CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
LEVEL OF KNOWLEDGE TOWARD HUMAN PAPILLOMAVIRUS/CERVICAL
CANCER & PRACTICE OF PAPANICOLAOU TEST SCREENING AMONG
FEMALE ADDIS ABABA UNIVERSITY STUDENTS IN ETHIOPIA
A thesis submitted in partial fulfillment of the requirements
For the degree of Master of Public Health,
Health Education
By
Iman Rumana Abdulkadir
August 2013
The thesis of Iman Rumana Abdulkadir is approved:
______________________________________________
__________________
Lawrence Chu, PhD., MPH, MS
Date
______________________________________________
__________________
Sloane Burke, PhD., CHES
Date
______________________________________________
__________________
Vicki J. Ebin, PhD., MSPH, Chair
Date
California State University, Northridge ii ACKNOWLEDGEMENT
I would like to express my deepest gratitude to Dr Vicki Ebin for accepting to be
the committee chair, on top of her many other obligations. In particular, I am very
thankful to Dr Ebin for her continuous support, assistance, encouragement and guidance
and for giving me the opportunity to travel to Africa for my thesis research. Without her
persistent help and tutelage this thesis would not have been possible.
I would like to thank Dr. Chu Lawrence for agreeing and taking his valuable time
to be a member of my thesis committee. I would like to thank him for his expertise,
valuable suggestion and numerous fruitful discussions that help improve my thesis work.
I would like to thank also Dr Sloan Burke for agreeing to be a member of my thesis
committee and for her expertise, encouragement as well as helpful suggestion and advise.
I thank Dr Jemal Hider, the Dean of School of Public Health at the Addis Ababa
University, Ethiopia, for giving me the opportunity to collaborate with the Department of
Preventive Medicine on my thesis project.
Special thanks are to Dr Fikre Enquselassie, head of Department of Preventive
Medicine, School of Public Heath at the Addis Ababa University Ethiopia, for agreeing
to collaborate in the project. I am also grateful to him for his supervision, guidance and
for facilitating the work at the other Addis Ababa University campuses.
My thanks are also to the student Deans at Addis Ababa University: Ato Hagos at
the School of Medicine & Black Lion Hospital and Education Center, Ato Yared at the
College of Natural Sciences, Dr Amanuel, at the College of Social Sciences, Ato Mesay
at the Ethiopian Institute of Architecture, Building Construction & City Development,
Ato Mesfin and Ato Fasil at the Addis Ababa Institute of Technology. Furthermore, I
iii would like to thank and acknowledge with much appreciation the crucial role of the staff
and students whose name I did not list for facilitating the execution of the survey in their
respective campuses. Last but not least, I would like to thank female Addis Ababa
University students for their willingness to participate in the study and for their interest
and feedback to improve women’s health in Ethiopia.
I would like to express my special thanks and gratitude to the California State
University, Northridge (CSUN) Research & Graduate Studies Thesis Performance
Support Program for finding my thesis worthy of funding and for giving me the honor of
receiving the award to complete my thesis research. iv DEDICATION
I dedicate my thesis to my mother Rukiya Mohamed and my late father
Abdulkadir Ahmed for their endless love, kindness and for being great pillars of support
through my life accomplishments. A special feeling of gratitude to my mother who
remind me daily the progress of my survey research and keeping me focused on my
thesis project.
I also dedicate the thesis to my grandmother Asiya and my late grandfather
Mohamednur Rizkay and late uncle Mohamed-Birhan Ahmed for their love and support
in my journey through life. I also dedicate this thesis to my sisters and brothers for their
encouragements, support and for believing in me all the way since the beginning of my
studies.
This thesis is also dedicated to my husband for his constant love, support and for
being a great source of motivation and inspiration. v TABLE OF CONTENTS
SIGNATURE PAGE……………………………………………...………………………ii
ACKNOWLEDGEMENT……………………………………………...………….……..iii
DEDICATION……………………………………………...……………………….…….v
LIST OF TABLES…………………...………………...……..…………………...…...…ix
LIST OF FIGURES……………….…..……………………...…………………….…….xi
ABSTRACT………………………………………………………………...…………...xii
CHAPTER 1 - INTRODUCTION………………………………………...………………1
Statement of the Problem…………………………………………...……………..3
Purpose of the Study……………………………………………………..………..4
Research Question………………………………………….……………………..4
Conceptual Framework………………………………………….…………….…..5
Alternative Hypothesis….…………….……………………………………….…..6
Limitations………………………………………………………………………...6
Definition of Terms……………………………………………..…………………7
Summary……………………………………………………………..………......11
CHAPTER 2 – LITERATURE REVIEW.……….....……………………...……………12
Introduction…………………………………………………………………..…..12
Human Papillomavirus, Cervical Cancer & Papanicolaou Test……………..…..12
Human Papillomavirus……………………………………..…...………..12
Cervical Cancer………………………………...…..…………...………..13
Magnitude of the Problem of Cervical Cancer…………………..…..…..14
Risk Factors…………………………………………..….………..……..15
Knowledge & Practice of Papanicolaou Test Screening………...……....15
Human Papillomavirus Vaccination……………………..………..……..16
Knowledge of Human Papillomavirus/Cervical Cancer………....…........18
Sexual Behavior………………………………………………………...………..20
Demographics……………………………………………………………..……..21
Barriers To Early Papanicolaou Test Screening…………….……………….…..21
Social Support…………………………………………………………………....23
Summary………………………………………………………………………....24
CHAPTER 3 – METHODOLOGY…………..…………………………...…………..…25
Introduction…………………………………………….…...…………………....25
Organization of the Study………………………………......…………………....25
vi Study Population……………………………………….…...…………………....26
State of Women Education in Ethiopia……………..…………………....26
Study Participant…………………………………………...………………….....28
Survey Design and Instrument…………………………..…………………….....28
Operationalizing Variables……………………………………………....29
Pilot Test……………………………………………………...………….……....34
Study Sample Selection……………………………………….………………....34
Study Sample Size………………………………………………….…………....36
Statistical Analysis…………………………………………………………….....36
Summary………………………………………………………………………....36
CHAPTER 4 – RESULTS………………………………………………...………..……38
Introduction………………………………...……………………….……………38
Survey Instrument Result…………………………………...……………………38
Study Participant Statistical Results………………………………..……………38
Demographics…………………………..….………..…………….…..…39
Education Level………………………..…………...…………….…..….39
Health Status and Living Condition……………….……………………..41
Sexual Behavior………………………………...…………………..……42
Level of Knowledge toward Human Papillomavirus………...……..……44
Level of Knowledge toward Cervical Cancer………...………………….46
Knowledge and Practice of Papanicolaou Test Screening………………49
Barrier to Early Papanicolaou Test Screening…………...……..………51
Social Support…………...…………………………………………….…53
Hypothesis Tests………..…...……………………….……………….…...56
Hypothesis 1…………...……………………….………………...56
Hypothesis 2…………...…………………….…………………...60
Hypothesis 3…………...…………………….…………………...64
Hypothesis 4…………...…………………….…………………...67
Hypothesis 5…………...…………………….…………………...70
Hypothesis 6…………...………………………….……………...73
CHAPTER 5 – DISCUSSION………………..…………………………...………..……76
Introduction……………………………………...………………….……………76
Demographics Characteristics………………………..…………………….……77
Hypothesis 1…………...………………….……….………….……………….…79
Hypothesis 2…………...…………………………………………………………82
Hypothesis 3…………...…………………………………...………………….…85
Hypothesis 4…………...…………………………..…………………………..…87
Hypothesis 5…………...……………………………………..…………..………90
Hypothesis 6…………...…………………………………………………………91
vii CHAPTER 6 – CONCLUSION………………..………………………...………...……93
Conclusion………………..…………………………………………….………..93
Implication for Public Health and Health Education…………….….…….……..94
To the Target Community…………….….…….…………………….…..95
To California State University, Northridge……………….….…….……96
Future Direction/Recommendations…………...…………….…………………..96
REFERENCES………………………………………………………………..…………99
APPENDIX A: Human Subjects Protocol Approval…………………………...…...….113
APPENDIX B: Addis Ababa University Acceptance Letter…………………………...116
APPENDIX C: Survey Questionnaire Cover Letter…….………..……………..……...117
APPENDIX D: Survey Questions For Addis Ababa University Female Students….…119
APPENDIX E: Research Advertisement Flyer…………………………………………128
APPENDIX F: Ethiopia Regional Map………………………………...……...……….129
viii LIST OF TABLES
TABLE 1: Frequency of Participant’s Education Level……….…….……..…….……..40
TABLE 2: Frequency of Graduate vs. Undergraduate by Region of Origin..…….....…..40
TABLE 3: Demographics Characteristics of Sample……..………..…….……………..41
TABLE 4: Frequency of Health Status and Living Condition……….………..………..42
TABLE 5: Frequency of Sexual Behavior……………………..…..…………….....…..43
TABLE 6: Frequencies of Level of Knowledge toward Human Papillomavirus…........44
TABLE 7: Frequencies of Level of Knowledge toward Cervical Cancer…………...….47
TABLE 8: Frequencies of Knowledge and Practice of Papanicolaou test Screening..…50
TABLE 9: Frequencies of Barrier to Early Papanicolaou Test Screening…………..….52
TABLE 10: Frequencies of Social Support……………..…………….………..……….54
TABLE 11: Chi-Square Test Between HPV is Transmitted through Sexual Contact
& Only Women with Multiple Sex Partners need Pap test...……..…….….57
TABLE 12: Chi-Square Test Between Knowledge on Long-term Effects of HPV
Infection and on whether Papanicolaou test Tell if Woman has
Cervical Cancer.……………………………………………………………58
TABLE 13: Chi-square Test between Heard of HPV and Adult Women should have
Pap test each year…………………………………………...…………..….59
TABLE 14: Chi-square Test between Heard of Cervical Cancer and Adult Women
should have Pap test each year……………...…………………………..….60
TABLE 15: Chi-Square Test Between Heard of Human Papillomavirus and Condom
Use by Sexual Activity……………..……...…………..…………..…….…61
TABLE 16: Chi-Square Test Between Heard of Human Papillomavirus and Condom
Use…...…………………………..…...………………..………..…...….…62
TABLE 17: Chi-Square Test between Heard of HPV & Sexual Activity……….…..….62
TABLE 18: Chi-Square Test between HPV Infection Risk Factors & Condom Use.…...63
ix TABLE 19: Chi-Square Test Between Respondent/Family Household Income per
Month and HPV Infection Major Risk Factor of Cervical Cancer……..….65
TABLE 20: Chi-Square Test Between Respondent Education Level and Highest
Risk Group for Acquiring HPV Infection……………………………....….66
TABLE 21: Chi-Square Test Between Respondent Education Level and HPV Infection
Major Risk Factor of Cervical Cancer……………….…………...….....….67
TABLE 22: Chi-Square Test Between Respondent/Family Household Income per
Month and ever had a Pap test……………….………………………....….68
TABLE 23: Chi-Square Test Between Respondent Education Level and ever had a
Pap test……….….………………………....……….………………...……69
TABLE 24: Chi-Square Test Between Lack of Health Service Facility in my Area
Prevented Me from Having Pap test and ever had a Pap test………….…..71
TABLE 25: Chi-Square Test Between Cultural Belief Prevented Me from Having
Pap test and ever had a Pap test………………....……...……………....….72
TABLE 26: Chi-Square Test Between Healthy No Need Pap test and Ever had a
Pap test…..……...……...…..……...……..……...…..……..……...……..…73
TABLE 27: Chi-Square Test Between No one encouraged me to have my first Pap test
and ever had a Pap test…………..………………..…………...………..….74
TABLE 28: Chi-Square Test Between Friend/Partner/Family Member accompany
me to have my first Pap test and Mother had/has Regular Pap test…....…..75
x LIST OF FIGURES
FIGURE 1: World age-standardized incidence rates of cervical cancer………....….……1
FIGURE 2: Conceptual Framework……….…………………………..……..…………...5
FIGURE 3: Percentage Distribution of Charter Cities and Regional State of Addis Ababa
University Female Student Participants………………………………….....39
Figure 4: Response frequency (%) of Knowledge on Human Papillomavirus Infection
Risk Factors………………...………….…………………………………….46
Figure 5: Knowledge on risk factors on the development of cervical cancer among female
Addis Ababa University students.………………………………………….....48
xi ABSTRACT
LEVEL OF KNOWLEDGE TOWARD HUMAN PAPILLOMAVIRUS/CERVICAL
CANCER & PRACTICE OF PAPANICOLAOU TEST SCREENING AMONG
FEMALE ADDIS ABABA UNIVERSITY STUDENTS IN ETHIOPIA
By
Iman Rumana Abdulkadir
Master of Public Health
Health Education
Cervical cancer is the leading cause of cancer-related deaths among Ethiopian
women. This is despite the fact that cervical cancer is preventable through increased
awareness, early screening and vaccination. There is a lack of data on knowledge about
Human Papillomavirus (HPV)/cervical cancer and the practice of Papanicolaou (Pap) test
screening among women in Ethiopia. The present study was carried with the aim to
assess the level of knowledge towards HPV/cervical cancer/Pap test and the practice of
Pap test screening among female Addis Ababa University (AAU) students. A crosssectional survey was conducted from December 2012-February 2013 at the AAU. Data
were collected from a representative sample of 406 participants using self-administered
questionnaires that consisted 37 items. Statistical Package for the Social Science (SPSS)
software, version 18 was employed for data entry and analysis. Among the respondents
(392, mean age 23.28 years) most were single (84.2%) and undergraduates (83.6%).
Only 18.2% of the students reported to be sexually active, of which 54.9% use condom.
About two-third (66.8%) have never heard of HPV and only 46.5% have heard about
cervical cancer. More than half did not know the risk factors of HPV infection, its mode
of transmission or its long-term effect. Only 5.2% had Pap test done of whom 93.7% did
xii not have a friend, a partner or a family member to accompany them. Most (73.8%) do
not discuss cervical cancer/ Pap test with their family. Of those who had Pap test, most
(31.6%) had it at 25 years or older. Most of the respondents (66.8%) reported that no one
encouraged them to have Pap test. Close to half of the students (40-48%) do not consider
lack of health service facility in their area, bad attitude of doctors/nurses or cost to be a
barrier for having Pap test. There are significant associations between knowledge toward
HPV infection/cervical cancer or social support and the responses to the need for Pap test
practice or use of condoms. The data shows that level of knowledge towards
HPV/cervical cancer is low among AAU female students. This study provides insight to
help design public health policies and education that address HPV/cervical cancer and the
practice of Pap tests in Ethiopia.
xiii CHAPTER 1
INTRODUCTION
Cervical cancer is one of the most common cancers in women worldwide with
over 500,000 new cases diagnosed each year (GLOBOCAN 2008 - International Agency
for Research on Cancer (GLOBOCAN 2008 - IARC), 2012; World Health Organization
(WHO), 2012). In 2008 alone about 275,000 women died of cervical cancer (Arbyn et
al., 2011; GLOBOCAN 2008 - IARC, 2012).
Figure 1: World age-standardized incidence rates of cervical cancer
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Of significance is that the number of new cases and deaths per year due to
cervical cancer are disproportionately high in developing countries, amounting to 86%
and 88% of the worldwide cases and deaths respectively (Arbyn et al., 2011). In
addition, when cervical cancer is detected, women in developing countries often present
with advanced case that is not treatable (Denny & Anorlu, 2012). The public health
burden of cervical cancer in poorer countries is shown by the fact that it is the primary
1 cause of cancer-related deaths among women of low-income countries (Arbyn et al.,
2011). This is, despite the fact that cervical cancer is preventable and if caught earlier,
curable (Centers for Disease Control and Prevention (CDC), 2012a; Sahasrabuddhe,
Parham, Mwanahamuntu, & Vermund, 2012). In Africa, although regional differences in
the incidence of cervical cancer exist, the Eastern and sub-Saharan Africa are among the
highest incidence rate regions in the world (Ferlay, et al., 2010).
The summary report on cervical cancer statistics in Ethiopia by WHO/ICOICHPVCC (2010) shows that close to 5,000 women are diagnosed with cervical cancer
each year of which about 70% of women diagnosed with cervical cancer die of the
diseases every year. Cervical cancer is the leading cause of cancer related deaths among
Ethiopian women (Gakidou, Nordhagen, & Obermeyer, 2008; WHO, 2012). While
several factors including lack of awareness on the link between Human Papillomavirus
(HPV) infection and cervical cancer, lack of knowledge and resources for early detection
and treatment all play a role in the high rate of cervical cancer related deaths in resource
poor countries, WHO identifies screening to be a crucial factor for cervical cancer
prevention (WHO, 2006). The public health threat of cervical cancer in Ethiopia is
exacerbated by the lack of data on the awareness and attitude of women towards HPV
infection, Pap tests and cervical cancer, a key component in cervical cancer prevention.
The present study aimed to fill this data gap in Ethiopia by assessing the level of
knowledge, behavior and attitude of female students at Addis Ababa University (AAU),
Ethiopia, concerning Human Papillomavirus related cervical cancer and regular Pap
screening as methods of its early detection. The study is hoped to provide critical
information on one of the key components in cervical cancer prevention and will
2 contribute to a public health policy on cervical cancer in Ethiopia, in general and female
university students-tailored cervical cancer sensitization strategy, in particular.
Statement of the Problem:
The 2010 report of WHO shows that over 3,200 women in Ethiopia die of
cervical cancer every year (WHO/ICO, 2010). Data collected from 57 countries shows
that Ethiopia is one of the three countries in the world with the least number of cervical
cancer screening coverage in women of age 25-64 (Gakidou et al., 2008). When
compared to the world, the age adjusted incidence rate of cervical cancer in Ethiopia is
more than twofold (35.9 cases per 100,000 women) of the world average (16.2 per
1000,000 women) (Ali, Kuelker & Wassie, 2012). Reasons for the high rate of cervical
cancer in a developing country such as Ethiopia include lack of knowledge, lack of
accessibility for health care and the absence of cervical cancer screening. Even when
care is accessible for few, the financial burden of cervical cancer for the overwhelming
majority of women in Ethiopia is prohibitively high (Hailu & Mariam, 2013). Of
significance is that the number of cervical cancer patients, cervical cancer related deaths
and the financial burden is bound to increase as the population of Ethiopia continues to
grow. According to the Central Intelligence Agency (CIA) (2013), the current Ethiopian
population is estimated to be 91,195,675 and of these, 25,536,896 are female of age 15
and above. At the current growth rate of 2.9%, the Ethiopian population will reach
173,611,000 by 2050 (United Nations, Department of Economic and Social Affairs,
Population Division, 2009). This population growth adds urgency to the need to make as
much effort to prevent and treat diseases in general and particularly diseases, such as
cervical cancer, that are preventable through increased knowledge and awareness of the
3 disease and early screenings. Early screening for cervical cancer is a key step in
controlling cervical cancer in resource deficient countries like Ethiopia (WHO, 2006).
However, barriers such as lack of knowledge, attitude and cultural beliefs are crucial
factors that contribute to the low rate of screening (Mosavel, Simon, Oakar, & Meyer,
2009). Thus, for cervical cancer prevention health education, it is imperative to have
baseline data on knowledge and attitude of the target population.
Purpose of the Study:
The purposes of the study is to assess the level of knowledge, behavior and
attitude toward Human Papillomavirus, cervical cancer and the practice of regular
Papanicolaou (Pap) test screening among female students, age 18 and older at Addis
Ababa University, Ethiopia in order to help design an appropriate intervention for
Ethiopian women in the future. To achieve this purpose the following steps were taken:
1.
Design a survey instrument to assess knowledge, behavior and attitude of female
Ababa University (AAU) students.
2.
Administer the survey questionnaire randomly to female AAU students.
3.
Collect, analyze and interpret data to determine the association between
independent and dependent variables.
4.
Draw conclusion and provide recommendation to help alleviate the burden of
cervical cancer among Ethiopian women.
Research Question:
The primary research question of the study is: “Is there a relationship between
level of knowledge, attitude and behavior toward Human Papillomavirus/cervical cancer
4 and practice of Papanicolaou test screening among female students at Addis Ababa
University, Ethiopia?”
Conceptual Framework
The conceptual framework was specifically constructed to guide the hypothesis.
As shown below, there is a bidirectional relationship between “level of knowledge
toward Human Papillomavirus/cervical cancer” and “knowledge/practice of Pap test
screening”. Level of knowledge toward Human Papillomavirus/cervical cancer is
affected by demographics and social support. On the other hand, knowledge/practice of
Pap test screening is influenced by demographic, barriers to early Pap test screening and
social support. Furthermore, demographics is an important factor that has an effect on
barriers to early Pap test screening, sexual behavior and social support.
Figure 2: Conceptual framework
5 Alternative Hypothesis:
The following specific hypotheses were tested:
HA1:
There is a relationship between level of knowledge toward Human
Papillomavirus/cervical cancer and level of knowledge and practice of Pap
test screening.
HA2:
There is a relationship between level of knowledge toward Human
Papillomavirus/cervical cancer and sexual behavior.
HA3:
There is a relationship between demographic and level of knowledge
toward Human Papillomavirus/cervical cancer
HA4:
There is a relationship between demographic and level of knowledge and
practice of Pap test screening.
HA5:
There is a relationship between barriers to early Pap test screening and
level of knowledge and practice of Pap test screening.
HA6:
There is a relationship between social support and level of knowledge and
practice of Pap test screening.
Limitations:
Study limitations are recognized weaknesses in the research that detract from
rigor. (Babbie, 2010). This study will have the following limitation:
1.
The study is limited to one university (Addis Ababa University (AAU)) in
Ethiopia. Other universities could not be included in the study, as
conducting survey at regional universities requires more funds. Thus, the
generalizability of data could be limited.
6 2.
The study could be limited by a non-response bias. For this survey, pen
and pencil self-administered questionnaire are used. Self-administered
questionnaires have the advantage of getting high reported prevalence of
sensitive behavior, such as “sexual behavior” in comparison to that
completed by the interviewer. However, they have the disadvantage that it
will be difficult to control the number of missed questions by responders.
3.
Regional state and ethnic diversity is not proportionally represented in the
study. The university accepts students from all over the country; some of
the regions have lesser literacy rate and hence, may have fewer numbers
of female students coming to AAU. This has limited the number of
representative students from such regions that could have participated in
the survey.
4.
The setting where responders provided answers to written questionnaires
could have influenced responses. For instance, in the presence of friends,
responders may tend to provide socially desirable responses.
5.
The study is not generalizable to general population of Ethiopian women
because collage students are more educated.
Definition of Terms:
The following terms are utilized to address the research questions and intended
population.
Addis Ababa University: is the oldest and the largest university in Ethiopia. According
to Addis Ababa University (AAU) (2011), the number of enrollees to the
undergraduate, graduate and continuing education programs for 2010 was
7 42,497 of which 12,149 were female students. The university provides
education leading to undergraduate (BA/BSc, BEd, Law, MD and DVM
degrees) and graduate degrees (MA/MSc, MEd, MPh, Specialty
Certificate and PhD) in various fields (AAU, 2011).
Cancer:
is a disease in which cells in the body grow and multiply out of control
and the cancerous cells, unlike the normal cells, fail to die. These
multiplying cells form a tumor or abnormal enlargements of tissue, which
may be either benign or malignant. Benign tumors are generally
innocuous and slow growing, whereas malignant tumors, commonly called
cancer, contained abnormal genetic material and grow more rapidly.
Cancer has the tendency to invade neighboring tissue/organ or to
metastasize and to grow in other parts of the body. Cancer is classified
according to its organ or tissue of origin, even if it spreads to other body
parts later (American Cancer Society (ACS), 2013a).
Carcinogen: is an agent with the potential to cause cancer (Genetic Home Reference
(GHR), 2013a).
Carcinoma: is “cancer that begins in the skin or in the tissues that line or cover internal
organs” (GHR, 2013b).
Cervix:
is the narrow, lower part of the uterus extending into the vagina (Marieb &
Hoehn, 2012).
Cultural Beliefs: refers to “the thoughts and ideas that are shared by several individuals
and that govern interaction between them and other groups. Cultural
8 beliefs differ from knowledge in that cultural beliefs are not empirically
discovered and analytically proved” (Greif, 1994).
Deoxyribonucleic Acid (DNA): is a self-replicating hereditary material present in
humans and nearly all-living organisms. It is the carrier of genetic
information (GHR, 2013c).
Dysplasia:
is “cells that look abnormal under a microscope but are not cancer;
abnormal growth or development of organs or cells” (GHR, 2013d).
Epithelium: is a primary tissue that covers the body surface, lines its internal cavities,
and forms glands (Marieb & Hoehn, 2012). Ethiopia:
is an east African country located west of Somalia. It is bordered by The
Sudan and Eritrea on the North; by the Sudan and South Sudan on the
West; by Kenya and Somalia on the South; by Djibouti and Somalia in the
East. According to the United State of America Central Intelligence
Agency (CIA) (2013) Ethiopia’s estimated population is 93,877,025 with
26,236,896 aged 15 and above female population. The median age of
male and female population is 16.5 and 17.1 years respectively (CIA,
2013).
Glandular cells: are tall type of cells that looks like columns. They are “mucusproducing cells located toward the top of the endo-cervical canal that help
guard the entrance to the uterus” (National Cancer Institute-National
Institute of Health (NCI-NIH), 2009).
Health care: is “the maintaining and restoration of health by the treatment and
prevention of disease especially by trained and licensed professionals (as
9 in medicine, dentistry, clinical psychology, and public health)” (MerriamWebster, 2013).
Human Papillomavirus: are small DNA viruses that can cause chronic infection and
malignant transformation, such as cervical cancer in women (Nelson &
Williams, 2007). The group comprises more than 150 related viruses but
only about 40 of the viruses are transmittable through sexual intercourse
and can infect both women and men (Nelson & Williams, 2007).
Metaplasia: is “the change in the type of adult cells in a tissue to a form abnormal for
that tissue” (The Free Dictionary: Medical Dictionary, 2013b)
Oncogenic:
refers to “giving rise to tumors or causing tumor formation (The Free
Dictionary: Medical Dictionary, 2013a)
Papanicolaou (Pap) Test: is a procedure commonly used to detect abnormal cellular
changes of the cervix, usually as a result of HPV infection, while they are
still benign and easily treatable (CDC, 2013a).
Squamous cells: is thin, flat type of cells that cover inside and outside surface of the
body. “They are found in the tissues that form the surface of the skin, the
lining of the hollow organs of the body (such as the cervix, bladder,
kidney, and uterus), and the passages of the respiratory and digestive
tracts” (NCI-NIH, 2009).
Uterus:
is hallow, thick-walled organ in the lower body of a female that receives,
retains, and nourishes fertilized egg; site where embryo/fetus develops
(Marieb & Hoehn, 2012).
10 Summary
Cervical cancer is the leading cause of cancer related deaths in Ethiopia. The
health and cost burden of cervical cancer in Ethiopia thus remains high. A unique feature
of cervical cancer is that it can be prevented through awareness, protective vaccinations
and early screening measures. In order for this to be implemented, however, availability
of scientific data on the level of awareness of the target community is crucial. There is
only limited data on Human Papillomavirus (HPV) and cervical cancer in Ethiopia. More
specifically, there is no data on this in one of the vulnerable segment of the community,
female university students of Ethiopians. In the absence of baseline a meaningful public
health policy progress towards reducing or preventing cervical cancer is a far cry. It is in
this context that the research project “Level of Knowledge toward Human
Papillomavirus/Cervical Cancer & Practice of Pap Test Screening among Female Addis
Ababa University Students in Ethiopia” was conceived and conducted. This study
provides the first data on the level of knowledge of female students of the Addis Ababa
University, Ethiopia, on HPV/cervical cancer and the practice of Pap test screening. The
data will contribute to the overall effort of reducing and preventing cervical cancer in
Ethiopia.
In the subsequent sections of the thesis, literature review followed with
methodology, result, discussion and conclusion will be presented.
11 CHAPTER 2
LITERATURE REVIEW
Introduction
In this chapter, literature is reviewed to examine the types of Human
Papillomavirus (HPV), the Pathophysiology HPV infection and cervical cancer. The
section also reviews the morbidity and mortality trends of (HPV), cervical cancer and the
practice of Pap test. In addition, the section also highlights the different risk factors,
barriers to screening, and social support variables that influence HPV infection and
cervical cancer globally in women and specifically in Ethiopian women.
Human Papillomavirus, Cervical Cancer and Papanicolaou Test
Human Papillomavirus
Human Papillomavirus (HPV) is a small deoxyribonucleic acid (DNA) virus that
is transmitted through sexual intercourse and infects both women and men (Nelson &
Williams, 2007). In most cases, HPV infection does not cause symptoms and most
women get rid of it naturally. However, when infection persists, chronic infection could
lead to malignant transformation such as cervical cancer in women (Nelson & Williams,
2007). The HPV group comprises more than 150 related viruses but only about 40 of the
viruses are transmittable through sexual intercourse and can infect both men and woman
(NCI-NIH, 2012). Out of 40 sexually transmittable HPV strains, about 13-15 are
considered to be of high risk viruses that cause cervical cancer (CDC, 2012b). These
include HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82 (Muñoz et al.,
2003). Of these high-risk viruses, HPV types 16 and 18 are responsible for up to 70% of
12 the cervical cancer cases, while HPV 16 is responsible for 85% of rare anal cancers
(Schiffman, Castle, Jeronimo, Rodriguez, & Wacholder, 2007; Muñoz et al, 2003).
Cervical Cancer
Cervical cancer is a slow growing cancer that arises from the epithelium covering
the tip of the cervix and it is consider a sexually transmitted disease (NCI-NIH, 2009).
There are four major steps in the cervical cancer development: 1) Human Papillomavirus
(HPV) infection of cervical epithelium 2) viral persistence, 3) progression of persistently
infected epithelium to cervical pre-cancer, and 4) invasion through the basement
membrane of the cervical epithelium (Schiffman, Casttle, Jeronimo, Rodriguez &
Wacholder, 2007). Nearly, all cervical cancer cases are due to persistent infection with
about 13-15 carcinogenic HPV (Schiffman et al., 2007).
Depending on the cell type involved, cervical cancer could be squamous cell
carcinoma, wherein the cancerous cells are the flat cells in the inner most surface of the
cervix, or cervical adenocarcinoma, wherein the involved cells are the glandular cells in
the inner lining of the cervix (NCI-NIH, 2009). Cervical cancer is divided into five
stages based on the degree of the disease. Early stage of cervical cancer are characterized
by dysplasia; stage 1 to 3 characterized by pre-invasive changes in the cervix called
cervical intraepithelial neoplasia (CIN) and stage 4 of invasive cancer within or outside
of the cervix (ACS, 2013a). According to Schiffman et al. (2007), most cases of invasive
cervical cancers are due to squamous cell carcinomas. Although early stages of cervical
cancer presents with no symptoms, at advanced stage, it may cause symptoms such as
pelvic pain and vaginal bleeding during intercourse, bleeding outside of the periods for
cycling women and after menopause (ACS, 2013c).
13 Magnitude of the Problem of Cervical Cancer
Cervical cancer is a global public health problem accounting for over 500,000
new cases and over 250,000 deaths worldwide each year (GLOBOCAN 2008 - IARC,
2012 & WHO, 2012). The most recent data from the NCI-NIH (2013) indicates that, an
estimated 12,340 new cases and 4,030 deaths from cervical cancer occur in the United
State of America (USA) in 2013. On the other hand, more than 86% of cervical cancer
cases occur in poor countries (Arbyn et al., 2011; GLOBOCAN 2008 - IARC, 2012).
According to GLOBOCAN 2008 – IARC (2012), Eastern and Western Africa are the two
regions with the highest age standardized cervical cancer rate (30 per 100,000) in the
world. Smith, Melendy, Rana, & Pimenta (2008) showed that, in the 25-35 age group,
Human Papillomavirus infection rate in females is the highest in Africa (20%) than other
regions of the world.
In Ethiopia, cervical cancer is the first leading cause of cancer mortality among
women (WHO/ICO- ICHPVCC, 2010). The summary report on cervical cancer statistics
in Ethiopia by WHO/ICO- ICHPVCC (2010) shows that close to 5,000 women are
diagnosed with cervical cancer each year. Out of these, about 70% of women diagnosed
with cervical cancer die of the disease every year. Given the limited available data, it is
possible that the prevalence and death rate may be even higher than the number reported.
Since there is shortage of health services in low-income countries, early detection
through Pap test or through other affordable screening methods is considered to be the
most effective and available method to decreases and prevent cervical cancer (WHO,
2006). Gakidou et al. (2008) showed that cervical cancer screening coverage in Ethiopia
is one of the lowest in the world. Available data show that the Ethiopian national average
14 coverage of cervical cancer screening is 0.6% and is even lower (0.4%) in rural areas
(WHO/ICO- ICHPVCC, 2010). While resources are important, knowledge and behavior
are also important societal factors that could have an impact on cervical cancer screening
coverage.
Risk Factors
Human Papillomavirus (HPV) is now well established to be the primary cause of
cervical cancer (Bosch, Lorincz, Muñoz, Meijer & Shah, 2002). Most women get HPV
infection in their lifetime. While most women get rid of HPV infection naturally, in
some, the infection persists and can cause cervical cancer (CDC, 2013b). Risk factors for
HPV infection include multiple sexual partners, having a partner who has had many
partners, being younger than 25 years of age, starting to have sex at an early age (16
years or younger) and having a male partner who is not circumcised (ACS, 2013b).
Failure to use condom can also increase the risk of HPV infection (CDC, 2013a). In
addition to having HPV, other risk factors for cervical cancer include, smoking, having
human immunodeficiency virus (HIV), compromised immune system, using birth control
pills for a long time (five or more years) and having given birth to three or more children
(CDC, 2011). Given that HPV infection is the main cause of cervical cancer, risk factors
for HPV infection are also risks for development of cervical cancer.
Knowledge and Practice of Papanicolaou Test Screening
Papanicolaou test (Pap test) can determine whether cells on the cervix may have
changed to become cancerous (CDC, 2012a). According to CDC, (2012a), Pap test
screening should begin at age twenty-one. The general recommendation of the United
States Preventive Service Task Force (2013) for cervical cancer screening (Pap test) for
15 women aged 21-65 is to be every 3 years while the recommendation for women older
than 65 years old and for those who want to have longer interval of screening to be every
5 years. However, Vesco et al. (2011) state that Pap tests should be done every one to
five years depending on the woman’s individual risk factors. Women with multiple
sexual partners, early onset of sexual intercourse, positive Human Papillomavirus (HPV)
test, and women who smoke and have many children are considered at high risk for HPV
infection, and thus for cervical cancer, and should be tested annually (Vesco et al., 2011).
In a matched case-control study on cervical cancer patients, a recent report showed that a
2 or 3 years Pap test intervals carry a higher risk to develop cervical cancer when
compared to a yearly screening (Miller, Sung, Sawaya, Kearney, Kinney & Hiatt, 2003).
One of the major challenges in cervical cancer prevention in developing countries,
such as Ethiopia, is the low coverage of cervical cancer screening. The Ethiopian
national average coverage of cervical cancer screening, for 18-69 years age group, is
0.6% and is 0.4% for the rural areas of the same age group (WHO/ICO- ICHPVCC,
2010). A similar report highlights also that the cumulative risk factor for cervical cancer
among Ethiopian women is more than two fold than that of the world average (Ali et al.,
2012). In addition to Papanicolaou test (Pap test), Human Papillomavirus (HPV) test is
done to determine the virus type that can cause changes to the normal cells of the cervix,
hence, CDC, (2012b) suggests having HPV test along with Pap test for women 30 and
older.
Human Papillomavirus Vaccination
One way to decrease the risk of genital Human Papillomavirus (HPV) infection is
through preventative measures such as vaccination. According to the CDC (2013a), there
16 are two types of vaccines; Cervarix (GlaxoSmithKline) and Gardasil (Merck). In 2006,
Gardasil are licensed and approved by the Food and Drug Administration to be used for
female aged 9 through 26 years. Gardasil works by protecting females against the most
common types of HPV, HPV types 6, 11, 16, and 18, that causes cervical cancer. In
addition to protecting against cervical cancer, Gardasil also protects against anal, vulvar
and vaginal cancers and genital warts (U.S. Food and Drug Administration, 2011).
Both vaccines, Cervarix and Gardasil, are given in 3 shots over 6 months.
Although Human Papillomavirus (HPV) vaccines are effective in preventing HPV
infection and related cervical cancer, their cost could be limiting, especially for women of
poor countries like Ethiopia. In deed, even in developed countries, such as the USA, cost
is one of the barriers that limit HPV vaccination among female undergraduate students in
the southeastern university (Burke, Vail-Smith, White, Baker, & Mitchell, 2010).
Currently, the vaccine price is estimated to be about $130 per dose ($390 for full series)
(CDC, 2012b). Information on cervical cancer vaccination in Ethiopia is scarce. Given
that cervical cancer screening coverage is low in developing countries like Ethiopia
(0.6%), HPV vaccination could have a higher impact (Ali et al, 2012). However, the
cost-effectiveness of HPV vaccination needs to be known to assess the feasibility of a
vaccination program. Using Cost-effectiveness analysis (CEA) models, as health care
assessment method, Techakehakij & Feldman (2008) showed HPV vaccination, at the
2004 cost, is cost effective in 46 developed countries (only a quarter of countries in the
world), with per capita Gross Domestic Product of $8505. In a recent cost effective
analysis study by Goldie et al., (2008), if funds are available for Global Alliance for
Vaccines and Immunizations (GAVI) eligible resource poor countries, vaccination
17 against HPV 16/18 is estimated to reduce the mean life time risk of cervical cancer in
Ethiopia by 60% (Goldie et al., 2008). However, before the introduction of HPV
vaccination, the acceptability of HPV vaccine by the community and the feasibility of
delivery of vaccines need to be determined. In this regard, a pilot study by PATH (2013)
reported the acceptability of HPV vaccine by the community as well as the feasibility of
vaccine delivery through government school programs. Obviously these studies need to
be done in a larger scale, to have fruitful vaccination program. Knowledge of Human Papillomavirus/Cervical Cancer
Several studies show that lower level of knowledge associated with lower rate of
cervical cancer screening and higher rate of cervical cancer. In a community-based study
in Arizona, knowledge about Papanicolaou (Pap) test and the use of cervical cancer
screening were lesser among Hispanic women with lower acculturation (Harmon, Castro,
& Coe, 1997). In line with this, Mexican-American women in Texas who knew about the
detection methods of cervical cancer and its guidelines were “more likely to have had a
recent screening” and suggested that “the low screening participation among MexicanAmerican women may be due to their limited awareness and knowledge about breast and
cervical cancer screening examinations” (Suarez, Roche, Nichols & Simpson, 1997).
Similarly, a study that examined knowledge, attitudes, and screening behaviors about
breast and cervical cancer, among adult Hispanics in the United State of America (USA),
knowledge was shown to be significantly related with recent screening history (Ramirez,
Suarez, Laufman, Barroso, & Chalela, 2000).
The level of knowledge about Human Papillomavirus (HPV), Papanicolaou (Pap)
test and cervical cancer are even lower in resource poor communities. Pap smear
18 utilization is shown to be higher among those with higher levels of education and
socioeconomic status in a cohort of 290 Lebanese/Armenian women (Arevian,
Noureddine, & Kabakian, 1997). On the other hand, in a descriptive exploratory study,
McFarland (2003) showed that knowledge about cervical cancer screening was low
among participants and among the low-income women. A study on awareness towards
HPV and cervical cancer among university female students in Nigeria showed that only
35.5% of the sampled students knew of HPV and as much as 91.7% of female nonmedical students had never heard of Pap smear screening (Iliyasu, Abubakar, Aliyu &
Galadanci, 2010). In a similar study, among female university students in South Africa,
about 40% are sexually active and only about 33% of those who heard of cervical cancer
knew HPV was a risk factor for cervical cancer (Hoque, 2010). By contrast, In the USA,
a study at the University of California, Fullerton showed most of the college women
knew about HPV (Lopez & McMahan, 2007). In an Australian study, among 90 women
aged 18-30 years, 89% knew about HPV (Giles & Garland, 2006). However, even at this
higher rate of women with knowledge about HPV and cervical cancer, 79.5% of the
respondents in the University of California, Fullerton study rated their knowledge about
HPV to be poor (Lopez & McMahan, 2007) and the Australian study suggested the need
for further education regarding HPV infection (Giles & Garland, 2006). In Ethiopia, such a study among university students is so far not available. The
only study on knowledge of Papanicolaou (Pap) smear screening was done in women
who sought reproductive health care at three teaching hospitals in Addis Ababa (Terefe &
Gaym, 2008). In this study, out of the 278 reproductive health patients, the majority
(81.2%) had never heard of Pap smear screening. Information on knowledge and
19 behavior of Ethiopian university students would help develop policies that particularly
target the health burden of female university students and the larger female community in
Ethiopia.
Sexual Behavior
Several groups of studies have clearly shown that Human Papillomavirus (HPV)
is predominantly and largely transmitted through sexual intercourse. Epidemiological
studies show that HPV infection prevalence is high among sexually active women of 1830 years old (Burd, 2003). Studies investigating the risk factors associated with the
presence of genital HPV have shown that the number of sexual partners is one of the key
determinants of HPV infection in women (Kjaer, et al., 2001). In a case control study
among women in four Latin American countries, Herrero et al., (1990) showed
association between early age at first sexual intercourse and increasing number of sexual
partners with invasive cervical cancer. The study showed that the likelihood of having
invasive cervical cancer among women with a reported first sexual intercourse age of 14
to 15 years, compared with >20 years, is two fold higher.
Likewise, consistent use of condom by male partner is shown to reduce Human
Papillomavirus (HPV) infection while non-use even in less than 5% of the time is
associated with higher risk of contracting infection by the female (Winer et al., 2006). A
cross-sectional investigation of high-risk men in a multi ethnic community in Tucson
who visited a public sexually transmitted disease clinic showed that regular condom use
was associated with reduced risk for oncogenic and overall penile HPV infection
(Baldwin et al., 2004).
20 Demographics
Cervical cancer prevalence due to Human Papillomavirus (HPV) is higher over
age 30 (CDC, 2012c). Awareness of cervical cancer and adherence to preventive
measures vary based on education level and cultural background. Women with high
educational levels use more preventive measures including Pap test screenings than less
educated women (Hofer & Katz, 1996). Cervical cancer is also disproportionately high
in resource poor countries (WHO, 2006). In the USA, despite a general decline in
cervical cancer prevalence, a temporal cervical cancer incidence and mortality study
showed that “cervical cancer incidence and mortality rates increased with increasing
poverty and decreasing education levels for the total population as well as for nonHispanic white, black, American Indian, Asian/Pacific Islander, and Hispanic women”
(Singh, Miller, Hankey & Edwards, 2004). On the other hand, assessment of factors that
are associated with invasive cervical cancer diagnosis in women who had health plan by
the time of diagnosis showed that being older, residing in higher poverty areas or having
a lower education level was associated with failure to seek for Pap test screening 3-6
months prior to diagnosis (Leyden et al., 2005). Still others have shown that in a multiethnic cohort study of English speaking women who visited ambulatory obstetric,
gynecology clinic in Chicago, when compared to ethnic or educational background, poor
health literacy was better in predicting knowledge about cervical cancer screening
(Lindau et al., 2002).
Barriers to Early Papanicolaou (Pap) Test Screening
A number of barriers could thwart efforts towards early cervical cancer screening.
The four types of barriers to cervical cancer screening are economic, structural,
21 informational, and individual/cultural. Specifically, the factors include lack of access to
medical care; lack of knowledge about Human Papillomavirus (HPV), its mode of
transmission and its risk of causing cervical cancer; lack of knowledge and attitude
toward importance of regular screenings; lack of financial resources to afford Pap exams
(McFarland, 2003). Women who do not practice routine Pap tests have a significantly
higher risk of developing cervical cancer (Dailard, 2003).
Cultural beliefs could also be barriers against seeking and adhering to Pap test
(Mosavel, Simon, Oakar, & Meyer, 2009). A study that included women both from rural
and urban areas of Mexico, showed that the primary barriers for cervical cancer screening
among women were lack of knowledge about cervical cancer cause and Pap test,
although other factors such as relationship problems with care providers, fatality and cost
also play role (Lazcano-Ponce et al., 1999). In a more recent rural Mexico study anxiety
over physical privacy is reported to be a major barrier for cervical cancer screening
(Watkins, Gabali, Winkleby, Gaona & Lebaron, 2002). In Botswana, a study identified
inadequate knowledge about Pap smear testing, negative attitudes of health professionals
and the limited access to doctors as major barriers to Pap smear screening (McFarland,
2003). In the USA, a study among Korean-American women showed structural and
psychological barriers to cervical cancer screening; the structural factors included
economic and language problems while the psychological barriers identified included
misinformation and a lack of knowledge about cervical cancer as well as fear/fatalism
and denial (Lee, 2000). A study on barriers and benefits of cervical cancer screening
among women in five Latin American countries showed also that access to quality
22 services, lack of privacy, costs, and courtesy of providers (Agurto, Bishop, Sánchez,
Betancourt & Roblesa, 2004) to be the main barriers for cervical cancer screening.
Although detailed data on cervical cancer related factors and barriers are not
available in Ethiopia, factors that are shown or estimated to play role in sub-Saharan
Africa are likely to apply to the Ethiopian condition as well. Anorlu (2008), in a review
regarding cervical cancer in sub-Saharan Africa, has identified socio-economic (poverty
and its ramifications such as access to medical care, hygiene…etc), biologics
(malnutrition, co morbidities, with TB, HIV/Aids, malaria, STD…) and lack of
knowledge/awareness about cervical cancer, Pap test and HPV as barriers to screening
and factors that contribute to the higher prevalence of cervical cancer.
Social Support
As stated by Gamarra, Paz & Griep (2009), social support is an important factor
in early cervical cancer detection by encouraging the practice of Papanicolaou (Pap) test.
Support from family members, close friends and doctors provide encouragement and
guidance to do Pap test suggesting that social support plays a key role in increasing
awareness about cervical cancer, Pap test and adherence to the Pap tests. Several studies
support these claims. A study in Singapore showed that women who “reported ever
having a Pap smear were more likely to have close friends with whom they could discuss
health (adjusted odds ratio (OR) 2.1, 95% confidence intervals (CI) 1.2–3.6)” (Seow,
Huang & Straughan, 2000). The importance of social support in cancer screening in
general and in cervical cancer specifically is further exemplified by data where low level
of cervical screening is observed, among some women, despite access to mammograms
and Pap test services (Gotay & Wilson, 1998). Based on their findings, authors of the
23 above study recommended improving social support as one of the tools to increase
cancer-screening rate and thereby reduce mortality among high-risk women.
Summary
The literature review section provided the latest available relevant information to
the study, including the state of cervical cancer in the world at large and in Ethiopia in
particular. Current information on knowledge towards Human Papillomavirus (HPV)
infection and cervical cancer as well as the practice of Papanicolaou (Pap) test, barriers to
early screening that have impact on cervical cancer are provided. This information not
only will help understand the rationale for the study but also will help health
professionals and policy makers to appraise the public health concern of HPV/cervical
cancer in Ethiopia.
24 CHAPTER 3
METHODOLOGY
Introduction
This chapter will outline the organization of the study followed with the
description of the study design and instruments used, the study population,
operationalization of variables and the statistical analysis employed.
Organization of the Study
The study was organized following the California State University, Northridge
(CSUN) thesis preparation guidelines. After the conception of the thesis idea, the
graduate advisor, Dr Vicki Ebin was consulted and the idea was approved. Following the
approval, the Graduate Thesis Committee was selected by the researcher. The committee
is composed of three full-time faculties: Vicki J. Ebin, PhD., MSPH, committee chair;
Lawrence Chu, PhD., MPH, MS and Sloane Burke, PhD., CHES, committee member,
from Department of Health Sciences, CSUN. The graduate research proposal was then
written by the researcher and developed with inputs from the Graduate Thesis Committee
chair. The final proposal contained the following sections: Introduction, Statement of the
Problem, Purpose of the Study, Study Limitations, Research question, hypothesis,
Definition of terms, Methodology outline, Literature Review, Implications and
Significance to the field of Health Education and Public Health, Proposed thesis chapters
and Reference. The proposal was submitted to the Institutional Review Board (IRB) at
CSUN to obtain approval for the use of human subjects in the research study. The CSUN
IRB declared this research as exempt on November 2012 (Appendix A).
In the meantime, the Addis Ababa University collaborators: Dr Jemal Hider, Dean
25 of School of Public Health and Dr Fikre Enquselassie, Head of Department of Preventive
Medicine at School of Public Health, were contacted and approval of collaboration
obtained (Appendix B). After preparing the necessary survey questionnaire printouts,
flyers and IRB approval, the researcher travelled, in December 2012, to Addis Ababa,
Ethiopia. The researcher met with Dr Fikre Enquselassie, discussed the details of the
project and planned the actual execution of the survey. The survey was then carried out
from December 2012 through February 2013 in Addis Ababa Ethiopia. Data collected
were brought to California State University, Northridge (CSUN). Data were collected,
analyzed and thesis written from February to May 2013. The study was performed
following the CSUN IRB approval and guidelines.
Study Population
Addis Ababa University (AAU) students are diverse in their ethnic background
because they represent the nine ethnically based administrative regions and two chartered
cities (Appendix F). According to AAU (2011), the number of female students enrolled
in undergraduate, graduate and continuing education programs in 2010 was 12,149.
State of Women Education in Ethiopia:
Data from the Federal Democratic Republic of Ethiopia, Ministry of Education of
Ethiopia show that there is a gender gap in enrollment at all levels of education as well as
inequalities in educational leadership (Federal Democratic Republic of Ethiopia-Ministry
of Education (FDRE-MOE), 2011). Despite significant improvement in girl’s education,
in 2009/2010, the gender parity index (GPI) for girl’s enrollment to primary cycle-1
(grades 1-4), primary cycle-2 (grades 5-9), secondary cycle-1 (grades 9-10) and
secondary cycle-2 are 0.93, 0.97, 0.80 and 0.46 respectively (FDRE-MOE, 2011).
26 Further more, the grade 5 and grade 8 completion rates for girls are only 73.7% and
44.5% respectively (FDRE-MOE, 2011). Similar trend of gender gap in enrollment is
reported by the United Nations Educational, Scientific and Cultural Organization
(UNESCO) (2012), whereby, at the end of 2009, the GPI based primary education
enrollment for girls was 0.94 while that of secondary enrollment was 0.77. In addition,
while the overall adult functional literacy rate in Ethiopia is low (40%), it is
disproportionately low among females (18% for females vs 42% for males) (FDREMOE, 2011 & UNESCO, 2012). In other words, about 4 out of 5 over the age of 15
years old Ethiopian women (82%) compared to about 1 out of 2 similar age Ethiopian
men (42%) are illiterate. The gender gap in enrollment is even more when compared
between urban and rural areas. For instance, in 2003/2004, the enrollment rate for
primary level (grades 1-8) in the urban area, Addis Ababa, was 97.6% for females and
90.3% for males (Pereznieto & Jones, 2006). By contrast, in the rural regions such as the
Southern Nations, Nationalities and Peoples (SNNP), Somali and Afar, the enrollment
rate of females compared with males was 52.6 % vs 74.2%, 7.8% vs 14.8% and 9.0% vs
12.6% respectively (Pereznieto & Jones, 2006).
While several factors play role for the overall low level of literacy and gender
disparity in education in Ethiopia, poverty is the main factor (UNESCO, 2012).
However, other factors including socio-cultural norms, whereby females are related to
mainly household work; the urban vs rural dwelling; having or not having literate
parents; gender based violence; lack of females in educational positions to look up to;
lack of schools that accommodate girl/women needs such as separate toilets; are reported
to play role in the low level of female education in Ethiopia (UNESCO, 2012; Pereznieto
27 & Jones, 2006 and Rose & Al‐Samarrai, 2001). Such a low level of literacy, particularly
among females, as well as the cultural taboo on issues of sex related diseases and the lack
of resources to educate women through print media, television or radio limit knowledge
and awareness of women in Ethiopia on sexually transmitted diseases.
Study Participant
Inclusion Criteria: The study participants for this study were Addis Ababa
University’s (AAU) full time undergraduate and graduate female students, age of 18 and
older. There is no upper age limit because most graduate students are working and are
likely to be older students. Exclusion Criteria: Part time AAU female students were not
considered for the study. The rational for exclusion was that the AAU does not provide
free meal for part time students, unlike for regular/full time students, and hence, the part
time students are not accessible for a random sampling that was designed to take place at
the cafeteria.
392 AAU female students were recruited for this from the following Addis Ababa
University’s (AAU) Colleges and Institutes: 1) College of Social Sciences, College of
Humanities, Language Studies, Journalism & Communication, College of Law and
Governance Studies, College of Education & Behavioral Studies, College of Natural
Sciences, College of Health Sciences, Ethiopian Institute of Architecture, Building
Construction and City Development and Addis Ababa Institute of Technology.
Survey Design and Instrument
According to Babbie (2010), a cross sectional study allows gaining specific
information at a particular point in time. Thus, a quantitative cross sectional study design
was implemented. The study was conducted from December 2012 to February 2013 at
28 the Addis Ababa University (AAU), Ethiopia. AAU is chosen because it is the oldest and
the largest university that accepts students from all the 11 regions of the country that
represent different geographic and ethnic groups. Thus, the chance to get a representative
sample of the target population is better at AAU than any other university in the country.
In this study, a survey questionnaire was used as the data collection tool
(Appendix D). The survey questionnaire was designed based on the literature review.
The survey questions were adapted from an earlier survey questionnaire with minor
changes (Lenselink et al., 2008). The survey instrument was developed in English due to
the fact that English is the teaching medium at the Addis Ababa University. In addition,
the AAU female students are ethnically diverse and speak different languages and
English is one of the common languages among the participants. The questionnaire was
anonymous and in all instances, students were informed that the survey is voluntary and
that they can withdraw from the study any time without any repercussion (Appendix C).
Operationalizing Variables:
The Addis Ababa University Female Students Survey Questionnaire consisted of
37 questions that fall into seven sections (Appendix D). Independent variables for this
analysis include age, region of origin, education level, income, marital status, barriers to
early Pap test screening and social support. On the other hand, the dependent (outcome)
variables for this analysis are level of knowledge toward Human Papillomavirus/cervical
cancer and level of knowledge/attitude/practice of Papanicolaou (Pap) test and sexual
behavior (Figure 2). These variables are used to test the proposed hypotheses.
In this analysis, the response “strongly disagree, disagree, do not know, strongly
agree & agree" were collapsed to four categories (strongly disagree, disagree, strongly
29 agree & agree), due to the fact that those who responded - do not know - were coded as
missing. The reason for collapsing the do not know category is because the frequency of
the do not know category was higher than the other categories and resulted in highly
significant (Chi-square test) relationship among variables. Thus, to avoid bias in the
analysis of relationship between the independent variables and the dependent variable
(knowledge), only the non-neutral responses (agree, strongly agree, disagree and strongly
disagree) were considered while the neutral response (do not know) was coded as
missing.
Demographic:
Respondent’s “region of origin” was assessed using question (Q2) in the survey.
The response for this question comprised twelve categories. Due to a small percentage in
some categories, “region of origin” was recoded into 6 categories where responses for
Afar/ Dire-Dawa/Harari/ Somali have been combined and created as new category.
Respondent’s “education level” was assessed using (undergraduate/graduate) question
(Q3) in the survey and is used as dichotomous variable. Respondent’s income was
assessed using “your/your family’s total household income per month” question (Q6) in
the survey. The response for this question comprised four categories.
Level of knowledge toward Human Papillomavirus/cervical cancer:
In this study “level of knowledge toward Human Papillomavirus (HPV)/cervical
cancer” is operationalized as “heard of HPV”, “highest risk group for acquiring HPV
infection”, “transmission of HPV, “long term effects of HPV infection” and “HPV
infection major risk factor for cervical cancer”.
“Heard of HPV” was assessed using question (Q13) in the survey and is used as
30 dichotomous variable (yes/no). The measurement of “highest risk group for acquiring
HPV infection” was surveyed under question (Q14). The response for this question was
recoded into a “correct response /incorrect response” and used as dichotomous variable.
Similarly, question on “transmission of HPV” (Q19) in the survey employs dichotomous
response (correct response /incorrect response). “Long term effects of HPV infection”
was measured using question (Q20) in the survey and is used as dichotomous variables
(correct response /incorrect response). “HPV infection major risk factor for cervical
cancer” was assessed using question (Q25A) in the survey and the response the question
consisted of four categories (strongly disagree, disagree, strongly agree & agree).
Knowledge and Practice of Papanicolaou Test Screening:
In this study “knowledge and practice of Papanicolaou (Pap) test screening” is
operationalized as “ever had a Pap test”, “mother had/has regular Pap test”, “only women
with multiple sex partners need Pap test” and “Pap test tell if a woman has cervical
cancer”.
“Ever had a Pap test” was assessed using question (Q26) in the survey. The
response for this question comprised three categories (yes, no & not sure). Similarly,
question on “mother had/has regular Pap test question (Q30) in the survey employed
categorical response (yes, no & not sure). The response to “only women with multiple
sex partners need Pap test” was surveyed under Q31C, using a categorical response
(strongly disagree, disagree, strongly agree & agree). However, when the response to
Q31C and Q19 (transmission of HPV) were used to assess the relationship between “level
of knowledge toward Human Papillomavirus/cervical cancer” and “knowledge and
practice of Pap test screening”, it was found that the expected cell count was more than
31 20%. As this violates the condition to use chi-square test (no more than 20% of the cells
should have expected counts less than 5), the response categories were collapsed in to
dichotomous variable (strongly disagree/disagree & strongly agree/agree) (Table 11).
Question on “Pap test tell if a woman has cervical cancer” was assessed using Q31A in
the survey. The response for this question comprised four categories (strongly disagree,
disagree, strongly agree, & agree).
Sexual Behavior:
In this study “sexual behavior” is operationalized as “condom use” and “sexual
activity”. The measurement of condom use employs question (Q12) in the survey.
“Condom use” was divided into five categories: not sexually active, never use condom,
sometimes use condom, most often use condom & always use condom. Those who chose
“sometimes”, most often” and “always” were coded “yes & sexually active”, whereas
those who chose “never” coded as “never & sexually active”. Therefore, the variables
are collapsed into three categories (yes & sexually active, never & sexually active & not
sexually active). Furthermore, from the three collapsed categories, those who responded
that they were “not sexually active” were coded as missing and “condom use” was again
recoded into “yes/no” and is used as dichotomous variable in chi-square analysis. Thus,
“condom use” was used both as categorical and dichotomous variables. Further more,
respondent’s sexual activity was assessed using “have you ever had sexual intercourse”
question (Q9) in the survey. The response category was “yes/no” and is used as
dichotomous variable.
32 Barriers to Early Papanicolaou Test Screening:
In this study, “barriers to early screening” is operationalized as “lack of health
service facility in my area prevented me from having Papanicolaou (Pap) test’, “cultural
belief prevented me from having Pap test” and “healthy no need Pap test”.
While assessing the relationship between “barriers to early Pap test screening”
and “knowledge and practice of Pap test screening” using categorical responses
“strongly disagree, disagree, strongly agree & agree”, it was found that the expected cell
count was more than 20%. As this violates the condition to use chi-square test (no more
than 20% of the cells should have expected counts less than 5), the response categories
were collapsed in to dichotomous variable (strongly disagree/disagree & strongly
agree/agree) (Table 19-21). “Lack of health service facility in my area prevented me
from having Pap test” was assessed using question (Q3) in the survey and is used as
dichotomous variable (strongly disagree/disagree & strongly agree/agree). Similarly,
questions on “cultural belief prevented me from having Pap test” (Q32F) and “healthy no
need Pap test” (Q32H) in the survey employed dichotomous response (strongly
disagree/disagree & strongly agree/agree).
Social Support:
In this study, “social support” is operationalized as “did anyone encourage you to
have your first Pap test?” and “did friend/partner/family member accompany you to have
your first Pap test?”
The measurement of “did anyone encourage you to have your first Pap test?” used
question (Q33) in the survey and was divided into seven categories: doctor, friend,
mother, family member, no one, sexual partner & other. “Did anyone encourage you to
33 have your first Pap test?” was recoded into “mentioned /not mentioned” and is used as
dichotomous variable in chi-square analysis. “Did friend/partner/family member
accompany you to have your first Pap test?” was assessed using question (Q34) in the
survey. The response for this question used “yes/no” dichotomy.
Pilot Test
Before initializing the large-scale survey, a pilot study was carried out to
determine the feasibility of survey instrument. The sample size for the pilot study was 6
female students, one from each different Addis Ababa University’s Colleges and
Institutes. The pilot study was carried out from November 14 to 20, 2011. One of the
comments given by some students in the survey questionnaire relates to the term “Pap
test”. When answering the section that relates to “Pap test”, students were confused
about the word “smear” and answered “Not sure”. Furthermore, when students were
asked to sign the consent form, they were worried to give out their name. Based on the
above comments, the researcher has changed the term “Pap smear” to “Pap test” and
made the survey questionnaire anonymous.
Study Sample Selection
A simple random sampling method was used to improve the representativeness of
the sample by reducing sampling error (Babbie, 2010). Specifically, the study employed
random sampling process (every fifth Addis Ababa University (AAU) female student
who came to dine at each of the AAU cafeterias) to avoid preferential treatment in
selection, which may introduce selectivity bias.
One week before conducting the survey research, flyers were distributed to
promote the study (Appendix E). For this, flyer was handed randomly to female students
34 at the different colleges’ and institutes’ cafeteria. The reason for choosing the cafeteria
for the recruitment sites was that, university students in Ethiopia are provided with free
dormitory and food. Thus, most students in a campus eat at the same cafeteria at fixed
times. This made Addis Ababa University (AAU) cafeterias the ideal place to reach out
and recruit representative students for the study. In addition, flyers were posted at the
university’s libraries, student health center, cafeterias and coffee shops. One week after
flyers were distributed and posted, the following procedures took place:
1.
A table was set with the questionnaires outside of each cafeteria.
2.
A small tent was put near the table, in order to maintain student’s privacy.
3.
Inside the tent, individual lecture type chairs were placed well spaced to separate
students.
4.
Questionnaires were handed randomly to every fifth female students who came to
dine at the cafeteria of each of the campuses. The reason for choosing the
cafeteria is that, university students in Ethiopia are provided with free dormitory
and food. Thus, all students in a campus eat at the same cafeteria at fixed times.
This makes AAU cafeterias the ideal place to reach out and recruit representative
students for the study. The distribution of the survey questionnaires was done by
the researcher.
5.
Female students who volunteer to participate in the study were given the
questionnaire and pen and seated on individual chairs inside the tent.
6.
The female students then completed a self-administered survey questionnaire
about their sexual behavior, whether they are aware of Human Papillomavirus
35 (HPV) infection, its mode of transmission, risks of HPV infection and cervical
cancer, methods screening as well as social support.
7.
Completed surveys were handed to the researcher and each student received an
incentive such as flash drive, phone card etc.
Study Sample Size
Power analysis was conducted for this study. A power of 0.83 and a two-tailed
alpha of 0.05 and an estimated effect size of 0.25 were considered acceptable to test our
hypothesis. For this we set out to recruit 300 participants with an additional 20% more
participant to account for possible dropouts (i.e., a total of 360). However, we were able
to successfully recruit a total 406 participants of which data from 392 was used for the
study. The actual 392 participants increased the power to 0.93 for an effect size of 0.25
(Lipsey, 1990). The remaining 14 students did not complete the questionnaire and were
dropped out.
Statistical Analysis
Data obtained from the 392 Addis Ababa University (AAU) female students study
participants were analyzed using Statistical Package for the Social Science (SPSS)
software, version 18 (SPSS, Inc., 2009). Frequency and Chi-square tests were used to see
if there are statistical significance and relationship between the variables.
Summary
The research was initiated and executed following the California State University,
Northridge (CSUN) thesis preparation guidelines. Research started following approval
by the CSUN’s Institutional Review Board. Study participants were female students of
the Addis Ababa University (AAU), Ethiopia. A quantitative cross sectional study design
36 was implemented and anonymous survey questionnaire was used as a tool. A total of 37
questions under 7 categories were used. The study was conducted in December 2012
through February 2013. Data were brought to CSUN and analyzed using Statistical
Package for the Social Science (SPSS) software, version 18. Frequency data as well as
Chi-square were used to test relationship and differences respectively. Data from a total
392 female AAU students (out of 406 recruited) were used for analysis.
37 CHAPTER 4
RESULTS
Introduction
In this chapter, study results will be presented. Results will be organized in
three main sections: survey instrument, study participant results and hypothesis tests. The
study participant result section will cover demography, sexual behavior, level of
knowledge toward Human Papillomavirus/cervical cancer, knowledge and practice of
Pap test screening, barriers to early screening and social support. The hypothesis test
section will cover analysis of associations between independent and dependent variables
for each hypothesis.
Survey Instrument Result
A total of 406 female Addis Ababa University students were recruited. Out of
these, 392 students (96.5% response rate) responded to the survey questions, while 14
were excluded due to incomplete responses to the questions.
Study Participant Statistical Results
The descriptive data are presented as frequency tables in tables 1 through 8.
Results on relationships between variables are presented as Chi-square. The descriptive
data are presented corresponding with the 7 categories of survey questions, i.e.,
demographics, sexual behavior, level of knowledge toward Human Papillomavirus, level
of knowledge toward cervical cancer, knowledge and practice of Pap test, barrier to early
Pap test screening and social support.
38 Demographics:
Age: The respondents’ age ranged between 18 and 56 years with a mean age of
23.28 years with a sd of ± 4.98. In table 1 below, the demographics characteristics of the
sample are given. Region of origin: Students from 7 administrative regions and 2 charter
cities participated in the study. However, most students (55.6%) were from the Addis
Ababa region followed by distant 12.2 %, 10.2% and 9.7% from the Amhara, Tigrai and
Oromia regions respectively (Figure 3).
Figure 3: Percentage Distribution of Charter Cities and Regional State of Addis
Ababa University Female Student Participants
*SNNPR: Southern Nations, Nationalities, & People’s Region
Education Level:
When stratified by education level 83.6% identified their education level as
undergraduate and the remaining 16.4% as graduate level (Table 1).
39 Table 1: Frequency of Participant’s Education Level (N = 391)
Variables
Sample (%)
Undergraduate
327 (83.6)
Graduate
64 (16.4)
Table 2 shows the frequency of female Addis Ababa University student
participants by education level and region of origin. The data depicts that the majority of
undergraduate students originated from Addis Ababa (56.9%), followed by Amhara
(11.6%), SNNPR (10.4%) and Oromia (9.5%). Similarly, most of the graduate students
are from Addis Ababa (48.3%), followed by Amhara (15.6%), Tigray (15.6%) and
Oromia (9.4%).
Table 2: Frequency of Graduate vs. Undergraduate by Region of Origin
(N = 391)
Region of Origin
Addis Ababa
Afar
Amhara
Dire-Dawa
Harari
Oromia
Somali
SNNPR*
Tigray
Undergraduate Participants
Graduate Participants
n (%)
n (%)
186 (56.9)
1 (0.3)
38 (11.6)
4 (1.2)
1 (0.3)
31 (9.5)
2 (0.6)
34 (10.4)
30 (9.2)
31 (48.3)
0 (0.0)
10 (15.6)
3 (4.7)
0 (0.0)
6 (9.4)
0 (0.0)
4 (6.3)
10 (15.6)
*SNNPR - Southern Nations, Nationalities, & People’s Region
In response to the question on marital status, most of the students (84.2%)
responded to be single and never married while 7.5% report being engaged and 6.2%
were married. The remaining 1.5% was divorced. When asked of their/their family’s
income, 35.2% indicated to have income of 5000 or more Ethiopian Birr (Birr) per month
40 while 21.0% report to have less than 1000 Birr/month. By the time of the survey the
current exchange rate of USA dollar to Ethiopia was: $1 = 18.50 Birr.
Table 3: Demographics Characteristics of Sample
Variables
Sample (%)
Income (n = 381)
Less than 1000 birr
1000 to 3000 birr
3001 to 5000
5001 or more
80 (21.0)
100 (26.2)
67 (17.6)
134 (35.2)
Income (n = 381)
Less than 1000 birr
1000 to 5001 birr
5001 or more
80 (21.0)
167 (43.8)
134 (35.2)
Marital Status (n = 388)
Single
Engaged
Married
Divorced
329 (84.8)
29 (7.5)
24 (6.2)
6 (1.5)
Health Status and Living Condition:
In table 2, the frequency data on health status and on off/on campus
housing/living is presented. When heath status is divided into 5 categories, the data show
that most students (47.4%) rate their health status as excellent followed with very good
(34.0%), good (14.4%) and faire or poor (4.1%). Because the relative percentage of
students who indicated a fair or poor health status was small, the heath status data was
recoded for analysis purpose. The data on student residency/housing showed that most
(61.4%) live on-campus.
41 Table 4: Frequency of Health Status & Living Condition
Variables
Sample (%)
Health Status (n = 388)
Excellent
Very good
Good
Fair
Poor
184 (47.4)
132 (34.0)
56 (14.4)
14 (3.6)
2 (.5)
Health Status recode (n = 388)
Excellent
Very good
Good
Fair/Poor
184 (47.4)
132 (34.0)
56 (14.4)
16 (4.1)
Living Condition (n = 389)
On-campus
Off-campus
239 (61.4)
150 (38.6)
Sexual Behavior
The sexual behavior frequency data is summarized in table 3. Out of the 390
respondents, students who report to ever had sexual intercourse were 18.2% while more
than 4 out of 5 (81.8%) indicate that they did not have sexual intercourse. In response to
a subsequent question on the age at first sexual intercourse, 19-20 years of age was the
most reported (30.6% of the 68 who reported to have had sexual intercourse). When data
were recoded, for those who report to have had sexual intercourse, the age at which most
(15.9%) students report to have had first intercourse is 24 years or younger.
In response to the question on the number of sexual partner/s that the respondent
has, most (80.4%) of the 384 respondents state that they do not have sexual partner. This
response was followed by a distant 12.8%state to have 1 partner. Out of 69 respondents
who had sexual intercourse, 28.9% had two or more sexual partners. When asked about
the use of condom, most (81.6%) of the 385 respondents state that they are not sexually
42 active. Out of the 71 who reported to have had sexual intercourse, 54.9% use condom
some times, often or always.
Table 5: Frequency of Sexual Behavior
Variables
Sample (%)
Ever had sexual intercourse (n = 390)
Yes
No
71 (18.2)
319 (81.8)
Age at first sexual intercourse (n = 383)
Never had sexual intercourse
18 years old or younger
19-20 years old
21-22 years old
23-24 years old
25-26 years old
27 years old or older
315 (82.2)
8 (2.1)
21 (5.5)
18 (4.7)
14 (3.7)
5 (1.3)
2 (.5)
Multiple sexual partner (n = 384)
No one (never had sexual intercourse)
1 Person
2 Person
3 Person
4 Person or more
315 (80.4)
49 (12.8)
11 (2.9)
5 (1.3)
4 (1.0)
Condom Use (n = 385)
Not sexual active
Never use condom
Sometimes use condom
Most often use condom
Always use condom
314 (81.6)
32 (8.3)
15 (3.9)
12 (3.1)
12 (3.1)
Condom Use recode (n = 385)
Not sexual active
Never & sexually active
Yes & sexually active
314 (81.6)
32 (8.3)
39 (10.1)
Condom Use recode (n = 71)
Yes
No
39 (54.9)
32 (45.1)
43 Level of Knowledge toward Human Papillomavirus (HPV)
Frequency data relevant to the category of level of knowledge toward Human
Papillomavirus (HPV) is presented in table 6. The majority of students (66.8%) report to
never have heard of HPV. In line with this, when asked what age group is at highest risk
if acquiring HPV, most (54.8%) students responded that they do not know. Similar trend
is observed where the response to questions on risk factors for HPV infection, what HPV
infection causes, if HPV infection affects female or male or both, the mode of HPV
transmission or the long term effects of HPV, most (more than 50% in each of these
questions, see table 4) students response with I do not know answer. Assessment of the
response to the question of “ever been diagnosed with HPV”, over 95% of the students
indicated to have never been diagnosed with HPV.
Table 6: Frequencies of Level of Knowledge toward Human Papillomavirus
Variables
Sample (%)
Heard of Human Papillomavirus (HPV) (n = 383)
Yes
No
127 (33.2)
256 (66.8)
Age group at highest risk of acquiring HPV (n = 385)
0-14
15-24
25-35
36 & up
Do not know
5(1.3)
120 (31.2)
37 (9.6)
12 (3.1)
211(54.8)
HPV Infection Risk Factors (n = 387)
One mentioned
Two mentioned
Three mentioned
Four mentioned
Do not know
44 90 (23.3)
5 (1.3)
26 (6.7)
38 (9.8)
228 (58.9)
Table 6: Frequencies of Level of Knowledge toward HPV Contd.
Variables
Sample (%)
Human Papillomavirus (n = 389)
Always causes problems
Sometimes causes problems
Never causes problems
Do not know
89 (22.9)
73 (18.8)
4 (1.0)
223 (56.9)
Kind of problem/s HPV infection cause (n = 381)
Genital warts
Vulval/vaginal irritation
Vaginal discharge
Painful sexual intercourse
Do not know
105 (27.6)
15 (3.9)
13 (3.4)
23 (6.0)
225 (59.1)
HPV infection affects (Sample: n = 389)
Only or mainly men
Only or mainly women
Both men and women
Do not know
9 (2.3)
61 (15.7)
102 (26.2)
217 (55.8)
Transmission of HPV (Sample: n = 389)
Shaking hands
Coughing on someone
By blood
Congenital
Intimate (sexual) contact
Do not know
6 (1.5)
4 (1.0)
25 (6.4)
5 (1.3)
139 (35.7)
210 (54.0)
Long-term effects of HPV (Sample: n = 388)
Disappears & no long-term effect
Abnormal Pap test
Cervical cancer
Infertility
Do not know
11 (2.8)
17 (4.4)
111 (28.6)
20 (5.2)
229 (59.0)
Ever been diagnosed with HPV (Sample: n = 389)
Yes
No
18 (4.6)
371 (95.4)
The level of knowledge of female Addis Ababa University students on risk factors
of Human Papillomavirus (HPV) is shown in the response frequency (%) chart below
(Figure 4). The most recognized risk factor, by the participants, for HPV infection is
45 “having more than two sex partners (30.2%) and the least identified is “failure to use
condom (15.8%).
Figure 4: Response frequency (%) of Knowledge on HPV Infection Risk Factors
HPV infection risk factors
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Level of Knowledge toward Cervical Cancer
In table 5 below frequencies related to level of knowledge toward cervical cancer
are given. Specifically, frequencies of variables on whether a respondent has heard or
been diagnosed of cervical cancer, family history of cervical cancer, knowledge on
whether Human Papillomavirus (HPV) infection or other factors such as smoking,
Human Immunodeficiency Virus (HIV) infection, multiple birth are risk factors are
evaluated. In response to the question of ever heard of cervical cancer, 46.5%
respondents (389) indicate to have heard of it. When the response to the question of ever
heard of cervical cancer is divided into 3 categories of yes, no and not sure, 3 out of 4
respondents (75%) did not have family history of cervical cancer, 3.8% had and 21.2%
46 were not sure. Nearly all students (96.4%) reported to have never been diagnoses with
cervical cancer.
Table 7: Frequencies of Level of Knowledge toward Cervical Cancer (CC)
Variables
Sample (%)
Heard of cervical cancer (CC) (n = 389)
Yes
No
181 (46.5)
208 (53.5)
Family history of cervical cancer (n = 392)
Yes
No
Not sure
15 (3.8)
294 (75.0)
83 (21.2)
Ever been diagnosed with cervical cancer (n = 386)
Yes
No
14 (3.6)
372 (96.4)
HPV infection major risk factor for developing CC (n = 385)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
20 (5.2)
21 (5.5)
202 (52.5)
68 (17.7)
74 (19.2)
HIV can increase the risk of developing (n = 385)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
17 (4.4)
35 (9.1)
168 (43.6)
94 (24.4)
71 (18.4)
Smoking can increase the risk of developing (n = 379)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
25 (6.6)
42 (11.1)
159 (42.0)
103 (27.2)
50 (13.2)
Given birth to 3+ children can increase the risk of developing CC
(n = 387)
Strongly Disagree
40 (10.3)
Disagree
76 (19.6)
Do not know
182 (47.0)
Agree
70 (18.1)
Strongly Agree
19 (4.9)
47 Table 7: Frequencies of Level of Knowledge toward Cervical Cancer (CC) Contd.
Variables
Sample (%)
Using birth control pills for 5+ years can increase the risk of developing CC
(n = 388)
Strongly Disagree
27 (6.5)
Disagree
87 (22.5)
Do not know
185 (47.9)
Agree
68 (17.6)
Strongly Agree
21 (5.4)
Possible signs of CC include vaginal bleeding & pelvic pain (n = 384)
Strongly Disagree
15 (3.9)
Disagree
18 (4.7)
Do not know
194 (50.5)
Agree
99 (25.8)
Strongly Agree
58 (15.1)
The most common response to either of the subsequent question on level of
knowledge of cervical cancer including if Human Papillomavirus (HPV) infection is a
major risk factor or if HIV, smoking, having multiple birth or long term use of birth
control pills increase the risk for cervical cancer or if vaginal bleeding and pelvic pain are
possible symptoms of cervical cancer, was do not know (Table 7 and Figure 5).
Figure 5: Knowledge on risk factors on the development of cervical cancer among
female Addis Ababa University students. Data show response frequency
(%) of DNK = do not know; SD/D = strongly disagree/disagree; SA/A =
strongly agree/agree to each of the 5 risk factors. Note that the relative percent
of students with a DNK response is higher than any other response for each
risk factor asked.
48 Using birth control pills for 5+ years can increase
the risk of developing cervical cancer
DNK
SD/D
SA/A
Having given birth to 3+ children can increase the
risk of developing cervical cancer
DNK
SD/D
SA/A
Smoking can increase the risk of
developing cervical cancer
DNK
SD/D
SA/A
HIV can increase the risk of
developing cervical cancer
DNK
SD/D
SA/A
HPV infection major risk factor for
developing cervical cancer
DNK
SD/D
SA/A
0
20
40
60
80
100
Percentage
Knowledge and Practice of Papanicolaou Test Screening
Table 8 below presents frequency data on the knowledge and practice of
Papanicolaou (Pap) test screening. Response data from the 389 respondents show that
only 5.2% had Pap test done while 85.5% did not have and 8.9% are not sure if they had
or not. On the question whether Pap test will help to screen for cervical cancer, 35.8%,
out of 385, agree or strongly agree that Pap test helps tell if a woman may have cervical
cancer while 48.6% do not know and 15.6% disagree or strongly disagree that Pap test
will have any help. On whether women should have Pap tests, 16.1%, out of 395, agree
or strongly disagree that women should have the test every year unless otherwise
instructed by their doctor while 47.7% do not know and 36% report that they disagree or
disagree with the statement.
The response to the question of at what age did the respondent have her first Pap
test, are evenly distributed across the 5 categories of answers although the 25 years or
older category of response is the most chosen (31.6%). In other Pap test related
49 questions, for most students (41.2%) the recommended frequency of Pap test screening is
every 2 or more years; 57.1% of the respondents indicated that they had a Pap test less
than a year ago while 42.9% reported that they either had it 2 or more years ago or never
had it. About half the respondents (50.7%) state also that their mothers had Pap test. On
the other hand, as in table 5 above, the most common responses to the last 3 variables
related to knowledge of cervical cancer and practice of Pap test in table 6 below is,
invariably, the do not know answer.
Table 8: Frequencies of Knowledge and Practice of Papanicolaou (Pap) Test
Screening
Variables
Sample (%)
Ever had Pap test (n = 387)
Yes
No
Not sure
20 (5.2)
332 (85.5)
35 (8.9)
Age first Pap test received (n = 19)
15 or younger
16-18
19-21
22-25
25 or older
3 (15.8)
5 (26.3)
2 (10.5)
3 (15.8)
6 (31.6)
Frequency of Pap test (Sample: n = 17)
Every 3-5 months
Every 6 months
Every year
Every 18 months
Every two or more years
4 (23.5)
3 (17.6)
2 (11.8)
1 (5.9)
7 (41.2)
Last time you had Pap test (Sample: n = 21)
Less than 1 year ago
1 year ago
2 years ago
3 or more years ago
Never
5 (23.8)
7 (33.3)
4 (19.0)
3 (14.3)
2 (9.5)
50 Table 8: Frequencies of Knowledge and Practice of Pap Test Screening Contd.
Variables
Sample %
Mother had/has regular Pap test (n = 375)
Yes
No
Not sure
37 (9.9)
190 (50.7)
148 (39.5)
Pap test help tell if a women may have cervical cancer (n = 377)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
31 (8.2)
28 (7.4)
183 (48.5)
78 (20.7)
57 (15.1)
Adult women should have Pap test each year (n = 377)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
13 (3.4)
48 (12.7)
180 (47.7)
91 (24.1)
45 (11.9)
Only women with many sex partners need Pap test (n = 379)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
62 (16.1)
84 22.2)
186 (49.2)
33 (8.7)
14 (3.7)
Barrier to Early Papanicolaou Test Screening
Table 9 below presents frequency data on barriers to early Papanicolaou (Pap)
test screening. Most of the variables are divided into 5 categories of strongly agree,
agree, do not know, disagree and strongly disagree. The data show that only 5.1% and
14.9% of the 376 respondents strongly agree and agree respectively with the statement
that lack of health facility in their area is a barrier for having a Pap test. Similarly, 13.2%
agree or strongly agree that bad attitude of doctors/nurses to prevent them from having
Pap test and 13% agree or disagree that cost is a barrier for them to have a Pap test.
However, in this set of questions more than 40% of the respondents disagree or strongly
51 disagree to the statement that either lack of health facility, bad attitude of doctors/nurses
or cost is preventing them from having a Pap test.
The data on cultural factors show that 43% of the respondents indicate that they
do not know if they feel shy to have Pap test while the remaining respondents are spilt
between the agree-strongly agree and the disagree-strongly disagree group. Similarly,
out of the 5 categories of responses, most respondents indicate the do not know response
to questions if cultural beliefs or being a virgin or the belief of being healthy prevents
them from having Pap test.
Table 9: Frequencies of Barrier to Early Papanicolaou (Pap) Test Screening
Variables
Sample %
Lack of health service facility in my area prevented me from having Pap
test (n = 376)
Strongly Disagree
50 (13.3)
Disagree
115 (30.6)
Do not know
136 (36.2)
Agree
56 (14.9)
Strongly Agree
19 (5.1)
Bad attitude of doctors/nurses prevented me from having Pap test (n = 372)
Strongly Disagree
52 (14.0)
Disagree
122 (32.8)
Do not know
149 (30.1)
Agree
41 (11.0)
Strongly Agree
8 (2.2)
Pap test is painful (n = 364)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
41 (11.3)
62 (17.0)
207 (56.9)
46 (12.6)
8 (2.2)
I could not afford the cost of having Pap test (n = 370)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
51 (13.8)
99 (26.8)
172 (46.5)
38 (10.3)
10 (2.7)
52 Table 9: Frequencies of Barrier to Early Papanicolaou Test Screening Contd.
Variables
Sample %
I feel shy to have Pap test (n = 358)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
38 (10.6)
69 (19.3)
161 (45.0)
69 (19.3)
21 (5.9)
Cultural belief prevented me from having Pap test (n = 365)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
43 (11.8)
89 (24.4)
160 (43.8)
58 (15.9)
15 (4.1)
I am a virgin and I don’t need Pap test (n = 385)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
43 (11.6)
92 (24.7)
141 (37.9)
60 (16.1)
36 (9.7)
I am healthy and I don’t need Pap test (n = 375)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
55 (14.7)
98 (26.1)
151 (40.3)
43 (11.5)
28 (7.5)
Social Support
Data in table 10 below show the social support frequencies. Out of the 362
respondents to a dichotomous set of questions (mentioned and not mentioned), support or
encouragement from either a doctor, a friend, a mother, a family member or from a
sexual partner, to have a Pap test, is indicated by only 14.4%, 5.2%, 2.8% and 2.5%
respondents respectively.
In separate questions related to support for practice of Pap test screening, 66.8%
of the respondents indicate that no one encouraged them to have their first Pap test, 73.8
53 % do not talk to their family about cervical cancer and Pap test, 68.9% do not talk with a
friend about Pap test and cervical cancer. In a specific question to whether the
respondent has a friend, partner or family member to accompany for a first Pap test,
93.7% indicate that, no they do not have. By contrast, to questions that address nonspecific general support, over 50% of respondents indicate that their agreement or strong
agreement to the statement that they share personal matters with one or more family
members and that their family or friends let them talk their personal matters (see the last
3 questions in table 8 below).
Table 10: Frequencies of Social Support
Variables
Sample %
Doctor encourages me to have my first Pap test (n = 362)
Mentioned
Not Mentioned
52 (14.4)
310 (85.6)
Friend encourages me to have my first Pap test (n = 362)
Mentioned
Not Mentioned
19 (5.2)
343 (94.8)
Mother encourages me to have my first Pap test (n = 362)
Mentioned
Not Mentioned
10 (2.8)
352 (97.2)
Family member encourages me to have my first Pap Test (n = 362)
Mentioned
9 (2.5)
Not Mentioned
353 (97.5
No one encourage me to have my first Pap test (n = 362)
Mentioned
Not Mentioned
262 (66.8)
100 (25.5)
Sexual partner encourages me to have my first Pap test (n = 362)
Mentioned
4 (1.1)
Not Mentioned
358 (91.9)
Friend, partner or family member accompany for first Pap test (n = 309)
Yes
21 (6.8)
No
288 (93.2)
54 Table 10: Frequencies of Social Support Contd.
Variables
Sample (%)
Talk about Pap test & Cervical Cancer with Family member/s (n = 385)
Yes
101 (26.2)
No
284 (73.8)
Talk about Pap test and cervical cancer with Friend/s (n = 386)
Yes
No
120 (31.1)
266 (68.9)
Have one or more friends with whom I can share personal matters (n = 389)
Strongly Disagree
40 (10.3)
Disagree
58 (14.9)
Do not know
56 (14.4)
Agree
142 (36.5)
Strongly Agree
93 (23.9)
Friends let me talk about problems until I feel better (n = 385)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
14 (3.6)
62 (16.1)
60 (15.6)
166 (43.1)
83 (21.6)
Can share personal matters with one or more family member/s (n = 384)
Strongly Disagree
34 (8.9)
Disagree
60 (15.6)
Do not know
58 (15.1)
Agree
161 (41.9)
Strongly Agree
71 (18.5)
Family lets me talk about problems until I feel better (n = 385)
Strongly Disagree
Disagree
Do not know
Agree
Strongly Agree
55 31 (8.0)
61 (15.8)
61 (15.8)
156 (40.4)
77 (19.9)
Hypothesis Tests
In this section data on associations between independent and dependent variables
are presented for each hypothesis.
Hypothesis 1
Hypothesis-1: There is a relationship between level of knowledge toward
Human Papillomavirus/cervical cancer and knowledge and
practice of Papanicolaou (Pap) test screening.
Listed below are relationships that were analyzed for hypothesis 1 using ChiSquare analysis.
1.
Human Papillomavirus (HPV) is Transmitted through Sexual Contact and
Only Women with Multiple Sex Partners need Pap test
2.
Long-term Effects of HPV Infection and Pap Test Tell if a Woman has
Cervical Cancer
3.
Long-term Effects of HPV Infection and Mother had/has Regular Pap Test
To investigate whether there exist an association between “Human Papillomavirus
(HPV) is transmitted through sexual contact” and “only women with multiple sex
partners need Pap test” a chi-square statistic was conducted. Table 11 below shows the
Pearson chi-square results and indicates that knowledge on transmission of HPV through
sexual contact is significantly associated to whether or not the responses to only women
with multiple sex partners need Pap test (χ2 = 8.23; p<0.01). Among the participants who
responded correctly on the “transmission of HPV through sexual contact”, 83.9%
strongly disagree/disagree to the statement of “only women with multiple partners need
Pap test”. Of those who responded incorrectly on the “transmission of HPV through
56 sexual contact”, 59.3% strongly disagree/disagree to the statement that “only women with
multiple partners need Pap test”.
Table 11: Chi-square Test between HPV Transmission through Sexual Contact
& Only women with Multiple Sex Partners need Pap test (N = 151)
HPV Transmission through
Sexual Contact
Variable
Correct
Response
n (%)
Incorrect
Response
n (%)
Only women with multiple
sex partners need Pap test
Strongly disagree/disagree
104 (83.9)
16 (59.3)
Strongly agree/agree
20 (16.1)
11 (40.7)
χ2
Sig.
8.232
p<0.01
In Table 12 below, the percent of responders for each category of responses is
summarized. The presence or not of association between knowledge on the long term
effect of HPV infection and on whether Pap test could tell if a woman has cervical cancer
was assessed using Chi-Square statistics. Among the students who knew the long term
effect of HPV infection, 78.4% agreed or strongly-agreed also to the statement that Pap
test tell if a woman has cervical cancer. By contrast, among those who did not know
about the long term effects of HPV infection, only 46.4% agreed or strongly-agreed with
the statement that Pap test can tell if a woman has cervical cancer. Pearson Chi-square
analysis shows that there is a significant association between knowledge about the longterm effects of HPV infection and the response to the statement that Pap test tell if
woman has cervical cancer (χ2 = 22.149; p<0.01).
57 Table 12: Chi-square Test between Knowledge on Long-term Effects of HPV
Infection & on whether Papanicolaou Test tell if a Woman has Cervical
Cancer (N = 143)
Long term effects of HPV
infection
Variable
Correct
Response
n (%)
Incorrect
Response
n (%)
Pap test tell if a woman
has cervical cancer
Strongly disagree
Disagree
Agree
Strongly agree
11 (10.8)
11 (10.8)
31 (30.4)
49 (48.0)
χ2
Sig.
22.149
p<0.01
13 (31.7)
9 (22.0)
15 (36.6)
4(9.8)
Further analysis of association between knowledge about Human Papillomavirus
(HPV) infection and knowledge about Pap test is given in table 13 below. Among the
students who have heard of HPV, 34.0% strongly-agreed to the correct statement that
adult women should have Pap test each year whereas only 10.5% of those who have not
heard about HPV strongly agreed with the correct statement about Pap test
recommendation. Chi-square analysis shows that there is a significant association
between having heard of HPV and the response to the statement that adult women should
have Pap test each year (χ2 = 20.907; p<0.001).
58 Table 13: Chi-square Test between Heard of HPV & Adult Women should have
Pap test each year (N = 192)
Heard of Human
Papillomavirus
Variable
Yes
n (%)
No
n (%)
Adult Women should have
Pap test each year
Strongly disagree
Disagree
Agree
Strongly agree
7 (6.6)
28 (26.4)
35 (33.0)
36 (34.0)
χ2
Sig.
20.907
p<0.001
5 (5.8)
18 (20.9)
54 (62.8)
9 (10.5)
In addition, the relationship between the “ever heard of cervical cancer”, as a
variable of knowledge on cervical cancer, with “adult women should have Pap test each
year”, as a variable of knowledge on Pap test, is shown in table 14. Among students who
have heard about cervical cancer, 31.7% strongly agreed with the statement about Pap
test, i.e., adult women should have Pap test each year. However, among those who did
not know about cervical cancer, only 8.2% of them have strongly agreed with the
statement about Pap test. Chi-square statistics showed that the relationship between the
two variables (knowledge about cervical cancer and knowledge about Pap test) is
significant (χ2 = 15.743; p<0.01).
59 Table 14: Chi-square Test between Heard of Cervical Cancer & Adult Women
should have Pap test each year (N = 196)
Heard of Cervical Cancer
Variable
Yes
n (%)
No
n (%)
Adult Women should
have Pap test each year
Strongly disagree
Disagree
Agree
Strongly agree
9 (7.3)
24 (19.5)
51 (41.5)
39 (31.7)
χ2
Sig.
15.743
p<0.01
4 (5.5)
23 (31.5)
40 (54.8)
6 (8.2)
Listed below are relationships found to be non-significant and/or with expected
cell count more than 20%.

Family history of cervical cancer & frequency of Pap test

Only women with multiple partner need Pap test & HPV transmission

Long term effect of HPV infection & frequency of Pap test

Long-term effects of HPV infection & mother had/has regular Pap test

HPV infection is the major risk factor for development of cervical cancer &
ever had Pap test
Hypothesis 2
Hypothesis-2: There is a relationship between level of knowledge toward
Human Papillomavirus/cervical cancer and sexual behavior
Listed below are relationships that were analyzed for hypothesis 2 using ChiSquare analysis.
1.
Heard of Human Papillomavirus and Condom Use
2.
Heard of Human Papillomavirus and Sexually Active
60 Table 15: Chi-Square Test between Heard of HPV & Condom Use by Sexual
Activity (N = 378)
Heard of Human
Papillomavirus
Variable
Yes
n (%)
No
n (%)
Use Condom
Yes & sexually active
20 (15.9)
17 (6.7)
Never & sexually active
21 (16.7)
11 (4.4)
Not sexually active
85 (67.5)
224 (88.9)
χ2
Sig.
26.883
p<0.001
Evaluation of the relationship between knowledge of the Human Papillomavirus
(HPV) as assessed by the response to a question whether the respondent has heard of
HPV, and the use of condom as a variable for sexual behavior, showed that while 15.9%
of those who heard of HPV indicate also that they use condoms (Table 15). However,
among those who have not heard of HPV, only 6.7% indicate to use condom. Among
those how have heard of HPV, those who still do not use condom are 16.7% while those
who did not hear of HPV and report to have never used condom are 4.4%. However, the
data show also 88.9% of those who did not hear about HPV report also to not be sexually
active while only 67.5% of those who have heard of HPV report to be not sexually active.
Chi-Square analysis shows that there is a statistically significant relationship between the
knowledge about HPV and the use of condom used as a variable sexual behavior (χ2 =
26.883; p<0.001).
However, given that the inclusion of the “not sexually active” category in the
analysis of relationship between “condom use and heard of Human Papillomavirus” in
table 15 above is less relevant, the response categories under the variable “use of
condom” were collapsed to a “yes/no” responses (Table 16). Under this circumstance,
61 among those who reported to use condom, 54.1% have heard of HPV. Similarly, 65.6%
of those who do not use condom report to have heard of HPV. Chi square analysis
reveled that there is no statistical significance relationship between the practice of use of
condom and having heard about HPV (χ2 = 0.953; p>0.05).
Table 16: Chi-Square Test between Heard of HPV & Condom Use (N = 69)
Heard of Human Papillomavirus
Variable
Yes
n (%)
No
n (%)
Use Condom
Yes
20 (54.1)
17 (45.9)
No
21 (65.6)
11 (34.4)
χ2
Sig.
0.953
p>05
Further analysis of the relationship between being “sexually active or not”, as a
sexual behavior and having “heard of HPV” as level of knowledge about HPV shows that
among those who are sexually active 57.8% have heard of HPV while only 27.7% of
those who are not sexually active have heard of HPV (see below Table 17). Chi-square
analysis showed that there is a significant relationship between knowledge (heard of
HPV) and sexual behavior (sexual activity) (χ2 = 021.733; p<0.01).
Table 17: Chi-Square Test between Heard of HPV & Sexual Activity (N = 374)
Heard of Human
Papillomavirus
Variable
Yes
n (%)
No
n (%)
Sexually Active
Yes
37 (57.8)
27 (42.2)
No
86 (27.7)
224 (72.3)
62 χ2
Sig.
21.733
p<001
In a separate analysis of a relationship between “use of condom” and “risk factors
for Human Papillomavirus (HPV) infection”, among those who identified “having more
than two sexual partner” as “HPV infection risk factor” 46.2% report to use condom
while among those who did not identify the “more than two sexual partner” as a risk,
59.1% report to use condom. Similarly, among those who identified/mentioned that”
partner has had more than two sexual partners” or that “first sexual activity at 16 years
old or younger” or “failure to use condom” as a risk factor for HPV infection, 55.6% or
46.7% or 50.0% report respectively to use condom. On the other hand, among those who
did not identify/mention the later three risk factors 53.8%, 56.4% and 55.4% respectively
report to use condom. The relationships between the responses to HPV risk factors and
condom use are not statistically significant (p>0.05) (Table 18).
Table 18: Chi-Square Test between HPV Infection Risk Factors & Condom Use
(N = 70)
Use Condom
Variable
Yes
n (%)
No
n (%)
12 (46.2)
26 (59.1)
14 (53.8)
18 (40.9)
p>05
10 (55.6)
28 (53.8)
8 (44.4)
24 (46.2)
p>05
7 (46.7)
31 (56.4)
8 (53.3)
24 (43.6)
p>05
7 (50.0)
31 (55.4)
7 (50.0)
25 (44.6)
p>05
Sig.
HPV infection Risk Factors
 More than two sexual partners
- Mentioned
- Not Mentioned
 Partner has had >2 sex partners
- Mentioned
- Not Mentioned
 1st sexual activity at 16 or younger
- Mentioned
- Not Mentioned

Failure to Use Condom
- Mentioned
- Not Mentioned
63 Listed below are relationships found to be non-significant and/or with expected
cell count more than 20%.

Age at first sexual intercourse & ever been diagnosed with HPV

Ever been diagnosed with HPV & condom use

Heard of cervical cancer & condom use

HPV infection is the major risk factor for development of cervical cancer &
condom use

Heard of HPV& condom use
Hypothesis 3
Hypothesis-3: There is a relationship between demographic and level of
knowledge toward Human Papillomavirus/cervical cancer.
Listed below are relationships that were analyzed for hypothesis 3 using ChiSquare analysis.
1. Respondent’s Family Household Income per Month and HPV Infection as
Major Risk Factor of Cervical Cancer
2. Respondent Class Stand and Highest Risk Group for Acquiring HPV
Infection
3. Class Stand and Kind of Problem/s HPV Infection Cause
4. Respondent Class Stand and HPV Infection Major Risk Factor of Cervical
Cancer
To assess the presence of a relationship between household incomes, as a
demographic variable, with knowledge on whether the Human Papillomavirus (HPV)
64 infection is a major risk factor for cervical cancer, Chi-square statistics was employed
(Table 19). The data shows that among students with a reported family income of less
than 1000 Ethiopian Birr, only 26.2% strongly agree with the statement that HPV
infection is a major risk factor for cervical cancer. By contrast, 56.1% of those with
reported income over 5000 Birr indicated strong agreement to the fact that HPV is a
major risk factor for cervical cancer development. On the other hand, while only 4.5% of
those with more than 5000 Birr income strongly disagree with the statement that HPV
infection is a major risk factor for cervical cancer, 21.4% of those who have less than
1000 Birr income strongly disagree with the statement.
The data further show that there is a statistically significant relationship (χ2 =
20.184; p<0.01) between income, as a demographic variable, and knowledge about HPV
infection as a major risk factor for cervical cancer.
Table 19: Chi-Square Test between Respondent/Family Household Income per
Month & HPV Infection Major Risk Factor for Cervical Cancer
(N = 176)
Respondent/Family Household
Income per Month
(Ethiopian birr**)
Variable
Less than
1000 Birr
1000 -5001
Birr
5001 Birr
or more
n (%)
n (%)
n (%)
HPV infection
major risk factor
for cervical cancer
Strongly disagree
Disagree
Agree
Strongly agree
χ2
Sig.
20.184 p<0.01
9 (21.4)
9 (21.4)
13 (31.0)
11 (26.2)
7 (10.3)
11.8)
28 (41.2)
25 (36.8)
** 1 US dollar = ~18.5 Eth Birr.
65 3 (4.5)
3 (4.5)
23 (34.8)
37 (56.1)
Chi-square analysis (Table 20 below) shows the presence or not of a relationship
between the responses to the question of who are at the highest risk of acquiring Human
Papillomavirus (HPV) infection versus the educational level of respondents. The data
showed that among the undergraduates 74.6% answered correctly to the question on
highest risk group for acquiring HPV infection, while only 51.2% of graduates had the
correct response to the question. Chi square statistics showed a significant relationship
between education level/class standing and knowledge of HPV (χ2 = 8.277; p<0.05).
Table 20: Chi-Square Test Between Respondent Class Stand & Highest Risk
Group for Acquiring HPV Infection (N = 173)
Highest Risk Group for
Acquiring HPV Infection
Variable
Correct
Response
Incorrect
Response
n (%)
n (%)
Education Level
Undergraduate
97 (74.6)
33 (25.4)
Graduate
22 (51.2)
21 (48.8)
χ2
Sig.
8.277
p<0.05
As shown below in Table 21, there is a statistically significant relationship
between class level and knowledge of HPV infection as a major risk factor for cervical
cancer development (χ2 = 9.271; p<0.05). Among the undergraduate respondents, while
43.4% agree that HPV infection is a major risk factor for developing cervical cancer,
55.3% of graduate respondents strongly agree to the statement that HPV infection is a
major risk factor for developing cervical cancer.
66 Table 21: Chi-Square Test between Respondent Education Level & HPV Infection
is a Major Risk Factor for Cervical Cancer (N = 183)
Education Level
Variable
Undergraduate
n (%)
Graduate
n (%)
HPV infection major risk
factor for cervical cancer
Strongly disagree
Disagree
Agree
Strongly agree
14 (10.3)
15 (11.0)
59 (43.4)
48 (35.3)
χ2
Sig.
9.271
p<0.05
6 (12.8)
6 (12.8)
9 (19.1)
26 (55.3)
Listed below are relationships found to be non-significant and/or with expected
cell count more than 20%.

HPV infection is the major risk factor for development of cervical cancer &
income

Class level & problems HPV infection cause &

Class level & highest risk group for acquiring HPV infection
Hypothesis 4
Hypothesis-4: There is a relationship between demographic and
knowledge/attitude/practice of Pap test screening
Listed below are relationships that were analyzed for hypothesis 4 using Chisquare analysis.
1.
Respondent/Family Household Income per Month and Ever had a Pap test
2.
Respondent Class Stand and Ever had a Pap test
67 Table 22: Chi-Square Test between Respondent/Family Household Income per
Month & Ever had a Pap test (N = 376)
Respondent/Family Household Income per
Month (Ethiopian birr**)
Variable
Less than
1000
n (%)
1000 to
3000
n (%)
3001 to
5000
n (%)
5001 or
more
n (%)
Ever had a
Pap test
Yes
No
Not sure
χ2
Sig.
27.372 p<0.001
9 (11.5)
3 (3.0)
1 (1.5)
7 (5.3)
53 (67.9)
16 (20.5)
90 (90.9)
6 (6.1)
60 (89.6)
6 (9.0)
119 (90.2)
6 (9.0)
** 1 US dollar = ~18.5 Eth Birr.
Table 22 above shows data on the practice of Pap test stratified by household
income. Among those who reported income less than 1000 Ethiopian Birr/month, 11.5%
reported to have had Pap test. However, among those who’s reported income is 10003000, 3001-5000 and 5001 or more Birr/month, those who had also Pap test is 3%, 1.5%
and 5.3% respectively. On the other hand, while 67.9% of those who had less than 1000
Birr income state that they had no Pap test, 90.2% of those who earn more than 5000 Birr
stated that they had no Pap test. Similarly, while only 20.5% of those with less than 1000
Birr income indicated that they are not sure if they had Pap test, only 9.0% of those who
earn more than 5000 Birr stated so. The data point towards increased level of Pap test
among low-income students. The data points also that the proportion of students who did
not have Pap test, within each income group, is higher among those who report higher
income/month. On the other hand, the proportion of students, within each income group,
those who state that they are not sure if they had or not of a Pap test is high in the low-
68 income group. Chi-square analysis shows that the relationship between monthly income
and the practice of Pap test is significant (χ2 = 27.372; p<0.001).
Table 23: Chi-Square Test between Respondent Education Level & Ever had a
Pap test (N = 386)
Ever had a Pap Test
Variable
Yes
n (%)
No
n (%)
Not Sure
n (%)
Education Level
Undergraduate
11 (3.4)
279 (86.6)
32 (9.9)
Graduate
9 (14.1)
52 (81.3)
3 (4.7)
χ2
Sig.
13.483
p<0.01
In the study where the relationship between levels of education and the practice of
Pap test (three categories) was evaluated, the percent of undergraduate students who
report to have had Pap test is 3.4% while it is 14.1% in the graduate group (Table 23).
Similarly, those who are not sure of having Pap test are 9.9% within the undergraduate
group while they are only 4.7% within the graduate group. The data indicates that the
proportion of students who had Pap test, within the graduate group, are higher than those
within the undergraduate group. The relationship between education level and the
Practice of Pap test is statistically significant as assessed by Chi square test (χ2 =13.483;
p<0.01).
Listed below are relationships found to be non-significant and/or with expected
cell count more than 20%.

Ever had a Pap test & income
69 Hypothesis 5
Hypothesis-5: There is a relationship between barriers to early Pap test
screening and knowledge and practice of Pap test screening.
Listed below are relationships that were analyzed for hypothesis 5 using crosstab
analysis.
1.
Lack of Health Service Facility in my Area Prevented Me from Having
Pap test and Ever had a Pap test
2.
Cultural Belief Prevented Me from Having Pap test and Ever had a Pap
test
3.
Virgin No Need Pap test and ever had a Pap test
4.
Healthy No Need Pap test and Ever had a Pap test
Data on the relationship between the “lack of health service facility in my area
prevented me from having a Pap test” and “ever had a pap test” is shown in Table 24
below. Among the respondents who reported ever having a Pap test, 58.8% strongly
disagree/disagree to the statement that lack of health service facility in my area prevented
me from having a Pap test. On the other hand, 72.7% of the respondents who never had a
Pap test reported that they strongly disagree/disagree to the statement that the lack of
health service facility in my area prevented me from having a Pap test. Among the
respondents who were not sure if they had Pap test or not, 56% stated that they strongly
agree/agree that lack of health service facility in their area prevented them from having
Pap test. Pearson chi-square result indicates a statistically significant relationship
between the responses to the statement that the lack of health service facility in my area
prevented me from having a Pap test and ever having had a Pap test (χ2 = 9.284; p<0.05).
70 Table 24: Chi-Square Test between Lack of Health Service Facility in my Area
Prevented Me from Having Pap test & Ever had a Pap test (N = 236)
Ever had a Pap test
Variable
Yes
n (%)
No
n (%)
Not Sure
n (%)
Lack of health service
facility in my area
prevented me from
having Pap test
Strongly
disagree/disagree
Strongly
agree/agree
10 (58.8)
141 (72.7)
11 (44)
7 (41.2)
53 (27.3)
14 (56)
χ2
Sig
9.284
p<0.05
Table 25 below presents data on the relationship between the variables, cultural
belief, as a barrier to Pap test, and Pap test practice by evaluating the responses to the
statement that cultural belief prevented me from having Pap test and the responses to the
question of whether respondents ever had Pap test. Among students who reported to
have had Pap test, 86.5% disagreed or strongly disagreed to the statement that cultural
belief prevented them from having Pap test while only 65.7% did so among the
respondents who stated that they did not have Pap test. Among those who reported to not
be sure if they had Pap test, 66.7% agreed or strongly agreed to the statement that cultural
belief prevented them from having Pap test. Pearson Chi-Square statistics shows that
there is a statistically significant relationship between the two variables, i.e., cultural
belief prevented me from having Pap test and ever had Pap test (χ2 = 12.094; p<0.05).
71 Table 25: Chi-Square Test Between Cultural Belief Prevented Me from Having
Pap test & ever had a Pap test (n = 202)
Ever had a Pap Test
Variable
Yes
n (%)
No
n (%)
Not Sure
n (%)
Cultural Belief
Prevented Me from
Having Pap Test
Strongly
disagree/disagree
Strongly
agree/agree
13 (86.7)
109 (65.7)
7 (33.3)
2 (13.3)
57 (34.4)
14 (66.7)
χ2
Sig.
12.094
p<0.05
Table 26 below shows the relationship between barrier variable, in this case belief
that I am healthy and do not need Pap test, and the practice of Pap test. The data reveals
similar trend as in table 25 above. Specifically, among those who have indicated that they
have had a Pap test, 87.5% of them disagree/strongly disagreed to the statement that I am
healthy and do not need Pap test. By contrast, only 69.6% of those who stated that they
never had Pap test and 48% of those who were not sure, if they had a Pap test,
respectively disagreed/strongly disagreed to the statement of I am healthy and do not
need Pap test. The relationship between a barrier variable, i.e., I am healthy and do not
need Pap test, and Pap test practice is significant as evidenced by the Pearson Chi-Square
statistics (χ2 = 7.646; p<0.05). 72 Table 26: Chi-Square Test Between Healthy No Need Pap test & Ever had a
Pap test (n = 222)
Ever had a Pap Test
Variable
Yes
n (%)
No
n (%)
Not Sure
n (%)
Healthy No Need
Pap Test
Strongly
disagree/disagree
14 (87.5)
126 (69.6)
12 (48)
Strongly
agree/agree
2 (12.5)
55 (30.4)
13 (52)
χ2
Sig.
7.646
p<0.05
Listed below are relationships found to be non-significant and/or with expected
cell count more than 20%.

Ever had a Pap test & a virgin and don’t need Pap test

Ever had a Pap test & healthy and don’t need Pap test
Hypothesis 6
Hypothesis-6: There is a relationship between social support and knowledge
and practice of Pap test screening
Listed below are relationships that were analyzed for hypothesis 5 using Chisquire analysis.
1.
No one encouraged me to have my first Pap test and ever had a Pap test
2.
Friend/Partner/Family Member accompany me to have my first Pap test
and Mother had/has Regular Pap test
In an effort to assess whether there is relationship between social support and Pap
test practice, responses to the question of “ever had Pap test” and to the statement “no
73 one encouraged me to have my first Pap test” were evaluated (Table 27). Among those
who had Pap test, only 17.6% stated that no one has encouraged them while the vast
majority of them (82.4%) did not identify with the statement. By contrast, 78.4% of
participants who did not have Pap test and 48.6% of participants who are not sure of
having Pap test stated that no one encouraged them to have their first Pap test. Chi
square test revealed that there is a relationship between the responses to the statement of
no one encouraged me to have my first Pap test and the practice of Pap test (χ2 = 41.221,
p< 0.001).
Table 27: Chi-Square Test between No one encouraged me to have my first Pap
test & ever had a Pap test (N = 358)
No one encouraged me to have
my first Pap test
Variable
Mentioned
n (%)
Not mentioned
n (%)
Ever had a Pap test
Yes
3 (17.6)
14 (82.4)
No
240 (78.4)
66 (21.6)
Not sure
17 (48.6)
18 (51.4)
χ2
Sig.
41.221
p< 0.001
Data were also assessed in order to gain insight on whether there is a relationship
between the variables of being accompanied by a family member/friend or partner on the
first Pap test and the Pap test practice of the respondent’s mothers (Table 28). Data show
that 38.1% of the respondents who indicated that their mother had/has regular Pap test
reported also that they have been accompanied at their first Pap test. By contrast, only
5.4% of those who indicated that their mother had/has regular Pap test reported that they
74 were not accompanied by family/friend/ partner at first Pap test. Chi square test reveled
that there is a relationship between the two variables (χ2 = 29.697, p< 0.001).
Table 28: Chi-Square Test between Friend/Partner/Family Member accompany me
to have my first Pap test & Mother had/has Regular Pap test (N = 298)
Variable
Friend/Partner/Family
Member accompany me to
have my first Pap test
Yes
n (%)
No
n (%)
Mother had/has regular
Pap Test
Yes
No
Not sure
χ2
Sig.
29.697 p< 0.001
8 (38.1)
6 (28.6)
7 (33.3)
15 (5.4)
150(54.2)
112 (40.4)
Listed below are relationships found to be non-significant and/or with expected
cell count more than 20%.

Dr encourage me to have1st Pap test & ever had a Pap test

Fm encourage me to have1st Pap test & ever had a Pap test

Friend encourage me to have1st Pap test & ever had a Pap test

Mother encourage me to have1st Pap test & ever had a Pap test

Sex partner encourage me to have1st Pap test & ever had a Pap test

Adult Women should have Pap test each year & friend/partner/family member
accompany me to have1st Pap test

Adult Women should have Pap test each year & sex partner accompany me to
have1st Pap test
75 CHAPTER 5
DISCUSSION
Introduction
In this section, result from the “Level of Knowledge toward Human
Papillomavirus/Cervical Cancer and Practice of Papanicolaou (Pap) Test Screening
among Female Addis Ababa University Students In Ethiopia” thesis project will be
discussed. The section is organized under the following sub-sections: Demographic
characteristics; Hypothesis-1: There is a relationship between level of knowledge toward
Human Papillomavirus/cervical cancer and knowledge and practice of Pap test screening;
Hypothesis-2: There is a relationship between level of knowledge toward Human
Papillomavirus/cervical cancer and sexual behavior; Hypothesis-3: There is a relationship
between demographic and level of knowledge toward Human Papillomavirus/cervical
cancer; Hypothesis-4: There is a relationship between demographic and knowledge and
practice of Pap test screening; Hypothesis-5: There is a relationship between barriers to
early Pap test screening and level of knowledge and practice of Pap test screening and
Hypothesis-6: There is a relationship between social support and level of knowledge and
practice of Pap test screening.
Cervical cancer is a major public health concern throughout the world (Arbyn et
al., 2011). It is now well documented that, early screening and vaccination against
Human Papillomavirus (HPV)/cervical cancer, albeit prohibitively expensive to some
communities, are critical to alleviate HPV infection and cervical cancer in women (CDC,
2013a). Equally important and a rather attainable public health tool is primary prevention
of cervical cancer. This could be achieved through health promotion strategies in sexual
76 behavior change to prevent and control genital HPV infection, thus cervical cancer
(Franco, Duarte-Franco, & Ferenczy, 2001). This is particularly relevant to resource poor
countries. A prerequisite for increasing awareness or developing and implementing any
public health program in a community, however, is the availability of basic information
and a database. Such information and data are acutely scarce in countries like Ethiopia.
It is on this basis that the proposed study aimed to determine the “level of knowledge
toward HPV/cervical cancer & knowledge and practice of Pap test screening among
female Addis Ababa University students in Ethiopia”.
Demographic Characteristics
The mean age of the respondent female students at Addis Ababa University
(AAU) is 23.2 years with a median age of 21.5 years. These are comparable to that of
other female university students who participated in Human Papillomavirus (HPV)
related knowledge and awareness studies in the world. For instance, in Nigeria the
Bayero University female students HPV study participants had a mean age of 22.7 years
(Iliyasu et al., 2010); in Malasia, the majority (78.9%) of female university students in the
Malay medical university HPV study had a mean age of 22 years (Rashwan, Saat & Abd
Manan, 2012); female high school and university students in the vicinity of Krakow,
Poland who participated in an HPV infection and vaccine awareness study had age range
of 17-26 years (Kamzol , Jaglarz , Tomaszewski , Puskulluoglu & Krzemieniecki, 2013);
participants at the female colleges in Kalkuata, India were aged 17-24 years (Saha,
Chaudhury, Bhowmik & Chatterjee, 2010).
Most of the respondents at the Addis Ababa University (AAU) were single
(84.8%) while 15.2% were married, engaged or divorced. According to the Ethiopian
77 Central Statistics Agency & ICF International (ECSA & ICFI) (2012a), the median age at
first marriage for women with no education is 15.9 years. In contrast, those with more
than secondary education get married almost eight years later with median age of 23.8
(ECSA & ICFI, 2012a). Thus, the lower percent of married students at AAU is in line
with the national trend for educated women. Nearly all of the students rate their health
status as good, very good or excellent and only 0.5% of the students rate their health as
poor. Given that most of the students are young, the healthy state of the students is not
unexpected.
More than half of the respondents in the present study are from Addis Ababa area
(55.6%), followed by Amhara (12.2%), Tigray (10.2%) and Oromo (9.7%) regions
(Figure 3). Given that each region has now its own university, it is not unexpected to
have most of the students at Addis Ababa University (AAU) to be of Addis Ababa origin.
Most of the female students (61.4%) live on campus, although an important number
(38.6%) live off campus, probably because most of the female students are of Addis
Ababa origin. The respondents were also 16.4% graduates and 83.4% undergraduates,
comparable to the overall AAU students graduate to undergraduate student ratio of 1.5 to
8.5 at enrollment (AAU, 2011). More than half (59%) of the undergraduate students and
a little less than half (48%) of the graduates are from Addis Ababa.
In response to income question, 21% responded to have < 1000 Birr (i.e., <12,
000 Birr/year = < ~US$650/year), while 35.2 % reported to have 50001 Birr or more
income per month (>60, 000 Birr/year = > ~US$3240/year). There is no available data
that reflects income based economic class division in Ethiopia. However, the more than
5-fold difference between the students who report <12,000 Birr/year and >60,000
78 Birr/year may reflect relative economic differences between the groups. Most of the
students who reported the more than 60,000 Birr/year come from the capital city Addis
Ababa. This is in line with the ECSA & ICF I (2012b) report that 88% of the population
in the Ethiopian urban areas is in the highest wealth quintile, while only 5% of the rural
population is in the highest wealth quintile.
Hypothesis:
Hypothesis 1: There Is A Relationship Between Level Of Knowledge Toward Human
Papillomavirus/Cervical Cancer And Level Of Knowledge/Practice Of
Papanicolaou Test Screening.
Addis Ababa University (AAU) female students who responded correctly to most
of the knowledge questions including on Human Papillomavirus (HPV), cervical cancer
and Pap test is between 30-50% of the respondents. Only 1 out of 3 female respondents
(33.2%) heard about HPV and only 46.5% heard about cervical cancer. The most
common response (40-52%) to the other knowledge questions, such as HPV transmission
and risks for cervical cancer, is the “do not know” response. These data show that the
level of knowledge towards HPV/cervical cancer among the respondents is low. In
addition, only 5.2% of the respondents ever had Papanicolaou (Pap) test and of these
(31.6%) had Pap test at 25 or older years.
Association studies, under hypothesis 1, further showed that there is a relationship
between the level of knowledge toward Human Papillomavirus (HPV)/cervical caner and
knowledge and practice of Pap test. More specifically, about 4 out of 5 students (83.9%)
who knew about the route of HPV transmission knew also that Pap test is not only for
women with multiple sex partners. Likewise, 3 out of 4 students who have knowledge
79 about the long-term effects of HPV infection agreed or strongly agreed also that Pap test
can tell whether a woman has cervical cancer. In addition more of the respondents who
have heard of HPV or cervical cancer strongly agree with the correct statement about Pap
test frequency for adult women than those who did not hear about HPV or cervical
cancer. This is in line with the significant association revealed between knowledge of
HPV/cervical cancer and the practice of Pap test screening (WHO, 2006).
There are no available data from other universities in Ethiopia to compare the
present results with. In the only study on knowledge on Pap smear screening done in
women who sought reproductive health care at three teaching hospitals in Addis Ababa,
Ethiopia (Terefe & Gaym, 2008), more than four out five of the reproductive health
patients (81.2%) had never heard of Pap smear screening. This is in stark contrast to the
knowledge and practice of Addis Ababa University (AAU) students (male and female) in
Ethiopia regarding human immunodeficiency virus (HIV) infection. In a recent study,
Regassa & Kedir (2011), reported that 59.2 % AAU students (male and female) had
experienced at least one of the three HIV preventions, (Abstinence, Be faithful &
Condom use) suggesting that student’s knowledge about HIV is better than that of
Human Papillomavirus (HPV). This difference in awareness on HIV infection versus
HPV is probably because several national and international agencies and policies have
made significant effort to increase awareness toward HIV infection both in Ethiopia and
across the world.
The present data show that the level of knowledge on HPV, cervical cancer and
Pap test is low among female university students at AAU. Similar trend is seen among
university students of several other developing countries. For instance, among university
80 female students in Nigeria, only 35.5% of the sampled students knew of HPV and as
much as 91.7% of the female students who attend in non-medical faculty colleges had
never heard of Pap smear screening (Iliyasu et al., 2010). Similarly, only 33% of the first
year female students in Mangosuthu University in South Africa have heard about cervical
cancer and of these, 32% knew that HPV is a risk factor for cervical cancer (Hoque,
2010). In Kolkata India, a study in female only colleges found that less than 50% of the
participants knew about risk factors of cervical cancer and a mere 11% ever heard about
Pap smear. On the other hand, in the United State of America, a study at the University
of California, Fullerton showed that 21.5% of the female student participants did not hear
about HPV (Lopez & McMahan, 2007). Likewise, in a more recent Polish students
study, nearly all (98.5%) of the female high school and university students knew about
cervical cancer, although authors conclude that the student’s general awareness level is
insufficient (Kamzol et al., 2013). In view of these data, the level of knowledge on HPV
and cervical cancer among female AAU students of Ethiopia is low.
Of significance is that, although the prevalence of cervical cancer is less than that
of breast cancer in Ethiopia, death due to cervical cancer is the leading cause of cancer
related deaths (WHO/ICO- ICHPVCC, 2010). This coupled with the low level of
knowledge on Human Papillomavirus/cervical cancer, and the practice of Pap test shown
in the present study suggest the need for public health policy that targets primary
prevention towards HPV/cervical cancer and early Pap test screening among women in
Ethiopia cannot be overemphasized.
81 Hypothesis 2: There Is A Relationship Between Level Of Knowledge Toward Human
Papillomavirus/Cervical Cancer And Sexual Behavior
Among the respondents of the female Addis Ababa University (AAU) students in
the present study, 18.2% were sexually active of which 28.9% had two or more sexual
partners, 54.9 % use condoms from sometimes to always and 43.3% had their first sexual
intercourse at 20 years or younger age. These values are comparables to other
communities of comparable socio-economic demographics. In the Bayero University
female students in Nigeria, 21.1% were sexually active of which 32.9% had 2 or more
sexual partners, 19% used male condoms, 5% used female condoms and the mean age of
sexual debut was 17.5 years (Iliyasu et al., 2010). The AAU student’s reported rate of
sexual experience however, is less than other communities. In a study by Hoque (2010),
39.5% of the first year Mangosuthu University female students in South Africa were
sexually active of which 78.5% use condoms and 27.9% had two or more sexual partners.
Study in young female students (age 12-26) most attending secondary schools in
Cameroon (Ayissi, et al, 2012), showed that 32.9% were sexually active of which 65.4%
reported using condoms and having an average life time sexual partner of 2. In a similar
study that included young students aged 13-24 years attending secondary schools and
universities in Tuscany, Italy, more than half were sexually active of which about half
regularly use condom and had a mean sexual activity debut age of 15.4 years (Boccalini
et al., 2012). Whether the AAU female student’s reported lesser rate of sexual activity is
because of an underreporting or characteristic of the AAU female student population
could not be determined from the study.
82 Given that sexual behaviors such as early debut of sexual activity, having multiple
sexual partners and the non-utilization of protective condoms are common risk factors for
Human Papillomavirus (HPV) infection and its persistence in a community (Boccalini et
al., 2012), the relatively low level of admitted sexual activity among the Addis Ababa
University (AAU) female students puts them at a relatively lower risk of contracting
HPV. However, the relatively lower level of regular use of condom among the sexually
active AAU students when compared to that reported by Hoque (2010), Ayissi, et al.
(2012) and Boccalini et al. (2012) is a concern that needs to be addressed to mitigate the
risk of HPV infection in those who are sexually active students. In addition, about one
out of three of the sexually active AAU students have 2 or more sexual partners that put
them at higher risk of contracting HPV. In agreement with this, several groups of studies
have clearly shown that HPV is predominantly and largely transmitted through sexual
intercourse. More specifically, studies investigating the risk factors associated with the
presence of genital HPV have shown that the number of sexual partners is one of the key
determinants of HPV infection in women (Kjaer, et al., 2001). It is highly likely that the
low use of condoms and the significant number of students who have two or more sexual
partners among the sexually active AAU students reflects the relatively low knowledge of
HPV, cervical cancer and Pap test described in section Hypothesis-1 above. The
corollary is that improving knowledge on the risk factors will lead to safer sexual
behavior is well advocated (Franco, et al., 2001).
Association studies revealed a significant relationship (p<0.01) between being
sexually active and heard of Human Papillomavirus (HPV) in that while more than half
(57.8%) of the sexually active students have heard of HPV, only about a quarter of those
83 who reported to be not sexually active have ever heard of HPV (27.7%). Surprisingly
though, among the sexually active students the relationship between knowledge on risk
factors for HPV infection and condom use, as a sexual behavior, did not show statistical
significance (P>0.05). Specifically, knowledge on whether having more than 2 sexual
partner; on whether one’s partner has had more than 2 sexual partners; on whether having
the first sexual intercourse at 16 or younger age; or on whether failure to use condom
constitutes a risk factor for HPV infection is not associated to the respondents practice of
condom use. For instance, among the students who identified that failure to use condom
is a risk factor for HPV infection, only half (50.0%) of them report that they use condom.
Likewise, among students who did not identify failure to use condom as a risk factor,
55.4% of them use condom. The rate of students who use condom is also similar among
students who demonstrated or lacked knowledge about the other risk factors of HPV
infection. These data suggest that the respondent’s knowledge of some of the risk factors
of HPV infection is not associated with their practice of condom use. This contrasts with
studies that showed low levels of HPV/cervical cancer knowledge, and perception of
seriousness and susceptibility to be coupled with high-risk sexual behaviors (Ingledue,
Cottrell, & Bernard, 2004) but is in agreement with the survey of nursing students where
knowledge about HPV was not correlated with condom use (Denny-Smith, Bairan, &
Page, 2006). Two possible explanations may be relevant to the lack of association
between knowledge about HPV and condom use data in the present study. One, the
sample size of sexually active students is relatively small (n =70) and as such the data
may not have enough power to detect significant associations. Another plausible
explanation for the apparent disconnect between knowledge and use of condom among
84 Addis Ababa University (AAU) female students may be the fact that the general
awareness of students about the benefits of condom use may have increased due to the
relatively well established Human immunodeficiency virus infection / acquired
immunodeficiency syndrome (HIV/AIDS) prevention advocacy in the world and
Ethiopia. The relative exposure of students to the message of use of condom in the
context of HIV/AIDS may have thus contributed to the rather similar rate of condom use
among students who know or do not know about the risks of HPV infection.
Hypothesis 3: There Is A Relationship Between Demographic And Level Of Knowledge
Toward Human Papillomavirus/Cervical Cancer
Association study under hypothesis 3 confirmed that there are significant
relationships between demographic variables such as household income or education
level and knowledge toward HPV/cervical cancer. Specifically, while only 26.2% of
female Addis Ababa University (AAU) students who reported monthly income of less
than 12,000 Birr/year (<$650/year) strongly agreed to the statement of Human
Papillomavirus (HPV) infection being a major risk factor for developing cervical cancer,
more than half (56.1%) of those who reported 60,000 Birr/year or more ($3240/year or
more) did strongly agree to the statement. Although there is no available data that
appraises the standard of living of Ethiopians based on monthly or annual income,
according to the most current report, the gross domestic product (GDP) per capita of
Ethiopia is $12,000 (CIA, 2013). In this context, although a 1000 Birr/month or less
(12,000 Birr/year or less = $650 or less/year) income can not be directly compared to the
GDP per capita figure, it is reasonable to assume that this income level is low both in the
Ethiopian and global measurers. The 5001 Birr/month or more (>60,000 Birr/year or
85 >~$3240/year) income is more than 5 fold higher than the reported low income of
students and may thus represent a middle to high income economic group in the
Ethiopian context.
Comparison of knowledge toward Human Papillomavirus (HPV) and cervical
cancer by education level showed that female Addis Ababa University (AAU) graduate
students had better knowledge than their undergraduate counterparts. Among the
graduate respondents, while 55.3% of graduate students strongly agree with the fact that
HPV infection is a major risk factor for cervical cancer, only 35.3% of the
undergraduates do strongly agree to the statement of HPV infection being a major risk
factor for cervical cancer. These findings are in agreement with reports (WHO, 2006)
that indicate that awareness of cervical cancer and adherences to preventive measures
vary based on educational level and cultural background. Women with high educational
levels will know that regular Pap test screenings are important and will thus have high
rates of Pap test screening. Cervical cancer is also disproportionately high in poor
communities and societies (WHO, 2006). However on a question related to the highest
risk group for acquiring HPV infection, 74.6% of undergraduates provided the correct
answer while only 51.2% of graduate did provide the correct answer. It is not clear why
undergraduate students performed well on this particular question than graduates. A
possible explanation might be that higher proportion of the female AAU undergraduate
students (57%) comes from Addis Ababa, the capital city of Ethiopia, than that of their
graduate counterparts (48%). Exposure to media (print, TV, radio and social media) is
higher in Addis Ababa than other parts of Ethiopia. It is thus possible that awareness
86 about aspects of sexually transmitted diseases, including HPV, may be better among
students who come from the capital city where access to media is better.
Overall, the current study agrees with the overall consensus that low income and
less educated communities have lesser opportunities to information and knowledge on
Human Papillomavirus (HPV)/cervical cancer. However, further study is warranted to
accurately appraise the relationship between income or education levels and
HPV/cervical cancer knowledge and the practice of Pap test screening among female
university students. This is particularly important in view of the fact that the number of
new cases and deaths per year due to cervical cancer are disproportionately high in lowincome countries, to the level of 86% and 88% of the worldwide cases and deaths
respectively (Arbyn et al., 2011).
Hypothesis 4: There Is A Relationship Between Demographic And Knowledge And
Practice Of Papanicolaou Test Screening.
The study demonstrated that knowledge and practice of Papanicolaou (Pap) test
screening among the Addis Ababa University (AAU) female students is low as shown by
the only 35.8% of the respondents agreed or strongly agreed that Pap test could tell if a
woman has cervical cancer and by the only 5.2% who ever had Pap test. The overall
knowledge about Pap test among the students is even lower than their knowledge toward
Human Papillomavirus (HPV) and cervical cancer as shown by close to half (46.5%) of
the students have heard of cervical cancer while only 5.2% had Pap test. Similar trend of
better awareness about cervical cancer (54%) than awareness about Pap test and a low
level of Pap test practice (6.4%) is reported among female university students in Nigeria
87 (Iliyasu et al., 2010). These data support the link between the low level of knowledge
about Pap test and the low level of Pap test practice.
Associations between variables were further determined by stratifying the level of
Pap test knowledge and practice by determinants such as education level (graduate vs
undergraduate), age or income level, as a demographic factor. Data showed a significant
association between education level and Pap test practice where 14.1% of the graduates
and only 3.4% of the undergraduates had Pap test. A number of factors are reported to
enhance or diminish efforts towards cervical cancer screening. Education and level of
knowledge about Human Papillomavirus (HPV), its mode of transmission and its risk of
causing cervical cancer as well as knowledge and attitude toward importance of regular
screenings, among others, are important determinants of Pap test practice (McFarland,
2003).
Similarly, when knowledge and Pap test practice is looked by age, as a
demographic factor, the mean reported age of those who had Pap test is higher (30.2
years) than those who did not (22.9 years). Furthermore, graduates have a mean reported
age of 27.8 years that is higher than the mean reported age of undergraduates (22.4
years).
Paradoxically, though, when knowledge and practice of Papanicolaou (Pap) test is
stratified by income level, the data show a relatively higher Pap test practice (11.5%)
among those who reported a lower income (<12,000 Birr/year or < ~$650/year) than
those who reported a higher income (60,000 Birr/year or more or $3240/year or more)
(5.3%). The discrepancy between the assumption that poorer communities have lower
rate of Pap test screening and the present data on income and Pap test practice could be
88 that the income level data used in the present study may not reflect the actual economic
status of families. Alternatively, other factors such as, small sample sizes could account
for the observed higher rate of pap test among the low income students and may limit the
interpretation of the data. This is shown by the fact that the total number of students who
report to have had Pap test is only 5.2% of all the participants. In addition access to a
possible free health services at the Addis Ababa University or at the regional state from
where the students came from may have contributed to the observation. Whether the
relatively higher Pap test practice among the low income students is related to their over
health status that increased their chance to have Pap test can not be inferred from this
study.
The overall data in the present data corroborate that demographic factors such as
education and age are associated with Pap test knowledge and practice. For instance,
That higher knowledge about Human Papillomavirus (HPV) and cervical cancer leads to
a behavior of Pap test practice is in line with the integrated behavioral model (IBM) that
considers intention to perform behavior as the main determinant of behavior and where
knowledge, skills, environmental constraints, and habits are independent determinants of
health behavior (Glanz, Rimer & Viswanath, 2008).
Of note is that CDC (2012b) recommends beginning Papanicolaou (Pap) test
screening at age twenty one. In a more recent matched case-control study on cervical
cancer patients, even a 2 or 3 years Pap test intervals is shown to carry a higher risk to
develop cervical cancer when compared to a yearly screening (Miller et al., 2003). In
view of these facts, it is critical that the low level of Pap test practice rate among female
89 students at Addis Ababa University be addressed to help reduce cervical cancer
incidence.
Hypothesis 5: There Is A Relationship Between Barriers To Early Papanicolaou Test
Screening And Knowledge And Practice Of Papanicolaou Test
Screening.
The data on barriers that could prevent students form having early Papanicolaou
(Pap) test screening show that up to 2 out of 5 female Addis Ababa University (AAU)
student respondents report that being virgin, shy, healthy, or cultural belief, cost and lack
of health facility in their area to prevent them from having Pap test. On the other hand,
30-50% of the respondents do not believe that lack of health service facility, bad attitude
of doctors/nurses, or cost prevents them from having Pap test.
Further association studies of the present data confirmed that there is a significant
relationship between either lack of access to health service facility, cultural belief, being
virgin or the belief of being healthy with the knowledge and practice of Papanicolaou
(Pap) test. Specifically, close to 6 out of 10 respondents (58.8%) who had Pap test, state
that lack of health service facility is not a barrier to have Pap test. On the other hand,
close to 9 out of 10 students (86.7%) who had Pap test, do not believe that cultural belief
prevented them from having Pap test and nor do they have the attitude/belief that they are
healthy and do not need Pap test. By contrast, about 1 in every 3 students (34.4%) who
did not have Pap test, agree that cultural belief prevented them from having Pap test and
believe that they are healthy and hence do not need Pap test (30.4%). The importance of
barriers in limiting Pap test practice is corroborated by prior studies. McFarland (2003)
reported that lack of access to medical care; lack of knowledge about Human
90 Papillomavirus, its mode of transmission and its risk of causing cervical cancer; lack of
knowledge and attitude toward importance of regular screenings; lack of financial
resources to afford Pap exams are barriers to early Pap test screening. Cultural belief is
also shown to limit Pap test seeking behavior and adhering to it (Mosavel et al., 2009).
While the above data that about 30-50% of the respondents do not consider the
barriers to prevent them from having Papanicolaou (Pap) test is a source for moderate
optimism, the fact that there are about 1-2 out of 5 students who report the barriers do
indeed prevent them from having Pap test is a concern. The concern is justified because
women who do not practice routine Pap tests have a significantly higher risk of
developing cervical cancer (Dailard, 2003).
Hypothesis-6: There Is A Relationship Between Social Support And Level Of
Knowledge And Practice Of Papanicolaou Test Screening.
The social support data showed that almost 70% of the respondents had no one to
encourage them to have their Papanicolaou (Pap) test, 93.2 % do not talk to their family
about cervical cancer and Pap test and as many as 73.8% do not talk with a friend about
Pap test and cervical cancer. In a specific question to whether the respondent has a
friend, partner or family member to accompany for a first Pap test, 93.7% indicate that,
no they do not have. Corresponding to this, only 14.4%, 5.2%, 2.8% and 2.5% had
encouragement from a doctor, a friend, a mother, a family member or from a sexual
partner, respectively to have a Pap test. Interestingly, over 50% of respondents share
personal matters with one or more family members and report that their family or friends
let them talk their personal matters.
91 The study showed also that there is a significant association between the social
support variable (having no one to encourage for Papanicolaou (Pap) test) and the Pap
test practice, (ever had Pap test). Among those who reported to not have had Pap test, the
overwhelming majority (78.4%) report that no one encouraged them to have Pap test
while only 17.6% of those who have had Pap test report to not have been encouraged for
the test. More over, the contrast between the lack of social support on Pap test (over 90%
of the respondents state to have no one to encourage them for Pap test) and the claim by
over 50% of the respondents to share their general personal matters with family or friends
suggest that the lack of social support is greater on the practice of Pap test than on
general personal matters. It is likely that the lack of support on matters of Pap test, as
evidenced in the present study, may contribute to the rather low level of knowledge and
Pap test practice among the female students of Addis Ababa University (AAU). Such a
high rate of lack of social support, as it relates to Pap test, is a concern. Increasing
awareness not only of students but also family members, doctors, friends and schools
officials could improve the rather low level of social support reported among students at
AAU. This is supported by studies that suggest increasing awareness and acceptance of
Human Papillomavirus vaccine through social network members among college-age
women (Bennett, Buchanan and Adams, 2012). Social support is also shown to be an
important factor in early cervical cancer detection by encouraging regular Pap test.
Support from family members, close friends and doctors provide encouragement and
guidance to do Pap test (Gamarra et al., 2009).
92 CHAPTER 6
CONCLUSION
This chapter will summarize the thesis work and provide conclusion, implication
and future direction/recommendation.
Conclusion
Human Papillomavirus (HPV) infection related cervical cancer is the primary
cause of cancer related death among Ethiopian women. This is despite the fact that
cervical cancer is preventable through primary prevention and screening. In Ethiopia, the
available data on HPV and cervical cancer are derived from hospitals and reproductive
health care records. The project “level of knowledge toward human
papillomavirus/cervical cancer & practice of Papanicolaou (Pap) test screening among
female Addis Ababa university students in Ethiopia” accessed a women population that is
less studied in Ethiopia.
Five basic conclusions can be drawn from the present study.
1.
The level of knowledge towards human Papillomavirus (HPV)/cervical cancer
and the practice of Pap test screening are low among female students of Addis
Ababa University (AAU), similar to most university students in developing
countries.
2.
More educated (graduates than undergraduates) and older students have better
level of knowing toward HPV/cervical cancer and practice Pap test screening.
3.
Although a third of the respondents report barriers to prevent them from having
Pap test, significant number of them seems to not know or to underestimate the
impact of barriers on their decision to have Pap test.
93 4.
The overwhelming majority of students (over 9 out of 10) claim to have no one to
encourage them to have Pap test.
5.
There are associations between the level of knowledge on HPV/cervical cancer
and the knowledge and practice of pap test screening; demographics with
knowledge and practice of Pap test and with sexual behavior; barriers and the
knowledge and practice of Pap test screening; and between social support and the
knowledge and practice of Pap test screening.
The fact that the level of knowledge on Human Papillomavirus (HPV)/cervical
cancer among the Addis Ababa University female students is low is of significant
concern because it foretells a greater lack of knowledge among the less educated, the
majority of Ethiopian women. Without increased awareness towards HPV/cervical
cancer by women, cervical cancer will remain to be a major health burden to Ethiopian
women. Nonetheless, given that HPV/cervical cancer is preventable through increased
awareness and preventive measure, the study provides also optimism, for it will have
implications in public health policy to improve awareness among women and reduce the
health and cost burden of HPV/cervical cancer in Ethiopia.
Implication for Public Health and Health Education
Key to the prevention of Human Papillomavirus (HPV) related cervical cancer is
increased awareness on risk factors, etiology, prevention, screening and treatment of
cervical cancer. Increase in awareness could be attained through education and national
health policy. One of the problems in developing and implementing any public health
program in the community is the lack of basic information and a database in resource
poor countries. It is on this basis that the proposed study intended to determine the “level
94 of knowledge of female Addis Ababa University (AAU) students in Ethiopia, on
HPV/cervical cancer & practice of pap test screening”.
The study will have several implications that are local to the target community but
will have implications also to the global health efforts of students and faculty at CSUN
and to the general understanding of HPV-cervical cancer.
To the Target Community:
The result from the study will help design health policy tailored to university
students. For instance, the Department of Health Science at California State University,
Northridge and the Addis Ababa University in Ethiopia could facilitate education on the
risk factors and prevention of Human Papillomavirus (HPV) infection at the university
health clinic visits or through regular awareness events and workshops. Given that the
risk of HPV infection is high among those who have low level of knowledge toward
HPV/cervical cancer, increasing awareness among college students will have a
significant impact in alleviating the deleterious health effects of HPV infection.
The impact of increased awareness about Human Papillomavirus (HPV)/cervical
cancer by female students at Addis Ababa University is even higher when one considers
1) that HPV is transmitted primarily through sexual activities and as such educating
female students will have impact on male genital wart incidence rate and illness that adds
burden to the public health 2) that the new graduates have the potential to teach women in
rural Ethiopia when they go back to their respective states and regions upon completion
of their studies. The study will also provide impetus to perform similar studies in other
universities and in the nation that will be instrumental in developing a national health
policy related to HPV and cervical cancer.
95 To California State University, Northridge:
Data generated from the study can be compared with studies at California State
University, Northridge (CSUN) and other university studies. The data will extend
understanding on Human Papillomavirus (HPV) and cervical cancer among university
students of diverse cultural and socioeconomic status. Generating original data on
HPV/cervical cancer from diverse communities is critical in developing global strategies
to reduce and prevent HPV/cervical cancer globally. As such, the study will extend the
CSUN, Department of Health Science’s endeavor to promote global health related to
HPV-cervical cancer. This is hoped to add to the international recognition of CSUN in
global health. In addition, experience to be gained from the collaborative international
inter-university research, will be of great help in developing efficient and fruitful future
international CSUN researches.
Future Direction/Recommendation
Overall, while the study is hoped to have the above significant implications, it is
evident that this study per-se will not provide the expected benefits if not followed with
further studies and measures that are necessary to refine and implement health policies.
Based on the data the following recommendations are made:
1.
Given the low level of knowledge on Human Papillomavirus (HPV)/cervical
cancer and Pap test among female students, the university needs to initiate and
implement awareness programs by inviting professionals and by organizing
awareness fares.
2.
Increase awareness not only among university students but also among the
general public through radio, TV, news papers, public gatherings, social media,
96 schools, at houses of worship and community gatherings at cultural and holiday
ceremonies…etc.
3.
In parallel, the university and/or public health services need to initiate a follow up
study and intervention through the development of “Human
Papillomavirus/Cervical Cancer & Practice of Pap test Screening Curriculum”
that incorporates aspects such as pretest and posttest evaluation of knowledge,
behavior and attitude, lessons plan and learner satisfaction survey. The goal of
such curriculum is to raise the awareness of Addis Ababa University female
students about the issues surrounding Human Papillomavirus, Human
Papillomavirus related cervical cancer, the practice of regular Pap test screening
and prevention strategies.
4.
The public health services need to initiate similar studies among high school
female students and Ethiopian women at large on the level of knowledge about
HPV/cervical cancer, acceptability of vaccines (if or when vaccines become
available), cultural sensitivity to sexual activity related education…etc. should be
done to have a public health policy relevant to HPV/cervical cancer in Ethiopia.
5.
The data shows that significant number of female students do not have family,
friend or professionals to talk to on matters of Pap test screening. The community
should be encouraged to speak out on issues of such significance and provide
social support to women and to each other on HPV/cervical cancer issues. The
HIV experience will help.
97 6.
Health professionals, particularly physicians, should be educated and/or
encouraged to speak on HPV infection and cervical cancer risk factors and
preventions to women who visit hospitals and health centers.
7.
The use of condoms by those who are sexually active should be encouraged.
8.
Exploit the resources, infrastructure and networking that the HIV/Aids
prevention campaign has in the nation to make a difference in HPV/cervical
cancer burden. The infrastructure and networking to fight HIV/Aids is relatively
well developed through concerted efforts at national and international levels. The
prospect of success in increasing awareness about HPV/cervical cancer is high
because the public is sensitized by several advocacies and public health policy
measures against HIV.
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112 APPENDIX A
HUMAN SUBJECTS PROTOCOL APPROVAL
113 114 115 APPENDIX B
ADDIS ABABA UNIVERSITY ACCEPTANCE LETTER
116 APPENDIX C
SURVEY QUESTIONNAIRE COVER LETTER
Dear Participant Students,
You are invited to participate in a study entitled “Level of Knowledge toward
HPV/Cervical Cancer and Practice of Papanicolaou Test Screening among Female Addis
Ababa University Students in Ethiopia”. The purpose of this study is to determine the
level of knowledge of female Addis Ababa University (AAU) students regarding HPV
related cervical cancer and regular Pap screening as methods of its early detection. The
study will be useful to guide effective prevention against HPV-cervical cancer in
Ethiopian women. You are being asked to participate in this study simply because HPVinfection and cervical cancer is a major health burden to women and as such your insight
as a female will provide valuable information towards the understanding of HPV and
HPV related cervical cancer in women in Ethiopia.
Your participation in the study is voluntary. You will only be asked to complete
the questionnaire once; there will be no follow-up study. If you decide to participate,
please complete the enclosed self-administered survey. The survey questionnaire relates
to your knowledge of HPV infection, its mode of transmission, methods of screening and
risks of HPV infection and cervical cancer and related information. The questionnaire
will not identify your name or identity. Thus, your identity in this study would be
anonymous. Your return of this survey is implied consent. This study will take
approximately 15-25 minutes of your time. Approximately 400 female Addis Ababa
University students will participate in this study.
117 There is no risk for participating in the study. There are no known harms or
discomforts associated with this study beyond those encountered in normal daily life.
There is no direct benefit you drive from the study. However, the study could provide
valuable information that will help guide health policy to prevent HPV related cervical
cancer in women in Ethiopia.
You can refuse to participate or to withdraw even after you decided to participate.
If you decide to withdraw from this study you should notify the research team
immediately. The research team may also end your participation in this study if you do
not follow instructions. There is no penalty or consequence of any kind for not
participating or for withdrawing from the study
Please feel free to ask questions regarding this study. You may contact Dr Vicki
Ebin or Iman Rumana Abdulkadir, if you have additional questions: Email:
vicki.ebin@csun.edu. Tel: 818‐677‐7053 or Tel: (251)-09-33-68-2456 or Email:
rumaana3@gmail.com
Thank you for your time.
__________________________________
Vicki J. Ebin, PhD, MSPH
Professor, MPH Graduate Coordinator
MPH and Public Health Programs
Department of Health Sciences
California State University, Northridge
118 ___________________________
Iman Rumana Abdulkadir
MPH Candidate
Department of Health Sciences
California State University, Northridge
APPENDIX D
SURVEY QUESTIONS FOR ADDIS ABABA UNIVERSITY FEMALE
STUDENTS
Please take the time to read and answer each question carefully that best represents your
response. This questionnaire is confidential and none of the information will be provided
to a third party.
1. Date of Birth:
__ __/__ __/ __ __ __ __
month day year
2. Which chartered cities or administrative regions do you identify with?
____ Addis Ababa
____ Afar
____ Amhara
____ Benishangul‐Gumuz
____ Dire Dawa
____ Gambela
____ Harari
____ Oromia
____ Somali
____ Southern Nations, Nationalities, & People’s Region
____ Tigray
____ Decline to state
3. Class level:
____ Undergraduate
____ Graduate
____ Other: Specify _____________________________________________
4. Do you live:
____ On-campus
____ Off-campus
4a. If off-campus, do you live with parents/family members?
____ Yes
____ No
119 5. College attend ______________________________________________________
_______________________________________________________________
5a. Specify School/Faculty/Institute _______________________________
___________________________________________________________
6. What is your/your family’s total household income per month?
_____ Less than 1,000 Birr
_____ 1,000 to 3,000 Birr
_____ 3,001 to 5,000 Birr
_____ 5,001 or more
7. What is your current marital status?
____ Single, never married
____ Engaged/committed relationship
____ Married/Living with a significant other
____ Divorced
____ Separated
____ Widowed
8. How would you rate your health overall?
_____Excellent
_____Very Good
_____Good
_____Fair
_____Poor
9. Have you ever had sexual intercourse?
_____Yes
_____ No
10. How old were you when you had your first sexual intercourse?
_____ I have never had sexual intercourse
_____ 18 years old or younger
_____ 19 – 20 years old
_____ 21‐ 22 years old
_____ 23 ‐ 24 years old
_____ 25‐26 years old
_____ 27 years old or older
120 11. During your life, with how many people have you had sexual intercourse?
____ I have never had sexual intercourse
____ 1 person
____ 2 people
____ 3 people
____ 4 people or more people
12. If you are sexually active, do you or your partner use a condom?
____ No I am not sexually active
____ No I never use condom
____ Yes I use condom sometimes
____ Yes I use condom most often
____ Yes I always use condom
12a. If never used a condom, what is/are the reason/s?
__________________________________________________________________
_____________________________
13. Have you heard of Human Papillomavirus (HPV)?
_____Yes
_____ No
14. What age group do you think is at the highest risk of acquiring HPV?
____ 0‐14
____ 15‐24
____ 25‐35
____ 36 and up
____ Do not know
15. Which of the following increases a woman’s risk of getting HPV? (Check all that
apply)
____ More than two sexual partners
____ If your partner has had more than two sexual partners
____ If your first sexual activity was at 16 or younger
____Failure to use condoms
____ Do not know
____ Other reasons: Specify _______________________________________
16. Do you think HPV
____ Always causes problems
____ Sometimes causes problems
____ Never causes problems
____ Do not know
121 17. What kind of problems might HPV infection cause?
____ Genital warts
____ Vulval/vaginal irritation
____ Vaginal discharge
____ Painful sexual intercourse
____ Do not know
____ Other: Specify __________________________________________
18. Is HPV an infection, which affects
____ Only or mainly men
____ Only or mainly women
____ Both men and women
____ Do not know
19. How do you believe that HPV is transmitted?
____ Shaking hands
____ Coughing on someone
____ By blood
____ Congenital
____ Intimate (sexual) contact
____ It in the air
____ From animals
____ Do not know
20. What are the long‐term effects of HPV?
____ Disappears and there are no long‐term effects
____ Abnormal Pap test
____ Cervical cancer
____ Infertility
____ Do not know
____ Other: Specify _______________________________________________
21. Have you ever been diagnosed with HPV?
_____Yes
_____ No
22. Have you ever heard of cervical cancer?
_____Yes
_____ No
23. Do you have a family history of cervical cancer?
_____Yes
_____ No
_____ Not sure
122 23a. If yes, which family member(s) were diagnosed with cervical cancer?
(e.g. mother, sister, aunt, grandmother
___________________________________________________________
24. Have you ever been diagnosed with cervical cancer?
_____Yes
_____ No
25. Please respond as to how strongly you disagree or agree with the following
statements.
Strongly
Disagree
Disagree
A. HPV infection is
the major risk
factor for
development of
cervical cancer.
B. HIV (the virus
that causes
AIDS) can
increases the risk
of developing
cervical cancer
C. Smoking can
increases the risk
of developing
cervical cancer
D. Having given
birth to three or
more children can
increase the risk
of developing
cervical cancer.
E. Using birth
control pills for a
long time (five or
more years) can
increases the risk of
developing cervical
cancer.
F. Possible signs of
cervical cancer
include vaginal
bleeding and pelvic
pain
123 Do Not
Know
Agree
Strongly
Agree
26. Have you ever had a Pap test?
_____Yes
_____ No
_____ Not sure
26a. If No, please go to question #30.
27. How old were you when you received your first Pap test?
_____ 15 or younger
_____ 16-18
_____ 19-21
_____ 22-25
_____ 26 or older
28. How often do you get a Pap test?
_____ Every 3-5 months
_____ Every 6 months
_____ Every year
_____ Every 18 months
_____ Every two or more years
28a. Why do you have a Pap test at this interval? _________________
_______________________________________________________________
29. How long has it been since you had a Pap test?
_____ Less than 1 year ago
_____ 1 year ago
_____ 2 years ago
_____ 3 or more years ago
_____ Never
30. Do you know whether or not your mother had/has regular Pap tests?
_____Yes
_____ No
_____ Not sure
30a. If yes, how often did/does she have Pap tests? ___________________
______________________________________________________
124 31. Please respond as to how strongly you disagree or agree with the following
statements.
Strongly
Disagree
Disagree
Do Not
Know
Agree
Strongly
Agree
A. Pap tests help tell if a
woman may have
cervical cancer
B. Adult women should
have Pap tests each
year unless otherwise
instructed by their
doctor.
C. Only women with
many sex partners
need Pap tests.
32. Please respond as to how strongly you disagree or agree with the following
statements.
Strongly
Disagree
Disagree
A. Lack of health
service facility in my
area prevented me
from having Pap test.
B. Bad attitude of
doctors/nurses
prevented me from
having Pap test
C. Pap test is painful
D. I could not afford the
cost of having Pap
test.
E. I feel shy to have Pap
test
F. Cultural belief
prevented me from
having Pap test
G. I am a virgin and I
don’t need Pap test
H. I am healthy and I
don’t need Pap test
125 Do Not
Know
Agree
Strongly
Agree
33. Did anyone in particular encourage you to have your first Pap test (please check
all that apply)?
_____ Doctor
_____ Friend
_____ Mother
_____ Family member
_____ No one
_____ Sexual partner
_____ Other:_________________________________________________
34. Did a friend, partner or family member accompany you when you went in for
your first Pap test (if yes please answer 33a)?
_____Yes
_____ No
34a) If yes did you find their presence comforting or distressing (please explain)?
___________________________________________________________
_____________________________________________________
35. Do you have a family member/members with whom you can talk about the Pap
test and cervical cancer?
_____Yes
_____ No
36. Do you have a friend or friends with whom you can talk about the Pap test and
cervical cancer?
_____Yes
_____ No
126 37. Please respond to the following statements:
Strongly
Disagree
Disagree
Do Not
Know
Agree
Strongly
Agree
A. I have one or more
friends with whom
I can share
personal matters.
B. My friends let me
talk about
problems until I
feel better.
C. I can share
personal matters
with one or more
family members.
D. My family lets me
talk about
problems until I
feel better.
Thank you for your help and time.
It is much appreciated!
127 APPENDIX E
RESEARCH ADVERTISEMENT FLYER
FEMALE ADDIS ABABA UNIVERSITY STUDENTS
WANTED FOR RESEARCH
PARTICIPANTS WANTED FOR VOULNATRY, ANONYMOUS AND
CONFIDENTIAL SURVEY TO HELP IMPROVE WOMEN’S KNOWLEGDE OF
HUMAN PAPOLOMAVIRUS-CERVICAL CANCER!
FEMALE STUDENTS MUST:

BE FULL TIME STUDENTS AT ADDIS ABABA UNIVERSITY

BE THE AGES OF 18 YEARS OR OLDER

BE WILLING TO FILL OUT AN ANONYMOUS QUESTIONNAIRE
If you are interested in participating or would like more information,
please call at this number: 0933-68-2456
NOTE:
Participants who completed the survey questionnaire will receive a small
token of our appreciation.
128 APPENDIX F
ETHIOPIA REGIONAL MAP
129