018.

Screened at least once during the last three years		Frequency	Percent
	Yes	44	5.4
	No	778	94.6

Factors associated with utilization of cervical cancer screening

After controlling the effect of other variables with binary logistic regression, age, marital status, educational status, age start at first sexual intercourse, history of MSP, history of STD, duration of FP use, family history of CC, gravidity, knowledge, and attitude about CC screening continued to be significantly associated with utilization of cervical cancer screening (P-values<0.2).

After controlling the effect of other variables with multivariable logistic regression analysis, women’s age [AOR: 3.126 (95% CI: 1.246, 7.845)], marital status [AOR: 3.41 (95% CI: 1.299, 8.972)], education level (secondary education level [AOR: 4.578(95% CI: 1.19, 17.65)] and College and above education level [AOR:7.27,95%CI: 2.07,25.513)]), age started sexual intercourse for the first time [AOR:3.021(95%CI:1.84, 4.97)], history of MSP[AOR:2.51 (95% CI:1.040, 6.06)], history of sexually transmitted disease [AOR:4.04(95% CI:1.68, 9.72)], knowledge about cervical cancer screening [AOR:4.02,95% CI:2.07, 7.77)] and attitude about cervical cancer screening [AOR:3.23,95%CI;2.52, 4.12)] were significant factors for utilization of cervical cancer screening (Table 6).

Table 6

Bivariable and multivariable analysis of factors associated with utilization of cervical cancer screening among women in Debremarkos town, Northwest Ethiopia, 2018.

Variable	Utilized		Crude OR[95%CI]	AOR[95%CI]
	Yes	No
Age of women
40–49	31	199	6.938(3.56,13.52)	3.126(1.246,7.8)*
30–39	13	579	1	1
Marital status
Others**	15	169	1.864(1.09,3.557)	3.41(1.299,8.97)*
Married	29	609	1	1
Religion
Muslim	1	32	0.542(0.072,4.062)
Christian	43	746	1
Educational status
Primary education	7	173	1.295 (.446,3.761)
Secondary education	10	202	1.584(1.059,4.240)	4.578(1.19,17.6)*
College and above	20	179	3.575(1.479,8.645)	7.27(2.07,25.51)*
No formal education	7	224	1	1
Ethnicity
Others***	1	12	1.484(.189,11.682)
Amhara	43	766	1
Occupation
Self-employee	14	295	1.131(1.426,3.005)
Private employee	16	176	2.167(.826,5.681)
Government employee	8	164	1.163(.394,3.430)
Housewife	6	143	1
Household income****
900–1600	10	191	1.686(.565,5.033)
1601–2699	18	275	2.108(.768,5.785)
> = 2700	11	151	2.346(.796,6.909)
<900	5	161	1
Age started sexual intercourse for the first time
< = 16	24	177	4.075(2.483,6.717)	3.021(1.84,4.97)*
>16	20	601	1	1
Multiple sexual partner
Yes	30	331	2.894(1.511,5.544)	2.511(1.04,6.06)*
No	14	447	1	1
History of smoking
Yes	2	15	2.422(.536,10.94)
No	42	763	1
History of STD
Yes	18	111	4.160(2.208,7.840)	4.037(1.68,9.72)*
No	26	667	1	1
Ever use a modern FP method
Yes	34	655	.638(.307,1.326)
No	10	123	1
Duration of modern FP method usage
> = 5 years	18	141	3.433(1.746,6.68)	1.771(.711,4.41)
1–4 years	19	511	1	1
Family history of cervical cancer
Yes	8	89	1.720(1.041,4.218)	1.897(.701,5.134)
No	36	689	1	1
Ever had got pregnant
Yes	39	656	1.451 (.517,3.101)
No	5	122	1
Gravidity
>5	19	147	3.469(1.790, 6.72)	1.421(.58, 3.47)
1–5	19	510	1	1
Ever had given birth
Yes	35	628	.929(.437, 1.974)
No	9	150	1
Parity
>5	7	98	1.257(.540,2.958)
1–5	30	528	1
Knowledge
Knowledgeable	31	454	1.702(1.01,3.29)	4.02(2.07, 7.77)*
not knowledgeable	13	324	1	1
Attitude
favorable attitude	33	439	2.317(1.81, 2.96)	3.225(2.52,4.12)*
unfavorable attitude	11	339	1	1

*p-value less than 0.05,

**single, divorced and widowed,

***Oromo and Gurage,

**** in Ethiopian Birr

Discussion

This study was conducted to assess the cervical screening practice among women in Debremarkos town, northwest Ethiopia. Accordingly, the study found that only 5.4% of women had cervical cancer screening practice. Similarly, factors like women’s age, marital status, education level, and age at first sexual intercourse below 16 years old, history of STDs, knowledge, and attitude towards cervical cancer screening were significantly associated with utilization of cervical cancer screening.

The study finding of cervical cancer screening utilization (5.4%) in the current study was in-line with similar reports in Arbaminch town, Southern Ethiopia(5.9%)[18]. The finding of this research was lower than the studies done at Addis Ababa, Ethiopia(10.8%) [19], at Mekelle town, Northern Ethiopia(19.8%) [15], at Hadiya Zone, South Ethiopia (9.9%)[20], in Ethiopia (17%) [21], Kenya(16%)[22]and Nigeria (11%) [23].The possible explanation for this might be the difference in the age of study population; the difference in the study area; the difference in the health status of the study population; the difference with sample size; the difference with the level of knowledge and attitude of the study population.

The finding of this study was also higher than studies done in Ethiopia (2.9%) [17] and Southern Ghana (0.8%) [24]. The possible explanation might be the difference in the study area and study population; the difference in the age of the study population.

As shown in this study, women’s age was one of the significant factors for the utilization of cervical cancer screening. Women in their age 40–49 years were 3.126 times more likely to utilize cervical cancer screening as compared to women in their age of 30–39 years [AOR:3.126(95% CI:1.246, 7.845)]. This finding was supported by the studies done in Northern Ethiopia, Addis Ababa, Southern Ethiopia, Ethiopia and Malawi [15, 17, 18, 25, 26]. The possible explanation for this might be like women's age increases the probability of getting information about cervical cancer and its screening will be increased which leads them utilized cervical cancer screening service. The other explanation also might be increasing risk with women’s age leads the women to have more contact health facilities.

Marital status was also one of the significant predictors for the utilization of cervical cancer screening. This study showed that women who were single/divorced/widowed 3.414 times more likely utilized cervical cancer screening as compared with married women [AOR:3.414,(95%CI:1.299,8.972)]. This result was supported by the study done in Thailand [27]. The possible explanation for this might be single women are more likely educated since they might be young and divorced women or widowed women are a more likely aged and increasing risk with women's age leads the women to have more interest to visit health facilities.

Educational status was also the main significant factor for the utilization of cervical cancer screening. Women who took college & above education 7.268 times more likely utilized as compared with women who did not take formal education [AOR: 7.268(95% CI:2.071,25.513)].Similarly, Women who attended secondary education 4.578 times more likely utilized as compared with women who did not attend formal education [AOR: 4.578 (95% CI: 1.187,17.649)]. This study was supported by the study done in Ethiopia and Kenya [17, 22]. This might be explained with, as the level of education increases, the women will have the chance to know about cervical cancer and its screening.

Age at first sexual intercourse was a significant predictor for the utilization of cervical cancer screening. Women who had started sexual intercourse with their age of 16 years and below were 3.021 times more likely to utilize cervical cancer screening as compared to those women who had started sexual intercourse after their age of 16 years[AOR: 3.021 (95%CI; 1.84, 4.97)]. The possible explanation for this might be women who started sexual intercourse at an early age, may have increased lifetime sexual partners which in turn increase the chance of being infected with sexually transmitted infection (STI) and STD with its signs and symptoms which lead to visit health facilities. No literature found to compare with this study because it is sensitive to issue information biases might occur which was tried to avoid these biases in our study with care full interviewing technique.

This study finding showed that woman who had a history of MSPs was another important factor for utilization of cervical cancer screening. Women who have had a history of MSPs were 2.51 times more likely to utilize cervical cancer screening as compared to those who did not MSP [AOR: 2.51(95% CI: 1.040, 6.062)]. This study was supported by the result of a study done in Addis Ababa, at Mekelle, Malawi, and Thailand [15, 25–27]. The possible explanation might be women, who had MSP history, would have the chance to be infected with STIs with its signs and symptoms which increases health facility visits.

The current study result showed that a woman who had a history of STD was another important factor in the utilization of cervical cancer screening. Women who have had a history of STD were 4.037 times more likely to utilize cervical cancer screening as compared to those who did not have STD history [AOR: 4.037, (95%Cl: 1.68, 9.72)]. This result was supported by the finding from Addis Ababa and Northern Ethiopia [15, 25]. The above association might be explained by women who have STDs and history of STD, will have an increased chance of visiting health institutions for treatment and other medical help.

Women’s knowledge about cervical cancer screening was another significant factor in the utilization of cervical cancer screening services. Women who were knowledgeable about cervical cancer screening were 4.02 times more likely to utilize cervical cancer screening service as compared to those who were not knowledgeable [AOR:4.02 (95% CI:2.07, 7.77)]. This finding was supported by the result of studies done in Northern Ethiopia, Malawi, Tanzania, and Thailand [15, 26–28]. The above reports might be explained by increasing the level of women’s knowledge about the benefits of screening directly lead the women to utilize cervical cancer screening.

Similarly, women’s attitude about cervical cancer screening was also a significant factor for utilization of cervical cancer screening service. Women who had a favorable attitude about cervical cancer screening were 3.225 times more likely to utilize cervical cancer screening service as compared to those who had unfavorable attitudes [AOR:3.225 (95%CI:2.52, 4.12)]. This study was supported by a study done in Northern Ethiopia, Southern Ethiopia, Southern Ghana and Thailand [15, 18, 24, 27]. The above reports might be explained with women who have a favorable attitude towards cervical cancer screening will have self-initiative to know about cervical cancer risk factors and benefits of its screening.

Conclusion

This study showed the magnitude of the utilization of cervical cancer screening was lowin Debremarkos town, Northwest Ethiopia. Age of the women, marital status, and educational status, age at first sexual intercourse, history of multiple sexual partners and sexually transmitted disease, knowledge and attitude were statistically significant factors of the utilization of cervical cancer screening.

23 Sep 2019

PONE-D-19-16524

Utilization of Cervical Cancer Screening and Associated Factors among Women in Debremarkos town, Amhara Region, Northwest Ethiopia: Community based cross sectional study

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Reviewer #2: No

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Reviewer #1: Utilization of Cervical Cancer Screening and Associated Factors among Women in Debremarkos town, Amhara Region, Northwest Ethiopia: Community based cross sectional study

Dear Editor, thank you for the opportunity to review this manuscript. Well done to the authors for sharing their work.

The paper presents data from a study conducted on utilization of cervical cancer screening and associated factors among women in Debremarkos town, Amhara Region, Northwest Ethiopia through a community based cross sectional study. However the study is much broader in scope that the title suggests as it includes knowledge and attitudes which I think should come out in the title. The work also requires a thorough edit as there are quite a number of grammatical and punctuation errors. There is also need to improve paragraphing throughout the write up to better present the manuscript. Here below are my specific comments and suggestions.

Suggested title: knowledge, attitudes and utilisation of cervical cancer screening services in Debremarkos town, Amhara Region, Northwest Ethiopia: A cross sectional study

Abstract

Should be adjusted based on revisions in other sections including presenting results on knowledge and attitudes.

Please provide a list of key words that best describe your article

Introduction

Instead of disease say common malignancy.

About 266000 – include timeframe; sentence requires editing

In Ethiopia, 70;95 cases – is there a typo here?

Avoid one sentence paragraphs. In fact, many sentences are hanging. You need to combine related sentences to form clear paragraphs.

Visual Acetic Acid is VIA not VAI

Write study aim in past tense. Let it also encompass knowledge and attitudes.

Methods

Not clear why an unconventional margin of error of 3.5% was used and not the usual 5%. This is so much an indication of sample size having been calculated afterwards. Please explain.

Name the local language(s) that questionnaires were translated to especially that this is a multi-lingual region.

Name the dependent variable(s).

How were study respondents selected through the various levels? What type of sampling was used? What were the inclusion and exclusion criteria? And where were the interviews carried out from?

What manipulations were done to form composite variables for knowledge and attitudes?

How was utilisation defined and how was this too manipulated for further analysis.

Results

Only describe key results and refer readers to the table for details. There is no need to mention every result in the write up as currently is.

Make the occupation categories informative. What does self-employed mean? Is it that they operate small businesses? How about private employees, what are these? Let these be made clear by using easy to understand descriptors so that readers will be on the same page.

HH income – indicate currency.

Reproductive and behavioural characteristics

Started sexual intercourse for the first time >> first had sexual intercourse at 16.

Many of the variables used for this section are vague, not well described and don’t add any information to the study. For example what do you mean by history of MSPs? In what period? Is it even informative? History of smoking? STDs? Within what time period? Why is this relevant?

Knowledge

The knowledge section is prominent and thus should be included within the study objectives or aim.

The knowledge questions too are vague. First of all indicate in the methods how knowledge and attitudes were scored and what you mean by being knowledgeable or positive attitude? Also show these results within your tables.

Cervical cancer screening can be practiced – what does this mean? What information can you take away from this? This is vague.

Convert knowledge questions into phrases. E.g. instead of ‘do you know the symptoms of cervical cancer’ we can have ‘knew symptoms of cervical cancer’ though why would such a question be relevant when you have a question on some of the symptoms themselves?

Cervical cancer is a killer disease. Of course it is. Don’t you think this is vague when asked this way?

Is cervical cancer curable disease if detected early? This is a leading question especially that you add the early detection. Question should have been only about it being curable.

Attitudes

Attitude too comes out prominently and so should feature in the study objectives / aim and title.

First two questions are same / similar as this questionnaire is responded to by women.

What is a family disease? Please make clear exactly what you were seeking and communicate it clearly.

What do you mean by hazardous to your health?

What is wellbeing and how really was this translated to the respondents. Or was it health? But what was the relevance of this very general question?

What is favourable attitude? What constituted it? Make this clear and present within your results.

Utilisation of cervical cancer screening

Where is the figure of 5.4%? Include within your tables. What was the definition of utilisation? Provide this early in the methods section.

Do not describe the analysis again. Need to omit the whole first paragraph which is full of repetitions.

Describe results from both bivariate and multivariate analysis. The section can also be made more informative by indicating the direction of the association.

Many of the results from further analysis are not informative at all and seem forced because of the very small numbers involved. You have cells with a single value. This is not sufficient to support further analysis and is responsible for some of the wide confidence intervals. You need to categorise most of these variables and repeat the analysis to present informative results. There is no need to have several categories with such small numbers. Otherwise, some covariates with very small numbers could be omitted. Also, do not forget that many variables especially for knowledge and attitudes are vague and you should carefully think whether they should actually be included in your model. Also the combined knowledge and attitude variables should be described earlier.

The asterisks used as footnotes in the tables are not used within the table.

Discussion

Do not repeat results within the discussion. First paragraph does not even show the comparison. Paragraphing, grammar and sentence structured all need to be improved.

Very long sentences should be revised and rewritten.

Many of the provided explanations for results are vague and do not show good grounding in the available cervical cancer literature. There is no evidence that exposure to risk factors leads to utilisation of screening. It could be more due to increased exposure to information and maybe increasing risk with age and thus more interest or contact with health facilities.

Marital status association can’t be explained to be due to having MSPs. This could be linked to preceding paragraph of age as widowed or divorced women are more likely to be older. Also, young ones are more likely educated… etc.

The explanation of age at first sexual intercourse seems forced and is vague. You can’t claim that symptoms of the disease would appear earlier in such a group. Also, you do not show any evidence between risk and likelihood to screen.

Some of the concepts being discussed can be merged and well synthesized and presented in shorter clear paragraphs than simply listing the results and forcing their explanations.

Knowledge and attitudes were presented in the results. Similarly, they should be discussed. Conclusion should also capture these.

Recommendation

Manuscript requires substantial revisions before it is sent for another round of review. I hope the above comments will help improve it.

Reviewer #2: -Formatting of the manuscript should follow the journal guideline

-Table, figures, main body should be according to the guideline

-Declaration sections also need some modification

**********

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14 Nov 2019

Dear reviewer

Thank you for your constructive comments on our manuscript. Again your suggestion towards title modification is also right.

� But from the outset, our outcome variable is "utilization of cervical cancer screening ". Knowledge and attitude are our independent variables so that variables that influence knowledge and attitude not fully included in the questionnaire. Again, during analysis, we have not used Likert scale analysis for attitude since we have used it as an independent variable. Because of these reasons, we have decided to put the original title (Utilization of Cervical Cancer Screening and Associated Factors among Women in Debremarkos town, Amhara Region, Northwest Ethiopia: Community based cross-sectional study).

� We have used a 3.5 % margin of error to increase sample size and the rule of thumb says if ‘P-value' less than 20% and greater than 80% we can use margin of error from 2% to 4%.

� Since it has yes/no outcome, the utilization of cervical cancer screening is analyzed by using binary logistic regression.

� The knowledge question was changed to binary (1=yes and no=0). Then calculated the mean value and women who answered knowledge questions score of mean value or above were considered as knowledgeable.

� The attitude question was also changed to binary (1=agree and 0=disagree + indifferent). Then calculated the mean value and women who answered attitude questions a score of mean value or above were considered to have a favorable attitude.

� Self employee means individuals who are doing their own small business and private employee means individuals who are salaried in the private sector. As you have recommended, the definitions are described in the bracket.

� History of MSPs, History of smoking, and SDs are adapted from different literatures. History of MSPs and History of smoking have been operated. They are relevant because different they are associated with cervical cancer screening in different studies.

� In attitude, the first two questions seem similar in concept but, women may not think as they are susceptible to cervical cancer even though they think as others are susceptible. That is why the two questions have different figure (25.2% versus 24.6% )

� We have used “Cervical cancer screening can be practiced” to say ‘All eligible mothers can have cervical cancer screening without complication’

� “Cervical cancer is a killer disease". We know as it is a killer disease but since it is a community-based study, women may not know whether it is a killer disease or not. So, it may be appropriate.

� A family disease means a disease that can be transmitted genetically.

� Hazardous to your health means cervical cancer may be dangerous which complicates women’s life.

� Wellbeing is used to show the benefit of cervical cancer screening to health. Even though it is a general question to assess the attitude of women towards cervical cancer screening. Women may think screening by itself induces cervical cancer.

� We have cells with a single value. The main reason is there is a small number of data that were found based on ethnicity (after merging of Oromo and Gurage, only one person was utilized screening) so, we could not merge it further.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

9 Dec 2019

PONE-D-19-16524R1

Utilization of Cervical Cancer Screening and Associated Factors among Women in Debremarkos town, Amhara Region, Northwest Ethiopia: Community based cross sectional study

PLOS ONE

Dear mr yeserah,

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Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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Reviewer #2: Partly

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Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Editor,

The manuscript has improved but I believe these few issues should also be considered:

• Throughout the manuscript, use women instead of mothers. e.g in sampling technique, table 3 etc.

• Have another look at paragraph 3 and 4 in the discussion. The writing does not bring out any key message and is unnecessarily long. In fact, have another read of the manuscript and address the typos and omissions, grammar and punctuation especially in the discussion.

• You may also refer to this recent publication very similar to yours in the same area to further support your discussion.

Uptake of pre-cervical cancer screening and associated factors among reproductive age women in Debre Markos town, Northwest Ethiopia, 2017 https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7398-5

Reviewer #2: It is better to consider the comments given in the main document. each of the comment given is very critical and should be addressed

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Submitted filename: utilization of cervical cancer screening1 (1).docx

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12 Dec 2019

thank you for your constructive comments.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

14 Jan 2020

PONE-D-19-16524R2

Utilization of Cervical Cancer Screening and Associated Factors among Women in Debremarkos town, Amhara Region, Northwest Ethiopia: Community based cross sectional study

PLOS ONE

Dear mr yeserah,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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Reviewer #2: Partly

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: No

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Submitted filename: Manuscript_Plose one.docx

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8 Feb 2020

dear reviewers and and editors, thank you for your comments. we are happy if you help us for this manuscript publication. since this research finding is presented with real data, we are happy if it is published as soon as possible.

thanks

Submitted filename: Response to reviewers.docx

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23 Mar 2020

Utilization of Cervical Cancer Screening and Associated Factors among Women in Debremarkos town, Amhara Region, Northwest Ethiopia: Community based cross sectional study

PONE-D-19-16524R3

Dear Dr. Aynalem,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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PLOS ONE

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Comments to the Author

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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Reviewer #1: Partly

Reviewer #2: Yes

**********

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Reviewer #1: No

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #2: Yes

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Reviewer #1: (No Response)

Reviewer #2: The author addressed all the comments given previously and incorporated with the new revised version. But my concern is in discussion section many of the literatures used had a different approaches of study and then how the different modalities of research finding will be equivalently compared with current study? if the author make this confusion, I am agree with the stand of this manuscript to be published.

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Reviewer #1: No

Reviewer #2: No

25 Mar 2020

PONE-D-19-16524R3

Utilization of cervical cancer screening and associated factors among women in Debremarkos town, Amhara Region, Northwest Ethiopia: Community based cross-sectional study

Dear Dr. Aynalem:

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