Awareness and factors associated with routine medical checkups for non-communicable diseases among adults in Gondar City, Ethiopia

Abstract

According to the Ethiopian health sector transformative plan, a small number of people were screened for common non-communicable diseases in the country. This study aims to assess the awareness level and factors associated with routine medical checkups for common non-communicable diseases among adults residing in Gondar City, Northwest Ethiopia, 2024. A community-based cross-sectional survey with multi-stage cluster sampling was conducted from May 22, 2024, to July 12, 2024. In the chosen kebele, every 7th household was selected using systematic random sampling; Bivariate and multivariate logistic regression analyses were done. Finally, variables with a P-value < 0.05 are considered statistically significant. The study included 776 participants, yielding a response rate of 96.3%. 62.5% (95% CI 59.1–66) of the study respondents had a good awareness of routine medical checkups. Multivariable analysis revealed that participants with formal education were significantly more likely to have good awareness compared to those who were illiterate, with odds ranging from 2.2 to 8.5 times higher. Additionally, good awareness was significantly associated with having a history of chronic illness (AOR = 2.1, 95% CI 1.4–3.2), engaging in good physical exercise level (AOR = 4.1, 95% CI 2.7–6.2), and accessing health insurance coverage (AOR = 2.4; 95% CI 1.8–3.4) towards routine medical check-ups. The study found that around two-thirds of participants had good awareness of routine medical check-ups. Awareness was significantly associated with higher educational attainment, presence of chronic illness, regular physical activity, and health insurance coverage. These findings highlight the need to strengthen public health education on the importance of routine medical check-ups. To advance sustainable development goal 3, “good health and well-being”, efforts should focus on enhancing health education, expanding insurance coverage, and promoting active lifestyles to improve awareness, encourage early detection of chronic diseases, and enhance overall health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-026-44487-4.

Introduction

Diseases for which there is no known transmissible cause are referred to as non-communicable diseases (NCDs)¹. NCDs, primarily cardiovascular disease, cancer, chronic respiratory disease, and diabetes, are the primary causes of disability and death worldwide. They also show the high burden in low- and middle-income countries (LMICs)^2,3. Based on the Global Burden Disease 2023 report, Age-adjusted mortality from NCDs is the highest in low Socio-demographic Index regions, especially in parts of Sub-Saharan Africa⁴.

Ethiopia reflects this regional pattern: national assessments and the country’s NCD strategic documents indicate increasing morbidity and mortality and highlight a continuing triple burden of communicable, maternal/neonatal/nutritional, and non-communicable diseases, with an estimated rate of 554 (95% UI: 502–605) per 100,000 population⁵. With no action, Ethiopia will be the first, among the nations in Africa, to experience a dramatic burden of premature deaths and disability from NCDs by 2040⁶.

Routine medical check-up (RMC) is a key component of preventive medicine applicable to all age groups and genders. It serves as an essential strategy for the early detection of NCDs⁷. Also known as a health screening, annual check-up, preventive health check, or general health examination⁸. It typically involves a comprehensive physical examination supported by laboratory tests, imaging studies, ultrasounds, and electrocardiograms to assess overall health status^9,10. Despite national efforts to scale up NCD interventions, the 2024 Ethiopia STEPS survey highlights a profound awareness deficit; this diagnostic and therapeutic gap suggests that a substantial proportion of the population remains underserved by existing routine screening and medical checkup frameworks¹¹. RMC is a critical preventive strategy for the early detection and management of NCDs, yet uptake remains low—only 35.3% among healthcare professionals in Addis Ababa in 2022¹². This shortfall presents a significant challenge to the country’s efforts to meet Sustainable Development Goal 3 (SDG 3), and in particular target 3.4, which aims to reduce premature mortality from NCDs by one-third by 2030^13,14.

In Ethiopia, there is limited evidence regarding public awareness of routine medical checkups for NCDs in Ethiopia. Therefore, assessing awareness level and associated factors towards RMC among the study population will strengthen routine check-ups, aligning with national NCD strategies, and the broader SDG agenda by providing pathways for early diagnosis, timely treatment and risk-factor management. It will assist policymakers in the process of developing health policies and health strategies and will add additional value to health professionals’ efforts in NCD prevention and management, specifically for the target populations.

Method

Study design, period, and area

A community-based cross-sectional study was conducted from May 22 to July 12, 2024, at Gondar City, Amhara region, Ethiopia. Gondar City is 748 km away from Addis Ababa (the capital city of Ethiopia). The city has 36 kebeles within six sub-cities. It has one comprehensive specialized hospital, one general hospital, two private general hospitals, and eight health centers.

Source and study population

The source population comprised all adult permanent residents of Gondar City. The study population was further refined to include adult residents of the selected kebeles during the data collection period. Inclusion was contingent upon permanent residency status, with the exclusion of individuals exhibiting severe mental illness or significant cognitive impairments that precluded the provision of coherent responses.

Sample size determination and sampling technique

The sample size was determined using a single population proportion formula. In the absence of prior studies on medical checkup awareness, a conservative proportion (P) of 50% was used. The calculation incorporated a 95% confidence interval (CI), a 5% margin of error (d), and an additional 5% to account for potential non-responses.

To account for the intra-cluster correlation inherent in the multi-stage cluster sampling design, a design effect of 2.0 was applied^15–17, increasing the requirement to 768. Finally, after incorporating a 5% non-response rate, the total target sample size was calculated to be 806 study participants were included.

A multistage sampling technique was employed to select study participants. Initially, three of the six sub-cities were selected via a simple random sampling (lottery) method, from which eight kebeles were further identified. The total sample size was distributed across the selected kebeles using proportional allocation.

At the kebele level, households (HHs) were identified using a systematic approach (Every 7th HH was selected). The initial household was determined by locating the geographic center of each kebele and selecting a starting point via lottery. Data collectors then proceeded in a consistent right-hand direction. In cases where a selected household was inaccessible, the immediately adjacent household was substituted to maintain the required sample size. In cases where more than one study participant was present in the selected household, the lottery method was used to select one participant (Fig. 1).

Fig. 1.

A schematic presentation of the sampling procedure for the study participants residing in Gondar City, Northwest, Ethiopia, 2024 (N = 806). Rural kebele =  , Urban Kebele = .

Variables of the study

Awareness of RMC for common NCD was our outcome (Dependent) variable. It is defined as having heard about non-communicable disease screening in the health facility, and it is necessary on an annual basis^12,18.

Drawing on an extensive review of the literature, 22 independent variables were identified for inclusion in this study. These variables were subsequently categorized into three distinct thematic factors.

• Sociodemographic factors: Age, Sex, Religion, Level of education, Marital status, Profession, Income, Work experience, Presence of comorbidities,

• Individual and clinical factors: Healthy behaviours (smoking, drinking, and physical exercise), Attitude towards RMC, Concern about chronic or serious illness, Availability of Health insurance, Chronic disease presence, Opinion of one’s health, Media usage,

• Institutional related factors: Availability of regular medical checkup services, Availability of chronic care services providers, Availability of health education, Cost of RMC, health insurance covers RMC, and distance to healthcare facilities.

Those variables were chosen from different literature which they have factors strongly related to routine medical checkups.

Measurements

For this study, common non-communicable diseases (NCDs) were defined as the four leading global causes of morbidity and mortality: cardiovascular diseases, cancers, diabetes, and chronic respiratory illnesses¹².To evaluate participant knowledge, awareness was assessed using 14 items adapted from validated literature. Participants were categorized as having good awareness toward routine medical checkups (RMC) if they correctly answered at least the first two fundamental awareness questions^12,18. Furthermore, attitude toward RMC was determined based on a composite score of the attitude-related items; individuals who scored at or above the calculated mean were classified as having a good attitude¹².

Current smokers were defined as individuals who had consumed at least 100 cigarettes in their lifetime and were actively smoking at the time of the survey¹⁹. Alcohol drinking habit was characterized by consumption within the past 30 days¹⁹. or a binge drinking pattern, defined as reaching a blood alcohol concentration of 0.08 g/dl—typically four bottles (300 ml) for women and five for men within a two-hour window²⁰ Furthermore, a low level of physical activity was assigned to participants who failed to meet the recommended weekly threshold of 150–300 min of moderate-intensity or 75–150 min of vigorous-intensity aerobic activity²¹. Finally, perceived health status was documented as a subjective self-rating where respondents assessed their overall level of wellness, considering any symptoms, physiological dysfunctions, or functional impairments²⁰.

A housing unit was defined as any building constructed primarily for residential use by a single household²². A household was characterized as a group of related or unrelated individuals living together, sharing housekeeping arrangements under a single household head who holds primary authority and economic responsibility^22,23. Geographically, the study focused on Kebeles, the smallest administrative units in Ethiopia—comparable to sub-districts—comprising approximately 2,000 households²⁴. Participants were considered permanent residents if they had resided in their respective Kebele for at least six months²⁵. Finally, household income was assessed using a wealth index adapted from the Ethiopian Demographic and Health Survey (EDHS) and analyzed via Principal Component Analysis (PCA) to categorize households into low, medium, and high-income²⁶.

Health facilities located between 0 km and 5 km (≤ 5 km) were grouped as the closest distance band. Health facilities located between 5 km and 10 km (> 5 km and ≤ 10 km) were grouped as the mid-range distance band. Health facilities located between 10 km and 15 km (> 10 km and ≤ 15 km) were grouped as the farthest distance band²⁷.

Data collection tool and quality control

The data collection questionnaire (interview-based) was adapted after a detailed review of the relevant literature and expert discussion with the field^5,21,22. The data questionnaire was prepared in English and translated into the Amharic language, then retranslated to English by language experts and health professionals to check for consistency and flow. Then the final questionnaire (Amharic version) was pre-tested with 10% (81 households) of participants in Arada Sub-City with the same setup, and the Cronbach-alpha was 83%. In the pretest result, more than half (57%) of them were male, and we didn’t find any major issues that needed to be corrected. However, the layout of the questionnaire was rearranged.

Six data collectors and one supervisor underwent two days of intensive training. The sessions covered the survey content, sampling techniques, interview administration, participant communication, and ethical protocols. After obtaining informed consent, data were collected via structured interviews. To ensure data quality, the principal investigator and supervisor conducted daily spot-checks and reviewed all completed questionnaires. Finally, the data underwent a rigorous clean-up and cross-checking process before analysis.

Data processing and analysis

Data were cleaned, coded, and entered into EpiData (version 3.1) before being exported to SPSS (version 23) for analysis. Descriptive statistics—including means with standard deviations, medians, and frequencies—were calculated based on variable types. We employed a two-stage regression approach: variables with p < 0.2 in bivariate logistic regression were entered into a multivariate model. Model fitness was confirmed using the Hosmer-Lemeshow test (p > 0.05). To assess individual-level associations, single-level logistic regression was used, with results reported as Adjusted Odds Ratios (AOR) at a 95% Confidence Interval (CI). Statistical significance in the final model was defined as p < 0.05.

Ethical consideration

The study was conducted after ethical clearance was obtained from the School of Nursing on behalf of an institutional review board of the University of Gondar with reference number S/N/123/2016. Oral consent/informed consent was obtained from each study participant. Participants were informed of the study’s objective and their right to discontinue or refuse to participate. The confidentiality of the information was maintained by assuring anonymity. The interview was conducted after receiving permission from the household heads and study participants.

Results

Socio-demographic characteristics among study respondents’

The study included 776 participants, which resulted in a response rate of 96.3%. From non-responses, almost half (43.3%) of households did not respond properly to the main outcome variable. The sample population had a mean age of 36 years and a standard deviation (SD) of 9.7 years. Two-fifths of the participants had secondary education (Table 1).

Table 1.

The socioeconomic characteristics of study participants residing in Gondar City, Northwest Ethiopia, 2024 (N = 776).

Variables	Categories	Frequency	Percent
Age in years Mean = 36.3 SD = 9.68	21–24	78	10.1
	25–29	101	13
	30–34	173	22.3
	35 – 39	214	27.6
	≥ 40–44	210	27.1
Sex	Female	322	41.5
	Male	454	58.5
Educational Level	Illiterate (Not able to read and write)	41	5.2
	Primary education (1–8 grade)	54	7
	Secondary education (9–12 grade)	315	40.7
	Certificate and Diploma	173	22.3
	Degree and above	193	24.9
Marital Status	Single	251	32.3
	Married	464	59.8
	Widowed	22	2.8
	Divorced	39	5
Religion	Orthodox	633	81.5
	Muslim	120	15.5
	Protestant	23	3
Income level (Wealth index)	Poor	268	34.5
	Medium	252	32.5
	Rich	256	33

SD = standard deviation.

Awareness level, Individual and clinical factors of the participants

Of the total study participants, two-thirds 62.5% (95% CI: 59.1–66.0) had a good awareness of routine medical check-ups. Approximately two-fifths (40.3%) of the participants reported a family history of chronic illness, while a significant majority (66.8%) had a personal history of chronic conditions. Over half of the respondents were covered by health insurance and perceived their health status as favourable.

Regarding individual and clinical-related factors, approximately one-third (34.1%) of the participants engaged in a good level of physical activity. In contrast, health risk behaviours were more prevalent, with nearly two-thirds (63.1%) reporting alcohol consumption within the 30 days preceding the study. Despite these behavioural trends, more than half of the participants (52.4%) demonstrated a good attitude toward routine medical check-ups (Fig. 2).

Fig. 2.

Level of awareness towards RMC among study respondents, Gondar City, Northwest Ethiopia, 2024 (n = 776). RMC routine medical checkups.

Factors associated with awareness of routine medical check-ups

Of the 21 independent variables screened for association with the Routine Medical Check-up (RMC) of awareness, religion was excluded due to ethical considerations. Following a preliminary bivariate assessment, eight variables met the inclusion threshold (p ≤ 0.20) and were progressed to the multivariable regression model.

Model integrity was assessed for multicollinearity using the Variance Inflation Factor (VIF). All VIF values were below 2, ranging from 1.035 (family health insurance) to 1.492 (work experience). These results indicate the absence of significant collinearity among the independent variables, ensuring the stability of the regression estimates.

Independent predictors of RMC awareness level were identified using backward stepwise (likelihood ratio) multivariable regression. The model exhibited a robust fit, with Hosmer-Lemeshow test p-values ranging from 0.217 to 0.846 throughout the five iterations. Ultimately, four factors remained significantly and independently associated with high RMC awareness: educational status, physical activity levels, health insurance coverage, and a history of chronic illness.

Educational status was a strong predictor of RMC awareness. Compared to those with no formal education (illiterate), participants with a primary education were 8.5 times more likely to demonstrate high awareness (AOR = 8.5; 95% CI: 3.4–10.0; p < 0.001). Similarly, the odds of having good awareness were significantly higher among those with a secondary education (AOR = 4.0; 95% CI: 1.9–8.5; p < 0.001), a certificate or diploma (AOR = 2.4; 95% CI: 1.5–4.0; p < 0.001), and a degree or higher (AOR = 2.2; 95% CI: 1.3–3.9; p < 0.001).

In addition to education, clinical and individual factors were significantly associated with RMC awareness. Participants with a history of chronic illness were 2.1 times more likely to demonstrate high awareness of RMC compared to those without such conditions (AOR = 2.1; 95% CI: 1.4–3.2; p < 0.001). Furthermore, individuals maintaining a good level of physical activity had 4.1 times the odds of high awareness compared to those with low activity levels (AOR = 4.1; 95% CI: 2.7–6.2; p < 0.001). Finally, insurance coverage played a crucial role; respondents with RMC-inclusive health insurance were 2.4 times more likely to be aware of these services than those without coverage (AOR = 2.4; 95% CI: 1.8–3.4; p < 0.001) (Table 2).

Table 2.

Bivariate and multivariate analysis of factors associated with RMC among study respondents, Gondar City, Northwest Ethiopia, 2024 (n = 776).

Variable	Awareness of RMC		COR (95% CI)	AOR (95% CI)	P - value	Remark
	Good	Poor
Educational status
Illiterate	11	30	1	1
Primary education (1–8)	23	31	15.4 (7– 34.2)	8.5(3.4–10)	< 0.001
Secondary education (9–12)	181	134	7.6(3.9–14.9)	4.0(1.9–8.5)	< 0.001
Certificate and Diploma	106	67	4.2(2.7–6.6)	2.4(1.5- 4)	< 0.001
Degree and above	164	29	3.6 (2.2–5.9)	2.2(1.3–3.9)	< 0.001
Have any chronic illnesses
No	204	54	1	1
Yes	281	237	3.2(2.3– 4.5)	2.1(1.4–3.2)	< 0.001
Level of physical exercise/activity
Lower	259	252	1	1
Good	226	39	0.2(0.1–0.3)	4.1(2.7–6.2)	< 0.001
Health insurance covers RMC
No	196	184	1	1
Yes	289	107	2.6(1.9–3.42)	2.4(1.8–3.4)	< 0.001

AOR = adjusted odd ratio, COR = crude odd ratio, RMC = routine medical check-ups.

Discussion

RMC is a form of preventive medicine involving a thorough history, physical examination, and screening of asymptomatic persons by health professionals regularly as part of a routine healthcare process. Our study revealed that two-thirds of the participants possessed a good awareness level of RMC. It is consistent with the German study, which found that 65.4%²⁸. The similarity may be attributed to the effectiveness of public health campaigns in routine medical check-ups reached in those study sites. The slight difference in percentages could be due to variations in healthcare systems, cultural attitudes towards medical check-ups, and the availability of health services. This result is encouraging as it suggests that a significant majority of the population understands the importance of annual health screenings in maintaining overall well-being and early detection of potential health issues.

However, our finding is lower compared to studies conducted in Benin (100%), Addis Ababa (86.9%), Ghana (90%), and Northern Vietnam participants^12,29–31. This discrepancy might be explained by differences in health education, socioeconomic factors, and accessibility to healthcare services. In regions with lower awareness, barriers such as limited access to healthcare, lower health literacy, and cultural beliefs may play a more significant role³². Moreover, this study was conducted on the general community, but other studies were conducted among the health professionals.

A notable finding in this study was the relatively high rate of routine medical the stands in stark contrast to the 2024 Ethiopia NCD STEPS Survey conducted by the Ethiopian Public Health Institute (EPHI) and the WHO, which reported that over 66.6% of the adult population had never been screened for hypertension¹¹. Several scientific justifications account for this discrepancy. First, the STEPS survey provides a national aggregate that includes vast rural populations where access to diagnostic facilities and health literacy are significantly lower. In contrast, our study was conducted exclusively in Gondar City, an urban center with a higher density of health facilities, specialized clinics, and a population that generally possesses higher educational attainment and health awareness. Urban residency is a well-documented predictor of increased healthcare utilization in Ethiopia, as residents benefit from shorter travel distances and better access to NCD-specific services compared to their rural counterparts. Furthermore, the variation may be attributed to the scope of the screening metrics. While the STEPS survey specifically measured “ever-tested for hypertension,” our study utilized a broader definition of RMC, which may encompass various health-seeking behaviours beyond blood pressure monitoring, such as glucose checks or general physical exams.

Among factors associated with RMC, those with higher education were significantly associated with a good awareness level of RMC. It was consistent with research findings of the People of Rawalpindi, Pakistan, that an increased educational level is associated with a good awareness level³³. People with higher levels of education are more likely to recognize the value of routine health screenings, which allow for the early identification and treatment of possible health problems. The positive association between higher education levels and routine medical check-ups aligns with existing literature suggesting that education fosters health literacy, awareness, and proactive health-seeking behaviour³⁴. Different pieces of evidence emphasize that incorporating health awareness about routine medical check-ups into educational initiatives may encourage proactive health-seeking behaviour and, in turn, enhance population health outcomes^35,36.

Our study finds that individuals with chronic illnesses were more likely to have good awareness of RMC compared to those without such conditions. This finding is consistent with research by A. Khalil, which demonstrated enhanced literacy (80%) among participants at high risk for chronic kidney disease (CKD)³⁷. This elevated awareness likely stems from direct personal experience and understanding of their health issues, both of which increase the perceived risk of comorbid conditions. Furthermore, evidence from Vietnam shows that the presence of chronic disease serves as a primary driver for frequenting routine medical check-ups²⁹. Moreover, the clinical utility of this awareness is underscored by a large-scale cohort study in China, which found that regular health check-ups were associated with lower mortality and improved management of chronic diseases, including cardiovascular disease and diabetes³⁸.

Similarly, participants reporting a good level of physical activity were more likely to possess a good awareness of RMC than those with a poor physical activity level. This association is supported by a study of the Chinese urban population, which posits that physical activity acts as a ‘gateway’ to broader health literacy and preventive awareness³⁹. This relationship highlights a behavioural clustering effect: individuals who engage in health-promoting behaviours, such as regular exercise, tend to be more health-conscious and proactive regarding preventive care. While the role of physical activity in reducing the risk of chronic conditions—including cardiovascular diseases, diabetes, and certain cancers—is well documented, it simultaneously fosters a ‘preventive mindset’ that prioritizes early detection⁴⁰. Consequently, rather than exercise diminishing the perceived necessity for screenings, it appears to reinforce the value of holistic health maintenance through RMC.

Furthermore, our findings revealed a strong positive association between health insurance coverage and RMC awareness level. This aligns with findings from Ethiopia, which noted that insured individuals are significantly more likely to engage with preventive services⁴¹. According to the framework provided by Sommers et al., health insurance functions as more than a financial safety net; it serves as a facilitator for health-seeking behaviours³⁴. By mitigating out-of-pocket cost barriers, insurance encourages more frequent clinical interactions, which subsequently elevates patient awareness related to routine screenings and long-term health maintenance. This suggests that integrating NCD routine screening messages into community health insurance campaigns could further enhance awareness. Collectively, these findings underscore the importance of expanding health insurance programs to enhance preventive care utilization, particularly in resource-limited settings^42,43.

The findings highlight the need for targeted educational interventions, especially among illiterate and low-education populations, integrating RMC awareness into chronic disease management programs, and physical activity promotion may yield synergistic benefits. Moreover, expanding health insurance coverage and embedding RMC principles within benefit packages could enhance awareness and uptake.

Conclusion

Our study highlights that a significant proportion of individuals exhibit good awareness of routine medical check-ups, with various factors influencing this awareness. Education emerged as a key determinant, with higher education levels correlating with good awareness of routine medical check-ups. Additionally, individuals with existing chronic conditions and a good level of physical activity/exercise demonstrated higher awareness levels. Lastly, health insurance coverage for the family was identified as a factor in enhancing good awareness by reducing financial barriers to healthcare access. Enhancing health education and expanding health insurance coverage are pivotal to increasing awareness and participation in routine medical checkups, directly supporting Ethiopia’s progress toward Sustainable Development Goal (SDG) 3.4.

Recommendation

This study underscores the critical roles of educational attainment, chronic disease management, physical activity, and health insurance access in promoting preventive healthcare. By addressing these interconnected determinants, healthcare systems can design more inclusive and effective strategies to foster a culture of preventive care, ultimately improving population health outcomes. These observed associations provide actionable insights for policymakers; specifically, prioritizing access to formal education and targeted health literacy programs—particularly among underserved populations—is essential to driving the nationwide uptake of routine medical check-ups.

Limitation

While this study identifies key determinants of RMC, several limitations must be noted. First, the household-based recruitment strategy may introduce sampling bias, as those away during work hours may have different health-seeking behaviours. Second, the reliance on self-reported data without clinical verification may lead to recall or social desirability bias. Furthermore, the absence of a globally standardized instrument necessitated a study-specific questionnaire, which may limit the external validity and comparability of the findings. Finally, the cross-sectional design prevents the establishment of definitive causal pathways. Future longitudinal research and the development of validated, standardized psychometric tools are essential to further elucidate the sociocultural factors influencing RMC uptake.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

AOR

Adjusted odd ratio

CI

Confidence interval

CKD

Chronic kidney disease

COR

Crude odd ratio

EDHS

Ethiopian demographic and health survey

NCD

Non-communicable disease

RMC

Routine medical check-ups

SDG

Sustainable development goals

WHO

World Health Organizations

Author contributions

F.Y.G., M.H.S., and B.F. Conceptualization of the research, Data Curation, investigation, validation, writing up the manuscript, and editing at each step.M.H.S., M.Y.M., H.S.M., M.W., and B.F. participated in data curation, Methodology, Writing and editing of the final versionAll authors reviewed the manuscript and agreed to submit it to the scientific report journal.

Funding

There was no funding for this research. However, the University of Gondar College of Medicine and Health Sciences has facilitated the process for this study.

Data availability

The datasets generated during the current study are available in the Mendeley repository at DOI 10.17632/pcx7sfvsj4.1. With a reasonable request, the full data can be accessed for any researcher.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

The study was approved by the Research Ethical Review Committee of the School of Nursing, College of Medicine and Health Sciences, on behalf of the University of Gondar review board with a reference number S/N/123/2016. All methods were carried out following relevant guidelines and regulations. A formal letter indicating the approval was obtained and submitted to the study Hospital administrative office, and the Amhara region health bureau. Permission letters were obtained from both the UoG School of Nursing and all four referral hospitals to interview each participant. Oral consent/informed consent was obtained from each participant for an interview and to participate in the physical examination. In all steps, confidentiality was maintained. Finally, after the whole process of data collection, the questionnaire was kept safe throughout the whole process of the research work.

Consent for publication

Consent for publication was secured during oral consent /informed consent from the participant and approved by the Research Ethical Review Committee of the School of Nursing, College of Medicine and Health Sciences, on behalf of the University of Gondar review board.