Determinants of utilization of cervical cancer screening among women in the age group of 30-49 years in Ambo Town, Central Ethiopia: A case-control study.

BACKGROUND: Globally, cervical cancer is the second most common and the leading cause of death in women in low-income countries. It is one of the potentially preventable cancers, and an effective screening program can result in a significant reduction in the morbidity and mortality associated with this cancer; however, evidence showed that only a small percentage of the women were screened. As a result, predictors of cervical cancer screening usage among women in Ambo town, central Ethiopia, were identified in this study.
METHOD: Unmatched, a community-based case-control study was conducted among 195 randomly sampled women in the age group of 30-49 years in Ambo town from February 1 to March 30, 2020. Data was collected using an interviewer-administered questionnaire. Descriptive, bivariate, and multivariable binary logistic regression analysis was done using SPSS.
RESULTS: A total of 195 study participants, sixty-five cases and one hundred thirty controls, participated in this study, making a response rate of 100%. Being in the age group of 30-34 years old (AOR = 0.2; 95% CI: 0.06-0.7), being Para five and above (AOR = 4.5; 95% CI: 1.4-14.1), modern contraceptive utilization (AOR = 5.4; 95% CI: 1.8-16.3) and having high-level knowledge regarding cervical cancer screening and its predisposing factors (AOR = 5.9; 95% CI: 2-17) were significantly associated with the utilization of cervical cancer screening.
CONCLUSION: The age of women, parity, use of modern contraception, and level of knowledge regarding cervical cancer screening and its predisposing factors were the determinants of the utilization of cervical cancer screening among women. As a result, the media, the health bureau, and health professionals should advocate raising awareness about cervical cancer and its preventative methods, which are primarily focused on screening.

Introduction

Cervical cancer is a slow-onset malignancy found in the interior lining of the cervix, at the junction of the vagina and uterus [1]. Cervical cancer continues to be a major public health problem affecting middle-aged women globally, with around 570,000 cases of cervical cancer and 311,000 deaths occurring in 2018 [2]. Similarly, according to global cancer statistics, cervical cancer ranks fourth for both incidence (6.6%) and mortality (3.5%) among females in 2018 [3]. Every two minutes, a woman dies from cervical cancer, with more than 90% of these deaths accounting for low- and middle-income (LMIC) countries [4].

In less developed regions, cervical cancer makes up 85% of the new cases and 87% of the deaths that occur with the second most commonly diagnosed cancer and the third leading cause of cancer death among females [5, 6]. Similarly, in Sub-Saharan Africa, cervical cancer incidence has been increasing, becoming the second most prevalent and incidental type of cancer among women after breast cancer [7].

In Ethiopia, cervical cancer is the most common (31.8%) diagnosed cancer among all cancer cases and the second leading gynecologic cause of death, next to breast cancer, among women aged 15–44 years in 2012 [8]. Every year in Ethiopia, 7095 women are diagnosed with cervical cancer and 4732 die from the disease, putting a 29.4 million population at risk for cervical cancer in 2012 [9]. By the year 2030, cervical cancer will kill more than 443,000 women yearly worldwide, most of them in sub-Saharan Africa, including Ethiopia [10].

Cervical cancer is robbing us of our mothers, daughters, sisters, and grandmothers, impacting our communities and threatening the social and economic fabric of society. Even though cervical cancer is preventable, treatable, and the only cancer with a clear path to elimination, thousands of women are dying unnecessarily in the prime of their lives from this preventable and treatable disease [4]. In Sub-Saharan Africa, approximately 80–90% of women have never had a pelvic examination, and less than 5% have access to screening [11].

Regular screening is associated with a 67% reduction in stage 1A cancer and a 95% reduction in stage 3 or worse cervical cancer and prevents 70% of cervical cancer deaths (at all ages). Also, if everyone attended screening regularly as recommended, 83% of cervical cancer could be prevented [12].

Cervical cancer mostly develops slowly; it usually takes ten years to become cervical cancer, and when detected early as a precancerous lesion, it can be treated effectively [13]. However, due to a lack of an effective prevention mechanism, the majority of cervical cancers (more than 80%) in Sub-Saharan Africa are detected in late stages, which is associated with low survival rates after surgery or radiotherapy [14]. Cytology-based screening (Pap smear test) has significantly reduced cervical cancer incidence and mortality in developed countries. Yet it has had limited success in Ethiopia and other resource-poor countries, as it requires repeated testing, laboratory analysis, and proper diagnostic, treatment, and follow-up protocols [15, 16]. Visual Inspection with Acetic Acid (VIA) is an evidence-based and affordable alternative approach for cervical cancer screening in low-resource settings. Studies have reported VIA sensitivity for detecting precancerous lesions comparable to or greater than cervical cytology, while requiring fewer resources and being feasible to carry out in low-level health facilities [15].

Visual Inspection with Acetic Acid combined with cryotherapy, ideally in a single visit approach (SVA), is an effective and efficient strategy for the prevention of cervical cancer in low-resource settings, and can be conducted by competent clinicians and nurses [17]. Visual Inspection with an Acetic Acid-based program using the SVA strategy has been shown to significantly reduce precancerous lesions of the cervix, cervical cancer incidence, and mortality [18].

The human papillomavirus (HPV) is a significant co-factor to cervical cancer. The development of vaccines against HPV has been a major advance for the prevention of this cancer. Nevertheless, large-scale implementation of HPV vaccination is still lacking in developing countries and will not replace the need for cervical cancer screening [19]. Cervical cancer prevalence is one of the disease spectrums that determine the country’s socioeconomic status, as well as the difference between the upper and lower classes within the country. The majority of these deaths can be prevented through universal access to comprehensive cervical cancer prevention and control programs, which have the potential to reach all girls with human papillomavirus (HPV) vaccination and all women who are at risk with screening and treatment for pre-cancer [16].

In Ethiopia, routine access to cervical cancer screening was not available and treatment of precancerous cervical lesions didn’t exist until the implementation of the Addis Tesfa project in 2009 [20]. According to the Information Centre on HPV and Cancer 2017, in Ethiopia, the overall coverage of cervical cancer screening was found to be 0.8%, with only 0.6% of all women, 1.6% of urban women, and 0.4% of rural women aged 18–69 years screened every three years [15, 21]. The government of Ethiopia launched screening for cervical cancer in 2014, and the VIA recommended for those women between the ages of 30 and 49 within every five years. Despite the fact that there are guidelines, protocols, and instruments available for those with a precancerous lesion, only a small number of women are screened for cervical cancer [21].

To eliminate cervical cancer, WHO targeted three goals: goal one says 90% of girls have to be fully vaccinated with the HPV vaccine by age 15, goal two 70% of women should be screened with a high-performance test by the age of 35 and again at 45, and goal three, 90% of women identified with cervical cancer should receive treatment (90% of women with pre-cancer treated; 90% of women with invasive cancer managed) that is designed to eliminate cervical cancer by reducing the number of cases to 4 cases per 100,000 women per year [4]. Similarly, the Ethiopian Federal Minister of Health aimed for at least 80% coverage of the target populations for pre-invasive cervical cancer screening and treatment by 2020 [22].

But a community-based cross-sectional survey of nine regions, including Addis Ababa city administration and Dire Dawa administration, shows an extremely low rate of cervical cancer screening (2.9%) [23]. Likewise, a study conducted in different parts of the country shows very low utilization of cervical cancer screening [24, 25]. Even a study conducted among female health care providers showed that only 17% of them had ever been screened for cervical cancer [26].

Poor access to screening and treatment services is attributed to more than 85% of women’s deaths in low and middle-income countries [27]. Most cervical cancer screening studies done in the country don’t elucidate factors affecting the utilization of cervical cancer screening. As a result, little is known about the determinants of cervical cancer screening utilization among women aged 30–49 years in Ambo and throughout the country [8, 28]. As a result, predictors of cervical cancer screening usage among women aged 30–49 years in Ambo Town were identified in this study.

Methods

Study setting

This study was conducted in Ambo town, West Shoa Zone, Oromia Regional State, central Ethiopia from February 1–March 30, 2020. Ambo town is found at a distance of 114 km from the capital city of Ethiopia, Addis Ababa, in the west direction. The town has three urban and three rural administrative kebeles. A kebele is the smallest administrative unit in Ethiopia. According to Ambo Town Administration Office 2018 data, the total population of the town was 108,000, of which 53,400 males and 54,600 females. The town has one referral hospital, one general hospital, two health centers, nine health posts, and twenty one private clinics. Ambo General Hospital was the only hospital providing cervical cancer screening during this study was conducted. Ambo General Hospital had 287 health care workers. Those were 8 special doctors, 19 general practitioners, 69 nurses, and other health care providers [29].

Study design, sample size, and sampling procedures

A community-based unmatched case-control study was conducted to identify factors that determine the utilization of cervical cancer screening among women in the age group of 30–49 years. All women in the age group of 30–49 living in Ambo town selected by simple random sampling techniques and available during the data collection periods were the sampling unit included in the study. The study excluded psychiatric and critically ill patients, as well as women who had already been diagnosed with cervical cancer and were receiving treatment. All randomly selected women in the age group of 30–49 years and residents of the study area who were screened for cervical cancer as cases and women of the same age group who didn’t get screening for cancer as controls were the study unit of this study.

The sample size for this study was determined by using a double population proportion formula using EPI-info version 7.2 with the assumption of power = 80%; confidence level = 95%, case to control ratio of 1:2, P1 = the proportion of women in the age group of 30–49 years with parity five and above screened for cervical cancer, and P2 = the proportion of women in the age group of 30–49 years with parity five and above not screened for cervical cancer, as the main predictors of the outcome, which was 2.1% and 13.0% among cases and controls, respectively. Finally, by considering 5% non-response rates, a total of 195 (65 from cases and 130 from controls) were generated, the largest sample size [24].

Cases were selected in Ambo General Hospital from the cervical cancer screening registration book by using a simple random sampling technique, and a list of selected study participants, their address, and phone number were taken from the registration book. Controls were selected from the nearest neighbors to the cases, and then the same interview questionnaire was administered to both cases and controls at their household.

Data collection tool and personnel

Data were collected by four trained BSc nurses under the supervision of two health officers using a pretested structured interviewer-administered questionnaire adapted and modified from similar literature [30–33, 39]. The questionnaire asks about sociodemographic factors, reproductive-related factors, knowledge questions with correct and incorrect answers, and attitudes about cervical cancer screening on a five-point Likert scale (1-strongly agree, 2-agree, 3-neutral, 4-disagree, and 5-strongly disagree).

Data management and analysis

Data quality was assured through pre-testing the data collection tools on 5% of the total sample size before it was used for the actual data collection in a similar population who were not included in the study subjects. Data collectors and supervisors were trained for one day by the principal investigator on the study instruments and consent form, how to interview, and data collection procedures. The data collection processes were closely supervised by supervisors and investigators. Before data entry, the questionnaires were checked for completeness, consistency, and correction measures made by supervisors and investigators.

The data were then coded, entered into EPI-Data 3.1, and exported to SPSS software version 25 for data processing, cleaning, and analysis. Descriptive analysis like frequency and percentage was carried out to describe sociodemographic characteristics, reproductive, knowledge, and attitude-related determinants of utilization of cervical cancer screening among women, and results were presented in texts, tables, and graphs. The bivariate and multivariate analyses were done using binary logistic regression to identify factors associated with the utilization of cervical cancer screening among women. Candidate variables for the final model (multivariate binary logistic regression) were identified using a binary logistic regression model at a p-value of less than 0.25, and the final model multiple logistic regression was done to see the independent effect of each explanatory variable on the study variable at a p-value of less than 0.05.

The Hosmer and Lemeshow goodness-of-fit (P-value = 0.348) was checked to test for model fitness. The independent variables were tested for multi co-linearity using the Variance Inflation Factor (VIF) and the Tolerance tests, and no variables were found to have a VIF greater than 2 to be omitted from the analysis.

Terms and operational definition

Cases:—Women who were screened for cervical cancer in the age group of 30–49 years.

Controls:-Women who didn’t screen for cervical cancer in the age group of 30–49 years.

Knowledge:—It is information that an individual has become aware of what cervical cancer screening is and factors that predispose to it. In this study, it was measured based on the ability of the respondents to correctly answer symptoms, risk factors, and preventive measures for cervical cancer and cervical cancer screening.

It was assessed using six items, each having correct and incorrect responses. Each item contains 1 point for a correct response, 0 for an incorrect response, and I don’t know. The maximum correct response contains 6 points and a minimum of zero. The knowledge of the study participants toward cervical cancer screening was assessed using the sum score of each item based on Bloom’s cut-off point [34]. The scores were classified into 3 levels as follows:

High-level of knowledge:-Knowledge scores that fell between 4. 8–6 (80%-100%).

Moderate level of knowledge:-Knowledge scores that fell between 3. 6–4. 7 (60%-79.9%).

Low-level of knowledge: - Knowledge score of less than 3. 5 points (< 60%).

Attitude:—Includes 8 items to assess the perception or outlook regarding causative factors and preventive measures of cervical cancer screening. All individual answers were summed up for total scores and calculate for means percent. The scores were classified into 3 levels (Positive Attitude, Neutral Attitude and Negative Attitude) according to Bloom’s cut-off point.

Positive attitude:—Attitude scores that fell between 6. 4–8 (80% - 100%).

Neutral attitude:—Attitude scores that fell between 4. 2–6. 3 (60% -79. 9).

Negative attitude:—Attitude score less than <4.2 (<60).

Modern contraceptives:—those women who used any type of modern contraceptives up to now which include Depo-Provera, pills, copper IUCD, ligation and implants.

Patient and public involvement

There was no patient or public involvement in this study. Patients were not requested to comment on the study design and were not involved in developing patient-relevant outcomes or interpreting the results. Patients were not involved in the development of the dissemination strategy.

Results

Socio-demographic characteristics of respondents

A total of 195 study participants, sixty-five cases and one hundred thirty controls, participated in this study, making a response rate of 100%. The majority of respondents were between the ages of 35–39 years (44.6%) for cases, while between 30–34 years of age (61.5%) for controls, and the median age for study participants (cases and controls) was 34 years. The mean age for cases and controls was 37.1 (±4.76 SD) and 34.3 (±4.76SD) respectively. The majority of study participants, 34 (52.3%) of cases and 84 (64.6%) of controls, were protestant religious followers. A larger proportion of the cases, 64 (98.5%), and controls, 124 (95.4%), were Oromo in their ethnicity. About 24 (36.9%) and 59 (45.4%) of cases and controls had diplomas and above educational levels, respectively (Table 1).

Table 1

Socio-demographic characteristics of women in the age group of 30–49 years in Ambo town, Oromia Regional State, Ethiopia, February to March 2020.

Socio-demographic variables of study participants (n = 195)	Frequency
	Number/percentage of cases (n = 65)	Number/percentage of controls (n = 130)
Age (in years)
30–34	19 (29.2)	80 (61.5)
35–39	29 (44.6)	33 (25.4)
≥40	17 (26.2)	17 (13.1)
Religion
Orthodox	25 (38.5)	38 (29.2)
Protestant	34 (52.3)	84 (64.6)
Muslim	4 (6.2)	3 (2.3)
Wakefatu	2 (3.1)	3 (2.3)
Others *	0 (0.0)	2 (1.5)
Ethnicity
Oromo	64 (98.5)	124 (95.4)
Amhara	1 (1.5)	6 (4.5)
Marital status
Married	56 (86.2)	110 (84.6)
Others **	9 (13.8)	20 (15.4)
Educational status
Cannot write or read	14 (21.5)	17 (13.1)
Primary (1–8)	14 (21.5)	27 (20.8)
Secondary (9–12)	13 (20)	27 (20.8)
Diploma and above	24 (36.9)	59 (45.4)
Occupation
Unemployed	37 (56.9)	56(43.1)
Government employee	21 (32.3)	49 (37.7)
Self-employee	7(10.8)	25 (19.2)
Monthly income
<1500 ETB	22 (33.8)	30 (23.1)
1500–3000 ETB	7 (10.8)	20 (15.4)
>3000 ETB	36 (55.4)	80 (61.5)

Others * Catholic (1), Adventist (1) others

** widow (8), single (13), separated (5), (ETB) Ethiopian Birrs.

Factors related to the reproductive health of study participants

The majority of both groups of study participants saw their first menstrual cycle at an age of fewer than 15 years, 51 (78.5%) and 98 (75.4%), and the mean age at their menarche (first menses) was 13.49 (±1.05) and 13.60 (±1.27) years for cases and controls, respectively. In the majority of the studies, participants started their first sexual intercourse at the age of 18 and above, 51 (78.5%) for cases and 102 (84.3%) for controls.

In the majority of both groups of study participants, their parity was less than five, 40 (65.6%) and 97 (89.8%) for cases and controls, respectively, and about 38 (62.3%) of cases and 69 (63.2%) of controls gave their first delivery in the age group of 20–24 years. About 51 (78.5%) of cases and 75 (57.7%) of controls used modern contraception, while the majority of respondents in both groups, 62 (95.4%) of cases and 124 (96.1%) of controls, never used condoms.

The majority of respondents’ husbands, 53 (94.6%) among cases and 102 (92.7%) among controls, had no other wife, while 58 (89.2%) of cases and 110 (90.9%) of controls had only one partner in their time life (Table 2).

Table 2

Reproductive health related factors of women in the age group of 30–49 years in Ambo town, Oromia Regional State, Ethiopia, February to March 2020.

Reproductive health related factors of study participants (n = 195)	Frequency
	Number/percentage of cases (n = 65)	Number/percentage of controls (n = 130)
Age at first menses (years)
<15	51 (78.5)	98 (75.4)
≥15	14 (21.5)	32 (24.6)
First coitrache
<18	14 (21.5)	19(15.7)
≥ 18	51 (78.5)	102 (84.3)
Parity
<5	40 (65.6)	97 (89.8)
≥5	21(34.4)	11 (10.2)
Age at first delivery
13–19	20 (32.8)	21(19.4)
20–24	38 (62.3)	69 (63.9)
≥25	3 (4.9)	18 (16.7)
Used modern contraceptives
Yes	51 (78.5)	75 (57.7)
No	14 (21.5)	55 (42.3)
Currently Your husband has another wife
Yes	3 (5.4)	8 (7.2)
No	53 (94.6)	102 (92.7)
Used condom
Yes	3 (4.6)	5 (3.9)
No	62 (95.4)	124 (96.1)
Number of partner in your life time
1	58 (89.2)	110 (90.9)
≥2	7 (10.8)	11 (9.1)

Knowledge related factors of respondents

Thirty-six (55.4%) of the respondents have high-level comprehensive knowledge among cases, whereas 23 (17.7%) of the respondents among control have high-level knowledge-based on blooms cut-off point (Fig 1).

Fig 1

Knowledge of cervical cancer screening among women in the age group of 30–49 years in Ambo town, Oromia Regional State, Ethiopia, February to March, 2020.

Factors related to the attitude of study participants

Thirty-six (55.4%) of the respondents have a positive attitude toward cases; ninety-one (70%) of the respondents have a positive attitude toward controls based on bloom cut-off point (Fig 2).

Fig 2

Attitude of cervical cancer screening among women in the age group of 30–49 years in Ambo town, Oromia Regional State, Ethiopia, February to March, 2020.

Determinants of utilization of cervical cancer screening

The result of backward likelihood multivariate logistic regression analysis revealed that only age, parity, use of modern contraception, and level of knowledge showed statistically significant associations with the utilization of cervical cancer screening among women, after controlling for potential confounders.

Hence, the odds of utilization of cervical cancer screening among women in the age group of 30–34 years were 0.2 times less as compared to women in the age group of 40 years and above (AOR = 0.2; 95% CI: 0.06–0.7)

The odds of using cervical cancer screening among Para five and above women were 4.5 times higher when compared to women who were less than Para five (AOR = 4.5; 95% CI: 1.4–14.1). Women who use modern contraception are 5.4 times more likely than their counterparts to use cervical cancer screening (AOR = 4.5; 95% CI: 1.8–16.3). Women who have a high level of knowledge regarding cervical cancer screening and its predisposing factors were 5.9 times more likely to utilize cervical cancer screening as compared to women who have a low level of knowledge regarding cervical cancer screening and its predisposing factors (AOR = 5.9; 95% CI: 2–17) (Table 3).

Table 3

Determinant of utilization of cervical cancer screening among women in the age group of 30–49 in Ambo town, Oromia Regional State, Ethiopia.

Variables	Status of utilization of cervical cancer screening among women in the age group of 30–49 Years
	Cases	Controls	COR(95%)CI	AOR(95%CI)	P-Value
Age
30–34	19	80	0.24(0.1–0.5)	0.2(0.06–0.7)*	0.010
35–39	29	33	0.88(0.38–2.03)	0.9(0.3–2.8)	0.817
≥40	17	17	1.00	1.00
Educational status
Illiterate	14	17	1.00	1.00
Primary (grade1-8)	14	17	0.63(0.24–1.64)	0.8(0.2–3.5)	0.814
Secondary(grade 9–12)	13	27	0.59(0.22–1.54)	0.9(0.2–4.4)	0.879
Diploma and above	24	59	0.49(0.21–1.12)	0.3(0.04–1.8)	0.173
Occupation
Unemployed	37	56	1.00	1.00
Governmental employee	21	49	0.7(0.3–1.3)	2.4(0.5–11.6)	0.278
Self-employee	7	25	0.4(0.2–1.1)	0.7(0.18–2.8)	0.626
Monthly income
<1500 ETB	22	30	1.00	1.00
1501–3000 ETB	7	20	0.48(0.17–1.33)	0.5(0.1–2.4)	0.422
>3000 ETB	36	80	0.6(0.31–1.21)	1.2(0.4–4.0)	0.731
Parity
<5	40	97	1.00	1.00
≥5	21	11	4.6(2–10.5)	4.5(1.4–14.1)*	0.009
Use of condom
Yes	3	5	1.2(0.3–5.2)		0.807
No	62	124	1.00	1.00
Use of modern contraception
Yes	51	75	2.7(1.3–5.3)	5.4(1.8–16.3)*	0.003
No	14	55	1.00	1.00
Age at first delivery
13–19	20	21	5.7(1.5–22.4)	7.8(0.9–6.5)	0.057
20–24	38	69	3.3(0.9–11.9)	4.5(0.9–22.5)	0.070
≥25	3	18	1.00	1.00
Level of Knowledge
Low level	17	49	1.00	1.00
Moderate level	12	58	0.6(0.3–1.4)	0.5(0.2–1.6)	0.249
High level	36	23	4.5(2.1–9.7)	5.93(2.0–17.0)*	0.001
Level of Attitude
Neutral attitude	91	29	1.00	1.00
Positive attitude	36	39	0.5(0.28–0.99)	1.1(0.4–3.1)	0.802

Case = women aged 30–49 screened for cervical cancer, Control = women aged 30–49 not screened for cervical cancer, Crude odds ratio (COR), Adjusted odds ratio (AOR), Confidence interval (CI),

*p < 0.05.

Discussion

Routine cervical cancer screening is critical and the most effective method for early detection and treatment of precancerous lesions and mortality reduction from cervical cancer. This study was conducted to identify determinants of utilization of cervical cancer screening among women in Ambo Town, Central Ethiopia. Thus, this study identified factors like women’s age, parity, use of modern contraception, and level of knowledge as determinants of utilization of cervical cancer screening.

The result of this study showed that women in the age group of 30–34 years were 0.2 times less likely to utilize cervical cancer screening as compared to those women in the age group of 40 years and above. This result was consistent with the studies conducted in Ethiopia, Dessie town, Debre Markos town, Finote Selam city, Zambia, Kenya, and rural areas of Mexico, which revealed that women in the younger age groups were less likely to utilize cervical cancer screening as compared with those women in the older age groups [18, 35–39]. A possible reason why women in the younger age groups were less likely to utilize cervical cancer screening is that they might consider themselves low-risk groups, and cancer-related morbidity and mortality are diseases of older age groups, which might be screened in their 30’s and above. Similarly, the explanation for this could be that of the bimodal distribution of cervical cancer, one in their 30s and the other in their 60s. These two age groups represent the ages at which cervical lesions become symptomatic.

Consequently, women see themselves as being at an increased risk of invasive cervical cancer as their age increases and seek health care and cervical cancer screening services. Additionally, in Ethiopia, the cervical cancer screening guideline promotes women aged 30–49 to be screened for cervical cancer, and women aged 40 and above might have better health-seeking behaviour and intention to be screened. Furthermore, this age group is more susceptible to giving birth at a productive age and has a chance of getting more gynaecological examinations, giving birth, and getting more health information about sexual and reproductive health, including cervical cancer screening services. The other explanation might also be that increasing risk with women’s age leads the women to have more contact with healthcare facilities.

However, the study conducted in Ethiopia’s Tigray region public hospitals and India indicated that women in the younger age groups were more likely to utilize cervical cancer screening than women in the older age groups [28, 40]. The possible reasons for the discrepancy in the results might be due to the variation in the study participants, time deference’, availability of information, and freedom of access to information regarding cervical cancer screening and its predisposing factors through social media and other routes.

The findings of this study revealed that being parity five or above among women was 4.5 times more likely to utilize cervical cancer screening when compared to being less than parity five. The result of this study was comparable with the study findings reported from Arba Minch town, southern Ethiopia, Tanzania, Dare Salaam, and India, which showed that women with a history of more parity were more likely to utilize cervical cancer screening [40-43]. This may be due to repeated visits to healthcare facilities for family planning, deliveries, and antenatal care follow-up so that they may get advice to use the service and also receive screening during their early deliveries.

In contrast, the study conducted at Finote Salam, Northwest Ethiopia and Jamaica revealed that women with a history of more parity were less likely to utilize cervical cancer screening as compared with women with a history of less parity [30, 43]. Differences in respondents’ ages, levels of awareness, access to information such as mass media and other social media, family, peers, cultural beliefs, sociodemographic status, women’s autonomy, economic conditions, physical and financial accessibility, disease patterns, and health service issues, as well as differences in the study design, study area, study period, study populations, and sample size, all contribute to the variation.

The result of this study showed that women who use modern contraception were 5.4 times more likely to utilize cervical cancer screening as compared with their counterparts. The findings of this study are consistent with the study conducted in Jimma Town, Southwest Ethiopia, Burkina Faso, Malawi, and India, which indicated that those women who used modern contraceptives were more likely to utilize cervical cancer screening as compared to their counterparts [40, 44–46]. This could be as a result of customers receiving counseling on cervical cancer screening and predisposing factors while receiving family planning services.

Women who had a high level of knowledge regarding cervical cancer screening and its predisposing factors were 5.9 times more likely to utilize cervical cancer screening as compared to women who had a low level of knowledge regarding cervical cancer screening and its predisposing factors. The finding of this study is consistent with the study conducted in Malawi, Mexico, Ghana, and Nairobi, Kenya, which revealed that women who have a high level of knowledge are more likely to utilize cervical cancer screening as compared to their counterparts [38, 39, 46, 47]. Furthermore, the findings of this study are similar to those of studies conducted in other parts of Ethiopia, including Arba Minch Town, Addis Ababa, and Jimma Town [25, 32, 41].

Conclusion

The age of women, parity, use of modern contraception, and level of knowledge regarding cervical cancer screening and its predisposing factors were the determinants of the utilization of cervical cancer screening among women. As a result, the media, the health bureau, and health professionals should advocate raising awareness about cervical cancer and its preventative methods, which are primarily focused on screening.

Strength and limitation of the study

To account for contextual variance in the research participants, cases and controls were recruited from the same neighborhood.

Because of the long time after the event, recall bias exists for queries like "first menses" or "first coitrache."

Even though data collectors were trained to maintain as much privacy as possible to boost respondents’ confidence and promote their responses, some respondents may withhold some information to give socially acceptable answers to particular questions.

Cervical cancer screening raw data.

(SAV)

Click here for additional data file.

15 Mar 2022

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Comments to the Author

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Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

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: Many grammatical errors are observed in the manuscript, the study is a case control study but in the conclusion section it is reported "Even though the facility of cervical cancer screening is available in almost all health facility levels but only a few of them utilized the services from existing data" this seems reporting prevalence of cervical cancer screening.

Reviewer #2: The manuscript is reasonably sound, and the data support the conclusions presented. However, there are matters require revisions. The statistical analysis seems rigorous. The authors reported availability of data and promised that provide the data with reasonable request. The manuscript requires language revision.

General comments:

This article tried to address important research question that is relevant and an interesting. The manuscript is generally well written and structured. However, in my opinion the paper has few shortcomings. For instance, research gap that authors would attempt to address in their project is not boldly stated.

It needs to show gap and must attempt to fill in some piece of information missed in the scientific literature. Otherwise, it is not novel research which is not contributing to the overall goals of science.

Title: Determinants of Utilization of Cervical Cancer Screening among Women in the Age group of 30-49 Years in Ambo Town, Central Ethiopia: a case-control study.

Why would you (authors) focus on this age group (30-49 years of age) as far as 15-49 years are also eligible?

ABSTRACT:

Background: What stated in this section might not be research gap. It seems effort attempted by government to facilitate cervical cancer screening. What were known and not known since guidelines and protocols endorsed by government of Ethiopia?

Methods: “multivariate” should be edited and corrected as “Multivariable”

Results: it would be clearer if the total number of study participants involved were mentioned.

Line 20. Is grand multiparity appropriate instead of saying para 5 and above?? It is optional.

Line 22: high level of knowledge can be merged to the list of variables showed association with CCS. No need of separate explanation.

Conclusions: I think it needs revision. I must be based on main findings.

Line 27: Why social media? Or would the authors say mass media? How many of women have access to social media? How feasible?

INTRODUCTION:

Line 31: It would be better if it changed to “introduction” than background. Because introduction consists of background and statement of the problem.

Line 37-40: these statements are not aligning with the prior statements and subsequent paragraph. The first paragraph state prevalence and death attributed to cervical Ca. The middle statements talking about methods of screening while the subsequent paragraph talking about Cervical Ca incidence by regions.

Similarly, lines 103-108 are not appropriate place for this paragraph. Check it.

Line 111: Dire Dawa is not a city administration. Rather, it is simply Dire Dawa Administration since it has the numbers of rural woredas and kebeles.

METHODS and MATERIALS:

Study setting- was missed.

This subtitle is important for what the authors stated from line 124-129. In addition, I personally want to incorporate other pertinent information such the numbers of health facilities, and trained health care providers who can provide CCS.

Data collection tool and personnel

Line 154-158: Here detail expiations about number of items used, response options, how composite scores made and relevant nature of tools, their validity are required. I suggest that merging and well synthesizing this section with operational definitions.

Line 189: there is phrase “overall knowledge”. What does it mean? Did the knowledge items have dimensions or domains? If that is the case define overall and dimensions too.

Data management & Analysis: add versions of software used (EpiData and SPSS)

RESULTS:

Line 215-216; Either median with IQR or mean with SD is enough based distribution of the data.

Table 1: replace ‘’Socio-demographic characteristics of

study participants (n=195)’’ with “variables”.

Line 226 and 229: replace “have seen” with “saw” and “started” respectively.

Line 234-235 remove “were”

Line 237: replace “have” with “had”

Table 2: variable “your husband has another wife”. It is not clear whether it is talking about polygamy or another wife or partner before she married him??

Table 2: “Number of partners”. It is not clear. Was it asking about number of partners in life or current number of partners?

Knowledge related factors:

Line 242-245: The statements are too long, and vague/not clear. It was also mentioned under operational definitions that authors followed Bloom’s cut-off point to determine levels of knowledge. The same is true in lines 249-251.

Lines 255-265 need revision. Things already addressed in method section should be omitted. E.g., criteria set for candidacy to multivariable analysis.

Lines 270, 273, and 275: The phrases “in the age group 30-49” are presented redundantly here and there unnecessarily. Since it was already mentioned in the title, no need of reporting them. Simply use “women who…….”

Line 279: “Towns”- delete “s”. Similarly, delete February to march” since it was mentioned in line 125.

Table 3: under monthly income (>3000ETB) the corresponding confidence interval was 0.4-4. But to maintain consistency use at least one digit after decimal point. The same is true for high level of knowledge (2-17). It would be better it 2.0-17.0 if appropriate or subsequent number.

DISCUSSION:

It would be appropriate if the first paragraph of discussion present summary of main findings. The main purpose of discussion is reporting findings one by one, interpreting, comparing with former findings and suggesting possible scientific justifications. In addition, explain newly emerged understandings from the current study.

This section needs strict revision, and arguments.

Line 292. It indicates misperception among younger women. Why that? Authors’ argument/ justifications should be scientific and strong enough to convince. Again, there are inconclusive findings? It is suggested that this must be exhaustively addressed and recommendations might be also required.

Line 301-308: it is wonderful ways of discussion.

Line 304: Add Tanzania, after Dare Salam.

Lines 311-313: These kind of stating justifications might be so superficial. It would better if authors specify reasons for difference than crudely reporting difference was due to “socio-demographic or sample size, time gaps”. Please, look them further in terms of design, inclusion criteria, age, awareness level etc.

CONCLUSIONS:

The first 3 lines (331-333) are enough. Recommendations are not appropriately made based main findings.

For instance, statements in line 334 and 335(availability of the service was not studied in the current study. Three paragraphs starting from line 336-348 have no importance.

FIGURES:

Figure 1: has no importance. I would suggest to omit it.

Figure 3: has miss classification in relation to what operationally defined.

REFERENCES:

• There is inconsistent way of reference writing. Some lacks volume, numbers, years etc.

• There are also old references published 10 years back. Unless special circumstances, it would better to use articles published since 2011 if guideline of journal allow.

OTHERS:

Minor editorial: punctuations, grammatical errors, inconsistent use terms

NOTE: in conclusion, the findings of the manuscript are informative. But it requires moderate revision.

**********

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Reviewer #1: No

Reviewer #2: No

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8 Apr 2022

Author's response to Reviewers Comments

Manuscript ID number: PONE-D-21-40695

Title of Manuscript: Determinants of Utilization of Cervical Cancer Screening among Women in the Age group of 30-49 Years in Ambo Town, Central Ethiopia, a case-control study

Authors:

1. Dereje Lema

2. Mecha Aboma: Corresponding Author: abomamecha@gmail.com

3. Teka Girma

4. Ababe Dechasa

Generally, in manuscript we used track change to incorporate or address the reviewers’ comments.

A Point by Point Response to Reviewer Evaluation

1. Reviewer Question, #1: Many grammatical errors are observed in the manuscript, the study is a case control study but in the conclusion section it is reported "Even though the facility of cervical cancer screening is available in almost all health facility levels but only a few of them utilized the services from existing data" this seems reporting prevalence of cervical cancer screening.

Answers from authors: The comment is accepted and corrected using track change and colored highlight throughout the manuscript, Line 407-4025

2. Reviewer Question, #2: The manuscript is reasonably sound, and the data support the conclusions presented. However, there are matters require revisions. The statistical analysis seems rigorous. The authors reported availability of data and promised that provide the data with reasonable request. The manuscript requires language revision.

Answers from authors: It is alright. As you indicate there are many errors. Using language expert we tried to correct using track change and colored highlight throughout the manuscript

3. Reviewer Question, General comments: This article tried to address important research question that is relevant and an interesting. The manuscript is generally well written and structured. However, in my opinion the paper has few shortcomings. For instance, research gap that authors would attempt to address in their project is not boldly stated.

It needs to show gap and must attempt to fill in some piece of information missed in the scientific literature. Otherwise, it is not novel research which is not contributing to the overall goals of science.

Answers from authors: The comment is accepted and correction and revisions is made using track change and colored highlight throughout the manuscript.

4. Reviewer Question, Title: Determinants of Utilization of Cervical Cancer Screening among Women in the Age group of 30-49 Years in Ambo Town, Central Ethiopia: a case-control study. Why would you (authors) focus on this age group (30-49 years of age) as far as 15-49 years are also eligible?

Answers from authors: The government of Ethiopia launched screening of cervical cancer in 2014 and the VIA recommended for those women between the age of 30-49 years within every five years (6). Currently in Ethiopia cervical cancer screening services are free of charge in the public health facilities and women of 30-49 can uses services through self-referral, referral by health extension workers, by referral of other health care professionals (nurses, midwives, doctors ,and public health professionals) , and opportunistic screening.

5. Reviewer Question, ABSTRACT: Background: What stated in this section might not be research gap. It seems effort attempted by government to facilitate cervical cancer screening. What were known and not known since guidelines and protocols endorsed by government of Ethiopia?

Answers from authors: The comment is accepted and corrected, and indicated by track change and colored highlight, Line 11-16

6. Reviewer Question, Methods: “multivariate” should be edited and corrected as “Multivariable”

Answers from authors: The comment is accepted and corrected as “Multivariable”, Line 20

7. Reviewer Question, Results: it would be clearer if the total number of study participants involved were mentioned.

Answers from authors: The comment is accepted and corrected as ‘‘a total of 195 study participants, sixty-five cases and one hundred thirty controls, were participated in this study making a response rate of 100%’’, Line 22-23

8. Reviewer Question, Line 20. Is grand multiparty appropriate instead of saying Para 5 and above?? It is optional.

Answers from authors: The comment is accepted

9. Reviewer Question, Line 22: high level of knowledge can be merged to the list of variables showed association with CCS. No need of separate explanation.

Answers from authors: The comment is accepted and corrected and indicated by using track change and colored highlight Line 25-26

10. Reviewer Question, Conclusions: I think it needs revision. It must be based on main findings.

Answers from authors: The comment is accepted and revision is made and indicated by using track change and colored highlight, Line 407-4025

11. Reviewer Question, Line 27: Why social media? Or would the authors say mass media? How many of women have access to social media? How feasible?

Answers from authors: The comment is accepted and corrected as ‘‘Mass media’’ Line 31

INTRODUCTION:

12. Reviewer Question, Line 31: It would be better if it changed to “introduction” than background. Because introduction consists of background and statement of the problem.

Answers from authors: The comment is accepted and corrected as ‘‘Introduction’’, Line 35

13. Reviewer Question, Line 37-40: these statements are not aligning with the prior statements and subsequent paragraph. The first paragraph state prevalence and death attributed to cervical Ca. The middle statements talking about methods of screening while the subsequent paragraph talking about Cervical Ca incidence by regions. Similarly, lines 103-108 are not appropriate place for this paragraph. Check it.

Answers from authors: The comment is accepted and revision is made and indicated by using track change colored highlight throughout the manuscript

14. Reviewer Question, Line 111: Dire Dawa is not a city administration. Rather, it is simply Dire Dawa Administration since it has the numbers of rural woredas and kebeles.

Answers from authors: The comment is accepted and corrected as ‘‘Dire Dawa Administration’’, Line 147

15. Reviewer Question, METHODS and MATERIALS:

Study setting- was missed.

This subtitle is important for what the authors stated from line 124-129. In addition, I personally want to incorporate other pertinent information such the numbers of health facilities, and trained health care providers who can provide CCS.

Answers from authors: The comment is accepted and corrected as: - ‘‘The town has one referral hospital, one general hospital, two health centers, nine health posts, and twenty one private clinics. Ambo General Hospital was the only hospital providing cervical cancer screening during this study was conducted. Ambo General Hospital had 287 health care workers. Those were 8 special doctors, 19 general practitioners, 69 nurses, and other health care providers (30).’’ Line 168-172. And study setting is added. Line 62

Data collection tool and personnel

16. Reviewer Question, Line 154-158: Here detail expiations about number of items used, response options, how composite scores made and relevant nature of tools, their validity are required. I suggest that merging and well synthesizing this section with operational definitions.

Answers from authors: The comment is accepted and revision is made and indicated by using track change and colored highlight. Number of items also addressed under operational definition., Line 198-204

17. Reviewer Question, Line 189: there is phrase “overall knowledge”. What does it mean? Did the knowledge items have dimensions or domains? If that is the case define overall and Dimensions too.

Answers from authors: The comment is accepted and revision is made and indicated by using track change and colored highlighted, Line 235-239

18. Reviewer Question, Data management & Analysis: add versions of software used (EpiData and SPSS)

Answers from authors: The comment is accepted and corrected as ‘‘EPI-Data 3.1 version SPSS software version 25’’, Line 2013-2014

RESULTS:

19. Reviewer Question, Line 215-216; Either median with IQR or mean with SD is enough based distribution of the data

Answers from authors: The comment is accepted

20. Reviewer Question, Table 1: replace ‘’Socio-demographic characteristics of study participants (n=195)’’ with “variables”.

Answers from authors: The comment is accepted and indicated by using track change and colored highlighted, and characteristics replaced with ‘‘variables’’

21. Reviewer Question, Line 226 and 229: replace “have seen” with “saw” and “started” respectively.

Answers from authors: The comment is accepted and indicated by using track change and colored highlighted, and “have seen” replaced with “saw” and “started” respectively.’’ Line 273, 276

22. Reviewer Question, Line 234-235 remove “were

Answers from authors: The comment is accepted and corrected, and indicated by using track change and colored highlighted ‘’were’’ is removed, Line 281, 282

23. Reviewer Question, Line 237: replace “have” with “had”

Answers from authors: The comment is accepted corrected, and indicated by using track change and colored highlighted, and “have” replaced with “had” , Line 284

24. Reviewer Question, Table 2: variable “your husband has another wife”. It is not clear whether it is talking about polygamy or another wife or partner before she married him??

Answers from authors: the comments accepted and corrected, and indicated by using track change and colored highlighted. It is talking about polygamy or currently having another wife

25. Reviewer Question, Table 2: “Number of partners”. It is not clear. Was it asking about number of partners in life time or current number of partners?

Answers from authors: The comment is accepted and corrected, and indicated by using track change and colored highlighted. It is talking about number of partners in life time

26. Reviewer Question, Knowledge related factors: Line 242-245: The statements are too long, and vague/not clear. It was also mentioned under operational definitions that authors followed Bloom’s cut-off point to determine levels of knowledge. The same is true in lines 249-251.

Answers from authors: The comment is accepted and correction is made and indicated by using track change and colored highlighted, Line 290-292, 296-298

27. Reviewer Question, Lines 255-265 need revision. Things already addressed in method section should be omitted. E.g., criteria set for candidacy to multivariable analysis.

Answers from authors: The comment is accepted and correction is made and indicated by using track change and colored highlight, Line 302-3013

28. Reviewer Question, Lines 270, 273, and 275: The phrases “in the age group 30-49” are presented redundantly here and there unnecessarily. Since it was already mentioned in the title, no need of reporting them. Simply use “women who…….”

Answers from authors: The comment is accepted and correction is made and indicated by using track change and colored highlight, Line 322, 324

29. Reviewer Question, Line 279: “Towns”- delete “s”. Similarly, delete February to march” since it was mentioned in line 125.

Answers from authors: The comment is accepted and correction is made and indicated by using track change and colored highlight, Line 328

30. Reviewer Question, Table 3: under monthly income (>3000ETB) the corresponding confidence interval was 0.4-4. But to maintain consistency use at least one digit after decimal point. The same is true for high level of knowledge (2-17). It would be better it 2.0-17.0 if appropriate or subsequent number.

Answers from authors: The comment is accepted and correction is made and indicated by using track change and colored highlight

31. Reviewer Question, DISCUSSION: It would be appropriate if the first paragraph of discussion present summary of main findings. The main purpose of discussion is reporting findings one by one, interpreting, comparing with former findings and suggesting possible scientific justifications. In addition, explain newly emerged understandings from the current study.

Answers from authors: The comment is accepted and revision is made and indicated by using track change and colored highlight throughout the manuscript, Line 334-338

32. Reviewer Question, This section needs strict revision, and arguments. Line 292. It indicates misperception among younger women. Why that? Authors’ argument/ justifications should be scientific and strong enough to convince. Again, there are inconclusive findings? It is suggested that this must be exhaustively addressed and recommendations might be also required.

Answers from authors: The comment is accepted and revision is made and indicated by using track change and colored highlight as follow: - ‘‘Similarly, the explanation for this could be that of the bimodal distribution of cervical cancer, one in their 30s and the other in their 60s. These two age groups represent the ages at which cervical lesions become symptomatic.

Consequently, women see themselves as being at an increased risk of invasive cervical cancer as their age increases and seek health care and cervical cancer screening services. Additionally, in Ethiopia, the cervical cancer screening guideline promotes women aged 30–49 to be screened for cervical cancer, and women aged 40 and above might have better health-seeking behaviour and intention to be screened. Furthermore, this age group is more susceptible to giving birth at a productive age and has a chance of getting more gynecological examinations, giving birth, and getting more health information about sexual and reproductive health, including cervical cancer screening services. The other explanation might also be that increasing risk with women’s age leads the women to have more contact with healthcare facilities.’’ Line 346-459

33. Reviewer Question, Line 301-308: it is wonderful ways of discussion.

Answers from authors: I thank you!

34. Reviewer Question, Line 304: Add Tanzania, after Dare Salam.

Answers from authors: The comment is accepted and Tanzania is added after Dare Salam Line 369

35. Reviewer Question, Lines 311-313: These kinds of stating justifications might be so superficial. It would better if authors specify reasons for difference than crudely reporting difference was due to “socio-demographic or sample size, time gaps”. Please, look them further in terms of design, inclusion criteria, age, awareness level etc.

Answers from authors: The comments accepted and revision is made and indicated by using track change and colored highlight as follow: Differences in respondents' ages, levels of awareness, access to information such as mass media and other social media, family, peers, cultural beliefs, sociodemographic status, women's autonomy, economic conditions, physical and financial accessibility, disease patterns, and health service issues, as well as differences in the study design, study area, study period, study populations, and sample size, all contribute to the variation. Line 377-383

36. Reviewer Question, CONCLUSIONS: The first 3 lines (331-333) are enough. Recommendations are not appropriately made based main findings. For instance, statements in line 334 and 335(availability of the service was not studied in the current study. Three paragraphs starting from line 336-348 have no importance.

Answers from authors: The comment is accepted and correction is made and indicated by using track change and colored highlight, Line 405-425

FIGURES:

37. Reviewer Question, Figure 1: has no importance. I would suggest to omit it.

Answers from authors: The comment is accepted and the figure is removed

38. Reviewer Question, Figure 3: has miss classification in relation to what operationally defined.

Answers from authors: The comment is accepted but the score/ or response for negative attitude was zero because all of the study participants has positive and neutral attitudes, (according to their response indicated)

39. Reviewer Question, REFERENCES:

• There is inconsistent way of reference writing. Some lacks volume, numbers, years etc.

• There are also old references published 10 years back. Unless special circumstances, it would better to use articles published since 2011 if guideline of journal allow.

Answers from authors: The comment is accepted, correction and revision is made and indicated by using track change and colored highlight

40. Reviewer Question, OTHERS: Minor editorial: punctuations, grammatical errors, inconsistent use terms

Answers from authors: The comment is accepted, correction and revision is made and indicated by using track change and colored highlight throughout the manuscript

41. Reviewer Question, NOTE: in conclusion, the findings of the manuscript are informative. But it requires moderate revision.

Answers from authors: The comment is accepted and revision is made and indicated by using track change and colored highlight throughout the manuscript.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

13 May 2022

20 May 2022

Author's response to Reviewers and Academic Editors Comments

Manuscript ID number: PONE-D-21-40695

Title of Manuscript: Determinants of Utilization of Cervical Cancer Screening among Women in the Age group of 30-49 Years in Ambo Town, Central Ethiopia, a case-control study

Authors:

1. Dereje Lema

2. Mecha Aboma: Corresponding Author: abomamecha@gmail.com

3. Teka Girma

4. Ababe Dechasa

Generally, in manuscript we used track change to incorporate or address the reviewers’ comments.

A Point by Point Response to academic editor and reviewer(s) Evaluation

1. Academic Editors Question, #1: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Answers from authors: The comment is accepted and corrected using track change and colored highlights throughout the manuscript. However, we didn’t use retracted and unpublished papers in the references, all of the references we used in this manuscript are available on Search Google or/and Google Scholars.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

21 Jun 2022

Determinants of Utilization of Cervical Cancer Screening among Women in the Age Group of 30-49 Years in Ambo Town, Central Ethiopia: A Case-Control Study

PONE-D-21-40695R2

Dear Dr. Aboma,

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

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Desalegn Admassu Ayana, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

30 Jun 2022

PONE-D-21-40695R2

Determinants of Utilization of Cervical Cancer Screening among Women in the Age Group of 30-49 Years in Ambo Town, Central Ethiopia: A Case-Control Study

Dear Dr. Aboma:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

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on behalf of

Dr. Desalegn Admassu Ayana

Academic Editor

PLOS ONE