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. 2020 Oct 7;15(10):e0239580. doi: 10.1371/journal.pone.0239580

The role of health education on cervical cancer screening uptake at selected health centers in Addis Ababa

Selamawit Hirpa Abu 1,*, Berhan Tassew Woldehanna 1, Etsehiwot Tilahun Nida 1, Abigiya Wondimagegnehu Tilahun 1, Mahlet Yigeremu Gebremariam 2, Mitike Molla Sisay 1
Editor: Stanley J Robboy3
PMCID: PMC7540882  PMID: 33027267

Abstract

Introduction

Cervical cancer is one of the most common causes of morbidity and mortality among women in developing countries including Ethiopia. Unlike other types of cancers, the grave outcomes of cervical cancer could be prevented if detected at its early stage. However, in Ethiopia, awareness about the disease and the availability of screening and treatment services is limited. This study aims to determine the role of health education on cervical cancer screening uptake in selected health facilities in Addis Ababa.

Methods

Two-pronged clustered randomized controlled trial was conducted in 2018 at eight public health centers that provide cervical cancer screening services using visual inspection with acetic acid (VIA) in Addis Ababa, Ethiopia. Each of the eight health centers were randomly assigned to serve as either an intervention or a control center. A two-pronged clustered randomized controlled trial was conducted in eight public health care centers. All the selected facilities provided cervical cancer screening services using visual inspection with acetic acid (VIA). Four health centers were randomly assigned to the intervention and control arms. The study participants were women aged 30–49 years who sought care at maternal and child health clinics but who had never been screened for cervical cancer. In the intervention health centers, all eligible women received one-to-one health education and educational brochures about cervical cancer and cervical cancer screening. In the control health centers, participants received standard care. Baseline data were collected at recruitment and follow-up data were collected two months after the baseline. For the follow-up data collection, participants (both in the intervention and control arms) were interviewed over the phone to check whether they were screened for cervical cancer.

Result

From the 2,140 women who participated in the study, 215 (10%) screened for cervical cancer, where 152(71%) were from the intervention health centers. Seventy-four percent of these participants reported that they learned about the benefits of screening from the one-to-one health education or the brochure. Women from the intervention health centers had higher odds of getting screened (AOR = 2.43,95%CI;1.58–2.90) than the controls. Women with the educational status of the first degree and those who have a history of sexually transmitted infections (STIs) had higher odds of getting screened (AOR = 2.03,95%CI;(1.15–2.58) and (AOR = 1.55,95%CI;1.01–2.36), respectively.

Conclusion and recommendation

Providing focused health education supported by printed educational materials increased the uptake of cervical cancer screening services. Integrating one-to-one health education and providing a take-home educational material into the existing maternal and child health services can help increase cervical cancer screening uptake.

Introduction

Cervical cancer is one of the most common types of cancers among women caused mainly by Human papillomavirus (HPV). In 2018 alone there were an estimated 570,000 new cervical cancer cases globally where 6,294 of the cases occurred in Ethiopia [1, 2]. In countries where there are no routine cervical cancer screening services, women seek health care after they develop the disease manifestations [3]. More than 80% of the cases in sub-Saharan Africa are detected at late stage decreasing the chance of survival [4]. In Ethiopia, an estimated 3,235 cervical cancer related deaths occur annually [4].

Several screening methods are used to detect precancerous lesions and cancer of the cervix. These screening methods are available, cheap, and can be performed safely at outpatient settings [5, 6]. Visual inspection with acetic acid (VIA) screening method is one of the simplest methods applied using household vinegar to see if there is a precancerous lesion. This screening method follows a single visit approach, decreasing treatment seeking related cost and the risk of loss to follow-up. The opportunity this test provides to treat the lesions at the spot is an added benefit as coupling screening with on spot treatment services increases the effectiveness of control programs [7].

Screening programs that have treatment for a positive diagnosis had proved to be a success [8]. Hence, the implementation of VIA is a promising intervention that will help to control the disease. The expansion of the pre-cancer screening and treatment of the lesion using Cryotherapy in Ethiopia affirms the above fact [3]. However, the uptake of cervical cancer screening is very low (19.8%) and absence of disease symptoms was often mentioned for not seeking screening services early on [9, 10].

Community-based health educational programs increase knowledge about cervical cancer and improve cervical cancer screening uptake [10, 11]. Women who have prior knowledge about cervical screening tend to seek cervical screening services compared to those who had no prior knowledge [10]. The Ethiopia Ministry of Health (MOH) recommends educating women who never had cervical cancer screening as a strategy to increase uptake. Using print media is one of the few approaches suggested to reach this target population [3].

In our study, brief face-to-face health education, and brochure which was designed using the Health Belief Model (HBM) was given for the intervention group. Health Belief Model is a theoretical model that can be used to guide health promotion and disease prevention programs. The HBM postulates that people will take action to prevent illness if they consider themselves as susceptible to a condition (perceived susceptibility), if they believe it would have potentially serious consequences (perceived severity), if they believe that a particular course of action available to them would reduce the susceptibility or severity (perceived benefits), and if they perceive a few negative attributes related to the health action (perceived barriers) [12]. In line with this, the educational brochure and the brief health education discusses what cervical cancer is, who are susceptible to the disease, how to detect the early stage of cervical cancer, how to prevent it and where to find cervical cancer screening services and that they can get the service for free. Thus, this study determined the role of health education on cervical cancer screening uptake at public health care facilities in Addis Ababa.

Methods

Study area and period

The study was conducted between August 2017 and January 2018, in Addis Ababa, the capital city of Ethiopia. The 3,147,000 residents of the city live in ten sub-cities and 116 districts [13]. Ethiopia has a three-tier health system where one primary hospital, health centers with its five satellite health posts occupy the lowest level (the primary health care unit). General and referral hospitals constitute the secondary and tertiary levels [14]. This study was conducted in eight health centers which provide cervical cancer screening service using VIA. The health centers are staffed by general practitioners, nurses, and midwives and serve about 250,000 people [14]. The selected health centers were Bole 17, Felegeselam, Lideta, and Addis Ketema primary health centers. The control sites were Kolfe, Kolfe Wordea 09, Arada, and Nifas-Silk health centers.

Study design and population

A two-pronged a cluster-randomized controlled trial was conducted among women aged 30–49 years; which is the eligible age group for cervical cancer screening in Ethiopia [3]. This study was conducted in an urban area where most people can read and write or have someone around to read for them. All study participants were selected from Addis Ababa who visited government health centers for family planning (seeking contraceptives or advice for infertility), immunization service, or seeking care for their sick children.

All study participants had no history of cervical cancer screening and were never diagnosed with cervical cancer. Pregnant women and women who gave birth in the past 45 days from the date of data collection were excluded from the study.

Sample size calculations

The sample size was powered to detect 15% and 10% women who would be screened for cervical cancer at the intervention and control health centers, respectively. By taking the level of significance at 5%, power 90% and 20% loss to follow up; 2,203 study participants were recruited from eight clusters with 230 study participants from each.

Sampling selection procedure

At the time of the study, 14 health centers were providing cervical cancer screening in Addis Ababa, all using VIA. Eight high test load health centers were selected based on the number of clients in the past year. The eight health centers were randomized into intervention and control arms, four health centers each.

Intervention

Staff nurses working in immunization, family planning, and children clinics were trained by the study team. The trained nurses provided one-to-one health education to all eligible mothers who come seeking care from the clinics within the health centers.

In the intervention health centers, eligible women were recruited from the selected three units (family planning, immunization service, and clinics for infants and children). After mothers were recruited into the study, background information was collected using a structured interview questionnaire. A one-to-one brief health talk lasting 5–10 minutes was provided by health care providers. Definition of cervical cancer, risk factors, susceptibility, mode of transmission, treatment, and benefits of cervical cancer screening was included in the discussion. When leaving the clinic, a brochure containing information under the topics similar to the brief health talk was issued to the participants. Participants who could not read and write attended the brief health talk but were told to have someone close to them read the content at their convenience. Two months from the time of intervention, participants in the intervention and control groups were communicated over the phone to check whether they were screened for cervical cancer. For those individuals that we could not contact for a follow-up interview, we have tried to reach them through their phone for three consecutive days. If a participant reported that she was not screened, reasons for not screening were asked and those who were screened were asked for the basis of their motivation.

Women in the control group were interviewed using the same standard questionnaire. In addition, only received standard care (did not receive either the one-to-one brief health talk or the educational brochure). According to the session schedule, health education on cervical cancer was supposed to be given twice a week. Early arriving patients and health service clients were the target audiences as health education sessions were held every morning before health care workers commence seeing patients.

Ethical consideration

Ethical clearance was obtained from the Addis Ababa University College of Health Sciences Institutional Review Board (IRB). Permission was obtained from all study health facilities. Each respondent was informed about the purpose and scope of the study. Verbal informed consent as it was approved by the Institutional Review Board; was obtained from recruited study participants prior to their enrolment. The data collectors put a mark on the checklist given on the consent form, regarding the study participants' responses to participate.

Data entry and analysis

Data was entered using Epidata version 3.1 software and later exported to STATA 14 for analysis. The descriptive analysis involved calculating the frequency and percentage of sociodemographic and health service-related variables. Generalized estimating equation (GEE) analysis with a binary response variable using a robust estimator and exchangeable working correlation matrix was used. This was carried out to consider the cluster effect of data among those who received services within the same facility and measure the independent effect of the intervention on the uptake of cervical cancer screening service.

Result

A total of 2,400 women who had never been screened for cervical cancer prior to this study were recruited. In the follow-up data collection, two thousand one hundred forty participants (89.2%) have participated. Most participants aged between 30 and 40 years with the mean age being 33 (SD±3.8). Eight hundred ninety-eight (85%) of the participants in the intervention group and 973(92%) of the controls were married. Nearly half of the participants in both groups were housewives. Nearly all participants were tested for HIV at least once in their lifetime, where 49(4.9%) from the intervention and 56(5.5%) from the control group were tested positive for HIV. Among those who were in the intervention group and screened for cervical cancer, 73% reported that their source of information was the one to one health education. However, in the control group, 92% of cervical cancer screening related information was obtained from health care providers (Table 1).

Table 1. Socio demographic and health related information of study participants at Addis Ababa, 2017.

Variable Intervention N = 1,062 (%) Control N = 1,078 (%)
Age  30–34 years 667(63.22) 753(71.65)
  35–39 years 280(26.54) 247(23.50)
  40–44 years 69(6.54) 39(3.71)
  45–49 years 39 (3.70) 12 (1.14)
  Unknown 0 1(0.10)
Marital status Married 898(85.12) 973(92.58)
  Never married 67(6.35) 48(4.57)
  Divorced/ Separated 75(7.11) 22(2.09)
  Widowed 15(1.42) 8(0.76)
Occupation Housewife 553(52.42) 673(63.97)
Government 190(18.01) 118(11.22)
Private 270(25.59) 237(22.53)
Other 42(3.98) 24(2.28)
Woman educational status Illiterate 147 (13.93) 154(14.64)
Primary school 351(33.27) 384(36.50)
Secondary school 356(33.74) 349(33.17)
Technical and vocational training 119(11.28) 99(9.41)
First Degree and above 82(7.77) 66(6.27)
History of STI No 925(88.52) 957(90.97)
  Yes 120(11.48) 95(9.03)
  Unknown 10(0.95) 0
Tested for HIV No 50(4.74) 28(2.66)
  Yes 1,005(95.26) 1,024(97.34)
HIV status Negative 956(95.12) 964(94.14)
Positive 49(4.88) 56(5.47)
Unknown 0 4 (0.39)
Religion Ethiopian Christian Orthodox 742(70.33) 721(68.54)
Catholic 6(0.57) 8(0.76)
Protestant 103(9.76) 93(8.84)
Muslim 203(19.24) 228(21.67)
Other 1(0.09) 2(0.19)
Source of information for screening Radio/Television 7(4.6) 1(1.59)
Relative /Friend 3(3.95 6(4.76)
Health Professional 27(18.42) 59(92.06)
One to one health education and Brochure 111(73.03) 1(1.59)
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In the study period, 215(10%) women were screened for cervical cancer and most were 152(70.7%) were from the intervention health centers. One to one health education and educational brochure was associated with cervical cancer screening (Table 2).

Table 2. Chi- square test result of cervical cancer screening practice and the intervention.

Variable Screened for cervical cancer x2 value P- value
Yes No
(n = 215) (n = 1925)
  Intervention 152(70.7%) 910 (47.3%)    
Type of the health center 42.45 0.000
  Control 63(29. 3%) 1,015(52.7%)    
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The frequently mentioned reasons mentioned by participants in the intervention group for not getting screened were lack of time (78%), not having been sick (12%) and not knowing about cervical cancer (7%). In the control group lack of time (53%), hasn’t been sick (22%) and not knowing about cervical cancer (21%) were mentioned (Table 3).

Table 3. Bivariable analysis result for reasons for not being screened for cervical cancer among women in the intervention and control health centers of Addis Ababa.

Reasons for not being screened Health centre type P-value
Intervention Control
Was busy 690(78%) 537(53.6) 0.000
Never been sick 107(12%) 219(21.9)
Don’t know the place 16(1.8%) 27(2.7)
Don’t know about screening 67(7.5%) 208(20.8)
Don’t like the diagnostic method 8(0.9%) 9(0.99)
Service was not available 2(0.23) 2(0.2)
Total 890 (100%) 1,002 (100%) 1,892 (100%)
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Multivariable analysis of the uptake of cervical cancer screening

Variables (Age, marital status, occupation, woman’s educational status, history of sexually transmitted infections (STI), HIV testing, HIV test result, religion, allocation to control and intervention group) that have p-value<0.2 with the uptake of cervical cancer screening on bivariate analysis was entered into the multivariable model.

Finally, age, marital status, woman’s educational status, occupation history of STI, HIV testing, allocation to control, and intervention group were included in the multivariable analysis. Factors which has a significant association with cervical cancer screening uptake were woman’s educational status, history of STI as well as allocation to the control and intervention group. Women from intervention health centers had higher odds AOR = 2.43 (95%CI;1.58–2.90) of getting screened than women from the control health centers. The odds of women with first degree and above to test for cervical cancer is higher AOR = 2.03,95%CI;(1.15–2.58) than the illiterates. Likewise, women who had a history of STI had higher odds to get tested AOR = 1.55,95%CI;(1.01–2.40) (Table 4).

Table 4. Bivariate and multivariable analysis of intervention effect on uptake of cervical cancer screening.

Variable Crude OR (95%CI) Adjusted OR (95%CI)
Group Control 1 1
Intervention 2.58(1.66–4.02) 2.43(1.58–3.9)
Age 30–34 years 1 1
35–39 years 0.98(0.70–1.38) 0.97(0.68–1.37)
40–44 years 1.40(0.96–2.89) 1.5(0.85–2.64)
45–49 years 1.89(0.89–4.02) 1.56(0.73–3.33)
Marital status Married  1 1
Never married 1.63(0.95–2.79) 1.45(0.84–2.52)
Divorced/ Separated 1.57(0.87–2.84) 1.39(0.77–2.51)
Widowed 2.15(0.74–6.21 2.09(0.71–6.17)
Educational status Illiterate 1 1 
Primary school 0.76(0.48–1.19) 0.75(0.47–1.20)
Secondary school 0.97(0.62–1.51) 0.97(0.61–1.52)
Technical and vocational training 0.99(0.56–1.74) 0.94(0.52–1.68)
First degree and above 2.0(1.15–3.49) 2.03(1.15–3.58)
Woman occupation House wife 1 1
Government 2.14(1.48–3.11) 1.60(1.03–2.49)
Private 1.14(0.80–1.63 1.04(0.71–1.52)
1.37(0.63–3.0) 1.11(0.49–2.49)
Religion Orthodox 1 -
Catholic 0.83(0.12–5.55)
Protestant 1.47(0.94–2.28)
Muslim 1.07(0.74–1.55)
History of STI No 1 1
Yes 1.57(1.04–2.36) 1.55(1.01–2.36)
Unknown 1.59(0.27–9.37) 1.27(0.25–6.53)
Tested for HIV No 1 1 
Yes 0.53(0.29–0.97) 0.57(0.31–1.04)
HIV test result Negative 1 -
Positive 1.11(0.59–2.08)
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Discussion

In this study, we found that a one-to-one health talk and issuing brochures as a reminder for women who visited selected health centers increased cervical cancer screening uptake. This was demonstrated among women in the intervention health centers who got the above-mentioned services than women who got only regular health education services in the control health centers.

In developing countries, the main reasons for the low uptake of cervical cancer screening services are attributed to a lack of knowledge about the disease and service availability [15]. Sociocultural factors are also pivotal in determining service uptake [15]. Similarly, in Ethiopia, lack of proper health information from health care providers and low awareness about the disease determined low uptake [9, 10]. In our study integrating one to one health education with maternal and child health care services increased uptake. This approach will help to reach a considerable number of mothers in a short while at an opportune time when they need the information the most. Due to the ongoing antenatal care service-based HIV screening, more than 95% of study participants, in both groups were tested for HIV. Similar to the HIV program if cervical cancer screening is integrated with the routine maternal health service programs like family planning; the uptake would have increased.

The combined one to one health talk and reminders (brochures) contributed to the increase in screening uptake. Another study from Bangladesh indicated the contribution of print media and audiovisuals in improving the awareness and increasing uptake of cervical cancer screening services [16]. Similarly, a systematic review of 66 interventional studies concluded that small media and one-to-one education are effective interventions to increase the uptake of screening for three cancers including cervical cancer [17]. Furthermore, the implementation guideline which was developed through reviewing systematic review studies and expert panel discussion in Ontario, Canada recommended that provision of one-to-one education and assessment of providers are effective interventions for the enhancement of cervical cancer screening uptake at the community-level [18].

In this study, women who were screened for cervical cancer reported that one-to-one health education and the educational brochure that they have received had helped them to decide in screening for cervical cancer. Similar studies have also reported that engaging the community through culturally appropriate health education and reading materials effected a 73% increase in cervical cancer screening uptake [11]. In our study, the intervention doubled the number of people screened for cervical cancer, yet the overall rate remained low. The reason for a smaller number of women screened in the control groups could be low awareness about the screening. For the intervention group, a low rate in the uptake of cervical cancer screening might be due to the short duration before the follow-up interviews where an average of six months was reported in other studies. The intervention would be stronger if it was assisted by more frequent sessions and reminders. Furthermore, our intervention targeted women who came to health facilities with their infants. This might discourage women to get screened especially right after they got the one to one health education. Most women had to go to their home to leave their children before getting screened.

One of the reasons for not getting screened for cervical cancer was the absence of disease symptoms. A considerable number of participants reported that they don’t know about cervical cancer screening and the availability of screening services. This indicates low awareness about cervical cancer screening is a barrier to the uptake of screening services. This signifies the need for interventions that raise the community’s awareness of cervical cancer and screening services.

Women who had university-level education were two times were likely to get screened. This finding is in line with studies conducted in Korea and Zimbabwe [19, 20]. Education increases the risk of awareness of people towards health risks. In addition, educated women have a better self- efficacy, and access to health care services. These might explain the increase in odds of screening among the educated. The same argument justifies the association between being a government employee and an increased odd of screening, as most positions in government offices require proper training. In contrast, studies done in developed countries indicated no association between educational status and cervical cancer screening [21]. This could be because of the fact that literacy level is high in those countries, unlike developing countries where nearly two-thirds of the participants in the intervention and control groups completed only primary and secondary education. In addition, more than half of the women in both groups were housewives. Hence, providing education about cervical cancer screening has a real difference in the uptake especially in the community with low educational levels.

This study also found that there is a significant association between history of sexually transmitted infections (STI) and cervical cancer screening uptake. Human papillomavirus (HPV), a sexually transmitted infection, is one of the strong predictors of cervical cancer. Health care service providers may emphasize on the need to screen for cervical cancer when women present with STIs. On the contrary, being tested for HIV was not associated with cervical cancer screening. HIV screening is routine testing to all pregnant women, nearly all women in the intervention and control groups were tested for HIV, this could mask the difference in screening for cervical cancer.

This study was not without limitation, the fact that we have measured the behavior (screening) after two months may underestimate the findings. On the other hand, this study was conducted in an urban area where most people can read and write or have someone around to read for them and could not be generalized to most parts of the country where about half of all women and a third of all men aged 15–49 were illiterate [22].

Conclusion

This study suggested that, provision of printed media and brief and focused health education by a health professional at primary health facilities could increase the uptake of cervical cancer screening service in Addis Ababa health centers. We recommend that integrating a one-to-one health education and administering educational brochures which are written in simple languages about cervical cancer and benefits of early screening with the existing maternal health programs are worthwhile.

Supporting information

S1 Fig. Flow diagram of the progress through the phases of a parallel randomized trial of two groups.

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S2 File

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Acknowledgments

We are grateful for Women’s Health Research Working Group at Addis Ababa University, College of Health Sciences for initiating this research. The Women’s Health Research Working Group Members at the College of Health Sciences who commented the proposal at the inception of the project are well acknowledged.

Data Availability

The data are all contained within the manuscript. If any details are needed, I can provide all the data without restriction.

Funding Statement

We are grateful for Women’s Health Research Working Group at Addis Ababa University, College of Health Sciences for initiating and giving support for this research project. Also, we are very thankful for ‘Impact of Maternal Death on Living children’ research project at Addis Ababa University, School of Public Health for funding this research. The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

References

  • 1.Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2018; 68(6):394–424. Epub 2018/09/13 [DOI] [PubMed] [Google Scholar]
  • 2.Bruni L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, et al. ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in the World. Summary Report 17 June 2019. [Date Accessed; August 4,2020]
  • 3.FMoH. National Cancer Control Plan 2016–2020. In: Directorate DPAC, editor. Addis Ababa, Ethiopia. October 2015. p. 1–85.
  • 4.Arbyn M, Weiderpass E, Bruni L, de Sanjosé S, Saraiya M, Ferlay J, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. The Lancet Global Health. 2020; 8(2):e191–e203. 10.1016/S2214-109X(19)30482-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.WHO. Guidelines for Screening and Treatment of Precancerous Lesions for Cervical Cancer Prevention. Geneva: World Health Organization; 2013. [PubMed] [Google Scholar]
  • 6.Chelimo C, Wouldes TA, Cameron LD, Elwood JM. Risk factors for and prevention of human papillomaviruses (HPV), genital warts and cervical cancer. The Journal of infection. 2013; 66(3):207–17. Epub 2012/10/30. 10.1016/j.jinf.2012.10.024 [DOI] [PubMed] [Google Scholar]
  • 7.National Cervical Cancer Coalition (NCCC). International cervical Cancer. 2016; Available from: http://www.nccc-online.org/about-nccc/international-cervical-cancer/
  • 8.Yibeltal Assefa DJ, Sileshi Lulseged, Gorik Ooms, Wim Van Damme. Rapid Scale-Up of Antiretroviral Treatment in Ethiopia: Successes and System-Wide Effects. PLoS Medicine. April 2009; 6 (4): e1000056 10.1371/journal.pmed.1000056 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Gebru Z GMaDA. Barriers to Cervical Cancer Screening in Arba Minch Town, Southern Ethiopia: A Qualitative Study. Journal of Community Medicine & Health Education. 2016; 6(1). [Google Scholar]
  • 10.Bayu H, Berhe Y, Mulat A, Alemu A. Cervical Cancer Screening Service Uptake and Associated Factors among Age Eligible Women in Mekelle Zone, Northern Ethiopia, 2015: A Community Based Study Using Health Belief Model. PloS one. 2016; 11(3):e0149908 Epub 2016/03/11. 10.1371/journal.pone.0149908 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Mark Dignan RM, Karen Blinson, H. Bradley Wells, L Douglas Case, Penny Sharp, Stephen Davis, Joseph Konen, Richard P. McQuellon. Effectiveness of Health Education to Increase Screening for Cervical Cancer among Eastern-Band Cherokee Indian Women in North Carolina. Journal of the National Cancer Institute, Vol 88, No 22, November 20, 1996; 88(2). [DOI] [PubMed] [Google Scholar]
  • 12.David Taylor MB, Natasha Campling, Sarah Carter, Sara Garfied, Jenny Newbould, Tim Rennie. A Review of the use of the Health Belief Model (HBM), the Theory of Reasoned Action (TRA), the Theory of Planned Behaviour (TPB) and the Trans- Theoretical Model (TTM) to study and predict health related behaviour change. January, 2006.
  • 13.Adugna A. Lesson 12: Health Institution and services. 2018 Available from: www.EthioDemographyAndHealth.Org
  • 14.FMoH. Health Sector Development Program IV2010/11–2014/15. October 2010.
  • 15.Abiodun O.A FOK, Olu-Abiodun O.O, Idowu-Ajiboye B.A and Awosile J.O. An assessment of women’s awareness and knowledge about cervical cancer and screening and the barriers to cervical screening in Ogun State, Nigeria. IOSR Journal of Dental and Medical Sciences. 2013; 10(3):52–8. [Google Scholar]
  • 16.Nessa A, Hussain MA, Rashid MH, Akhter N, Roy JS, Afroz R. Role of print and audiovisual media in cervical cancer prevention in Bangladesh. Asian Pacific journal of cancer prevention: APJCP. 2013; 14(5):3131–7. Epub 2013/06/28. 10.7314/apjcp.2013.14.5.3131 [DOI] [PubMed] [Google Scholar]
  • 17.Brouwers MC, De Vito C, Bahirathan L, Carol A, Carroll JC, Cotterchio M, et al. What implementation interventions increase cancer screening rates? A systematic review. Implementation Science. 2011; 6(1). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Brouwers MC, De Vito C, Bahirathan L, Carol A, Carroll JC, Cotterchio M, et al. Effective interventions to facilitate the uptake of breast, cervical and colorectal cancer screening: an implementation guideline. Implementation science: IS. 2011; 6:112 Epub 2011/10/01. 10.1186/1748-5908-6-112 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Mupepi SC, Sampselle CM, Johnson TRB. Knowledge, Attitudes, and Demographic Factors Influencing Cervical Cancer Screening Behavior of Zimbabwean Women. Journal of Women's Health. 2011; 20(6):943–52. 10.1089/jwh.2010.2062 [DOI] [PubMed] [Google Scholar]
  • 20.Ha Kyun Chang J-PM, Seung Won Byun, Sung-Jong Lee, Yong Seok Lee, Hae-Nam Lee, Keun Ho Lee, et al. Factors associated with participation in cervical cancer screening among young Koreans: a nationwide cross-sectional study. BMJ Open 2017; 7:e013868 10.1136/bmjopen-2016-013868 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Chrysostomou AC, Stylianou DC, Constantinidou A, Kostrikis LG. Cervical Cancer Screening Programs in Europe: The Transition towards HPV Vaccination and Population-Based HPV Testing. Viruses. 2018; 10(12). Epub 2018/12/24. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Central Statistical Agency. Ethiopian Demographic and Health Survey 2016. In: Program TD, editor. Rockville, Maryland, USA. July 2017.

Decision Letter 0

Stanley J Robboy

9 Mar 2020

PONE-D-19-25303

Role of Health Education on Cervical Cancer Screening Uptake at Health Centers of Addis Ababa

PLOS ONE

Dear Mrs. Abu,

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

We would appreciate receiving your revised manuscript by Apr 23 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Stanley J. Robboy, MD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.plosone.org/attachments/PLOSOne_formatting_sample_main_body.pdf and http://www.plosone.org/attachments/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type of consent you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians.

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

4. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as: a) the recruitment date range (month and year), b) a description of any inclusion/exclusion criteria that were applied to participant recruitment, c) a description of how participants were recruited, and d) descriptions of where participants were recruited and where the research took place.

5. Please provide a sample size and power calculation in the Methods, or discuss the reasons for not performing one before study initiation.

6. Please amend the manuscript submission data (via Edit Submission) to include author Abigiya Wondimagegnehu and Mitike Molla.

7. Please amend your authorship list in your manuscript file to include author Mitike Sisay and Abigiya Tilahun.

8. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical.

9. Thank you for stating the following in the Acknowledgments Section of your manuscript:

"We are grateful for Women’s Health Research Working Group at Addis Ababa University, College of Health Sciences for initiating and giving support for this research project. Also, we very thankful for ‘Impact of Maternal Death on Living children’ research project at Addis Ababa University, School of Public Health for funding this research."

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

10. Your ethics statement must appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please also ensure that your ethics statement is included in your manuscript, as the ethics section of your online submission will not be published alongside your manuscript.

11. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 3 in your text; if accepted, production will need this reference to link the reader to the Table.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

**********

5. Review Comments to the Author

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

Reviewer #1: This study assessed the effect of providing cervical cancer prevention information on subsequent cervical cancer screening. The study is interesting particularly because of the dramatic increase in cervical cancer screening after a relatively simple intervention such as providing health education and giving brochures to women seeking routine care.

Major issues:

The article is poorly written. I suggest that authors use a professional language proofreading services if English is not their first language.

In the introduction section, the authors do not mention the current gold standard for cervical cancer screening, which is once every three years for women age 21 to 65 years, and once every five years for women age 30 to 65, if the screening is combined with HPV testing. The authors do not mention if the same screening guidelines are applicable in Ethiopia.

Methods: The authors do not explain why the study was limited to women aged 30 to 49 years.

The figure on the participant flow is confusing. It reads as if patients were allocated to the intervention and control health facilities. However, in the methods section, it states that facilities were selected randomly, and patients who visited those facilities received either the intervention or control based on the the facility they visited.

One major problem as well is the description of the control group. The authors do not describe what 'regular health education' means. They mention that education about CC is given twice a week. It is unclear what CC means.

Results:

The authors have provided descriptive information about the women who received the intervention and control. However, since the randomization was done at the facility level, I suggest that the authors conduct statistical tests to see if the treatment and control groups were statistically significant.

Minor issues:

Background: the authors should provide more recent statistics on the prevalence of cervical cancer globally and in Ethiopia, if available. Using figures from 2012 appears rather dated.

Reviewer #2: Overall, this is a well-designed study on a very important topic. My primary concern is that much of the paper is not grammatically correct. Editing for language and ease of reading would be helpful. The authors do a good job describing how their intervention affected uptake of cervical cancer screening and the population characteristics that affected whether subjects were screened. It would be helpful to have a more in-depth discussion of the identified barriers to screening an possible ways to overcome these barriers.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2020 Oct 7;15(10):e0239580. doi: 10.1371/journal.pone.0239580.r002

Author response to Decision Letter 0

3 Jun 2020

Response to academic editor and Reviewers

Dear Reviewers,

Thank you for your valuable comments. We have responded for each comment one by one

Comment

1- Please ensure that your manuscript meets PLOS ONE's style requirements

Response- We have ensured that the manuscript meets PLOS ONE’s style requirement

2- Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you

have specified what type of consent you obtained

Response- Now additional information is given (page 6)

3- Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses.

Response- The survey questionnaire developed for this study is now included as supporting information.

4. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as: a) the recruitment date range (month and year), b) a description of any inclusion/exclusion criteria that were applied to participant recruitment, c) a description of how participants were recruited, and d) descriptions of where participants were recruited and where the research took place.

Response- Comment accommodated (See methods section, page 4 and 5)

5. Please provide a sample size and power calculation in the Methods, or discuss the reasons for not performing one before study initiation.

Response- Sample size calculation is now provided at the methods section (Refer page 6)

6. Please amend the manuscript submission data (via Edit Submission) to include author Abigiya Wondimagegnehu and Mitike Molla.

Response – Comment accommodated

7. Please amend your authorship list in your manuscript file to include author Mitike Sisay and Abigiya Tilahun.

Response – Author Mitike Molla and Abigiya Wondemagne are already in the authorship list

8. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical.

Response- The title online submission and the title in the manuscript are identical

9. Thank you for stating the following in the Acknowledgments Section of your manuscript:

"We are grateful for Women’s Health Research Working Group at Addis Ababa University, College of Health Sciences for initiating and giving support for this research project. Also, we very thankful for ‘Impact of Maternal Death on Living children’ research project at Addis Ababa University, School of Public Health for funding this research."

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

Response- Now, statement related to the funding is removed from the acknowledgement section. We have only put this in the funding statement

10. Your ethics statement must appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please also ensure that your ethics statement is included in your manuscript, as the ethics section of your online submission will not be published alongside your manuscript

Response- Ethics statement is already included in the methods section of the manuscript.

11. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 3 in your text; if accepted, production will need this reference to link the reader to the Table.

Response- Table 3 is now referred in the text

12. Methods: The authors do not explain why the study was limited to women aged 30 to 49 years.

Response- Now it is explained in the methods section why 30-49 age group is only included. The reason is the Ethiopian Cervical Cancer screening Guideline recommends VIA screening for women in the age group of 30-49 years.

13. The figure on the participant flow is confusing. It reads as if patients were allocated to the intervention and control health facilities. However, in the methods section, it states that facilities were selected randomly, and patients who visited those facilities received either the intervention or control based on the the facility they visited.

Response- From 14 primary health centres that were giving cervical cancer screening using VIA at the time the study period; only 8 health centres were randomly selected. From the eight health centres that were selected for this study; randomly 4 health centres in each arm were assigned randomly

14. One major problem as well is the description of the control group. The authors do not describe what 'regular health education' means. They mention that education about CC is given twice a week. It is unclear what CC means.

Response -Now, CC is corrected to cervical cancer.

Regular health education – is a health education done in all health facilities focusing on any health concern; mostly the education is done for a mass (People who come to the health facilities to get different health services). As part of this, cervical cancer is one of the health topics addressed at the health facilities in Ethiopia.

15. The authors have provided descriptive information about the women who received the intervention and control. However, since the randomization was done at the facility level, I suggest that the authors conduct statistical tests to see if the treatment and control groups were statistically significant.

Response- we have conducted Chi- square test result of cervical cancer screening practice with type of health center (Intervention/Control) (As shown the in the table below)

Variable Screened for cervical cancer x2 value P- val-ue

Yes

(n=211) No

(n=1926)

Type of the health center Intervention 152 (70.70%)

910 (47.27%)

42.4519

0.000

Control 63 (29.30%) 1,015 (52.73%)

Proportion of women screened for cervical cancer among the intervention group was higher than the control group. And there is association between receiving health education and educa-tional brochure with cervical cancer screening practice.

16. The authors should provide more recent statistics on the prevalence of cervical cancer globally and in Ethiopia, if available. Using figures from 2012 appears rather dated.

Response- Comment accommodated. Now 2018 data is given about the prevalence of cervical cancer screen-ing ( See Introduction section)

17. My primary concern is that much of the paper is not grammatically correct. Editing for lan-guage and ease of reading would be helpful.

Response- We have done grammatical correction and edited for language ease for reading.

18. The authors do a good job describing how their intervention affected uptake of cervical cancer screening and the population characteristics that affected whether subjects were screened. It would be helpful to have a more in-depth discussion of the identified barriers to screening and possible ways to overcome these barriers.

Response- Comment accommodated (Page 15, paragraph 2)

Attachment

Submitted filename: Response (2).odt

Click here for additional data file. (7.6KB, odt)

Decision Letter 1

Stanley J Robboy

2 Jul 2020

PONE-D-19-25303R1

The Role of Health Education on Cervical Cancer Screening Uptake at Selected Health Centers in Addis Ababa

PLOS ONE

Dear Dr. Abu,

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

The topic of cervical cancer screening is important and the authors are encouraged to address the concerns raised in the reviews.  Given that the current submission is itself also a revision, I have served this time as one of the new reviewers.  When resubmitting, please have someone thoroughly familiar with English proofread the manuscript for language consistancy.  Plos One itself provides no editing, but can provide names where editing assistance is available.

==============================

Please submit your revised manuscript by Aug 16 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Stanley J. Robboy, MD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Partly

Reviewer #4: Partly

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

Reviewer #3: Yes

Reviewer #4: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: No

Reviewer #4: No

**********

6. Review Comments to the Author

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

Reviewer #3: This study examined the effect of health education on cervical cancer screening uptake in 2,139 women at selected health facilities in Addis Ababa, Ethiopia, where awareness of the disease and availability of screening and treatment are limited. A RCT was conducted at eight public health care centers that provide cervical cancer screening services using visual inspection with acetic acid; each center was assigned to either intervention (one-on-one health education, and receipt of a brochure explaining cervical cancer and benefits of screening) or control (regular care). After two months, women were contacted to ask whether they had been screened for cervical cancer.

This paper deals with a very important topic, and an easily and inexpensively implemented intervention, but given the results, it is NOT effective. The authors found a significant effect in the intervention group; however, they need to address more fully the obvious problem that even in the intervention group, there was only 14% uptake of services. The intervention may work better than nothing, but it isn’t working very well if >85% of the women who received the intervention did not seek screening. Although the authors surmise what the reason for the low rate of uptake might be, they do not take the opportunity to put forward ideas about what might have been done differently or what might have been wrong with the intervention.

Was any attempt made to schedule an appointment for the women at the time they were enrolled, or at any time after the intervention? Education helped but was in no way enough to motivate these women; it either missed the mark in the way the information was conveyed, or did not include enough information to be taken seriously. Scheduling an appointment on the spot would be far more effective than leaving it up to these women themselves, who are older and therefore probably assume they have managed to go without screening this long without any bad effects, so “why bother?”

At two months, the majority of the women in the intervention group (almost 80%) said that the primary reason for not seeking screening was because they “were busy;” in person, this sort of excuse could be directly addressed. The majority of the women are housewives, with presumably older children (given their age range). If the intervention included an attempt to schedule an appointment, perhaps this “too busy” issue could be directly addressed with these women and solutions found (were they really “too busy,” or did they just need further nudging, reassurance and a stronger emphasis on the importance of screening?). If this study is to be valuable to future researchers, the authors should put more emphasis on what went wrong, why, and how it might be fixed.

The study needs to be edited by a native English speaker; there are many incomplete or incoherent sentences and grammatical errors.

Other comments:

Abstract:

[Methods]

“The eight health centers were stratified into two equal numbers of groups as intervention and control.” A more clear way to state this would be: Each of the eight health centers was randomly assigned to serve as either an intervention or a control center.

Introduction

Delete the reference to global cases of cervical cancer; it isn’t really relevant. Should just read, “In 2018 alone, 6,294 new cases of cervical cancer occurred in Ethiopia…”

Methods

A table for the sample size calculation really isn’t necessary. This information can be included in the text.

[Data entry and analysis] First sentence should read “Data entry and data analysis were done using….respectively.”

Table 1.

The authors should consider testing the differences between the two cohorts, given that the groups each come from four different centers.

Table 2.

Could the authors address whether they had difficulty contacting the women after two months? It appears from Table 2 that follow-up was very good but not complete. What efforts were made to contact the women who could not be reached? The authors should summarize this information in the results (including reporting the percentage of incomplete assessment in each group). It would be interesting to compare statistically the reasons that women gave for not being screened between the two groups (simple chi-square tests could be used).

[Multivariable analysis]

The way in which the authors describe the modeling process needs to be improved. Their main predictor is group status; the other variables in the model should be described as variables for which they adjusted the primary predictor in the model, based on the bivariate results. The emphasis should be on the intervention/control group status. This is buried in the paragraph, which is not a very good description of the steps that went into the analysis. This section could be more detailed.

Table 3.

The title of the table should not be “Multivariable Analysis…” if it also contains the bivariate analysis (I am assuming this is what the “Crude OR” refers to). The unadjusted analyses should show results of all models, even those for covariates that did not turn out to be significantly associated with the outcome. The columns for variables not included in the multivariable analysis would just be left blank in the “Adjusted OR” columns. Group status should be listed first. P-values should be reported for both the unadjusted and adjusted models. There is a “1” missing (as reference) for Marital Status for Crude OR.

Discussion

7% of the intervention group reported that they were not screened because they didn’t know about cervical cancer screening and availability of the services. This is surprising in the group that received the intervention and indicates some failing of the intervention for them. Did the authors pursue this, to determine why these women claimed to lack awareness?

This is an important paper which should be published, but it still needs some work.

Reviewer #4: PONE-D-19-25303R1

Reviewer comments for the authors.

ABSTRACT

Several phrases in the abstract or in the underlying main article are unclear and are noted below

Methods

one-to-one brief health education : Need further description. The One to one brief health education in the interventional center is obvious. How does health education in the interventional center differ from the non-interventional (control) center? A clearer description is needed describing the differences of the client receives at the interventional vs non-interventional centers.

pectoral description : “Pectoral” refers to the chest muscles; I believe the authors mean “pictures.”

After two months : Did clients sometimes have the treatment at the time of the initial visit or did they actually have to go home and then return for a special cancer screening

called through their phones : Awkward. Called by phone somehow sounds better

Results

215 (10%) : Medical care in Addis Ababa. The intervention essentially doubled the number of people screened for cervical cancer, yet the overall rates remained low (10% of all women in the study). The goal, ideally, is for a 100% rate of screening. Am I correct only about 3% (64) of the non-interventional cluster came for screening? The discussion section of the paper might wish to offer thoughts as to why the rates for both groups remained so low.

first degree or above : To what does first degree refer: education?

STI: Spell out

Introduction

3rd Paragraph: The expansion …

study done among 1186 women in Mekelle : Interesting that the rate of screening at Mekelle was roughly 6 times greater there than at your institution (19.6% vs 3% of your noninterventional cluster). What is the difference in your two populations

5th para: In our study …

theoretical : I do not believe you mean “theoretical,” more likely the word should be “practical”

Methods

Study area and period

The study was conducted in Addis Ababa, the capital city of Ethiopia between August 2017 and January 2018.: the sentence is constructed awkwardly. The authors mean the study was conducted between August 2017 and January 2018, but as written states that Addis Abba was the capital between those two dates.

tire: Tier, not tire

Unlike other regions in the country,: Why are the Addis Ababa health centers unlike those of other parts of the country? Do the others lack general practitioners, nurses, or midwives? Also, for those of us unfamiliar with the health system in Ethiopia, what are the key characteristics of the second level and tertiary level care providers?

Study design and population

Two-pronged a cluster: Do you mean “a two-pronged” rather than “two-pronged a”?

30-49 years. Which is : I believe you mean “30-49 years, which is” rather than a new sentence “30-49 years. Which is”

under 5 clinics for their babies : I think you mean “babies and children under five years of age”

Women who gave birth in the past 45 days and pregnant : awkward wording. The sentence reads as if someone had recently given birth but is still pregnant.

Intervention group:

one-to-one brief health talk : Given one to one talk. How was the brochure the interventional group received different from that the control clients received? Within the interventional group, what was more effective, the personal talk, or whatever reading material the client received?

Each woman who participated in the intervention group : Would it be correct to assume that women in the intervention group did NOT have the screening performed at the same time as they came for the initial interview? Did many of the women at the initial interview schedule their return visit for VIA or did they return home, and once there, schedule a visit? This seems to me to be important in determining what type of a future educational campaign might be waged. If the former, more women need to be encouraged to come to the centers and have one to one interviews. If the latter, then the campaign may consist more of brochures sent out throughout the community

Control group:

except the regular health education : It is unclear of what “regular health education” consists.

What exactly is the difference between “regular” in the controls and the brochures in the interventional group. This would seem to be an important facet to clarify in a study of this type. Some more detail would be helpful.

Ethical consideration:

Each respondent was informed about the purpose, scope, and expected the outcome of the research and verbal informed consent as it was approved : Unclear: Were control told they would not be given 1-1 counseling?

“Expected the outcome” -- I think you mean “Expectations of the outcomes”?

The data collectors put a mark on the checklist given on the consent form, regarding the study participants' responses to participate. : Are the authors’ saying checkmarks were put on all clients forms, so that at the end of the study the authors could determine the total number asked, and thus also what percent of those asked to join the study, regardless whether intervention or control, actually refused? I presume that is from where the number, 2139, derives.

The study is also hazy about what “participates” means, which affects the study numbers, and hence percentages reported.

When a woman came to Bole-17 for example, was she asked if she would participate, and if so, only then did she receive a one-on-one session?

Also, was VIS performed on the same day and possibly even at the same time as the interview, or did clients have to return on a subsequent day, which certainly would reduce compliance and therefor the number of study participants completing all desired aspect?

Generalized estimating equation (GEE) analysis with a binary response variable using a robust estimator and exchangeable working correlation matrix was used.: I am not an epidemiologist or statistician and have no idea what the sentence means. Can this be simplified and expressed correctly, but with words I might understand?

Result

A total of 2,139 women who had never screened : Add the missing word “been” after “never”

During the study period,: Until this point, the two populations seem relatively similar. The rest of the paragraph left me stunned, and unprepared to understand how the population as a whole differed from both the interventional and control clients. (Actually the answer came only late in the discussion – ALL pregnant women are routinely tested for HIV. Thus, nearly 100% of the clients have been tested for HIV. Is this normal for Africa, for Ethiopia, specifically for Addis Ababa, or specifically for the population of patients with which your group deals? Somewhere earlier, there needs to be a description, however brief, of your population.

The remainder of the paragraph should present the data to help the reader. Possibly the authors might wish to present the HIV data, then the STI data and finally the cervical data.

In the discussion, somewhere, you may wish a few comments about how your group is forward-looking and trying to advance medical care in Ethiopia in ways that are economically practical.

Regarding the health status of participants,: My comments refer to this paragraph and also table 1. The single most striking fact of table 1 is that over 90% of all your clients, regardless of whether intervention or control, were tested for HIV, now or in the past. From the discussion, I presume this is routine.

With this high rate of HIV testing, why is there not greater concern about STI's and cervical cancer? It seems cervical cancer is relatively ignored. Is this because the women generally know nothing about cervical cancer and do not understand it? Is this part of the overall education programs your medical centers/leaders are trying to bring to the Ethiopian citizenry? The discussion might expand on this subject.

STI. Where 1,005(95%): Spell out STI as it is the first time of use in the text.

I believe the two phrases belong to one sentence.

Table 1. Socio demographic and Health Related Information of Study Participants at Addis Ababa, 2017

Diploma

First Degree and above: What is the difference between diploma and first-degree; Will most readers understand?

Religion

Orthodox : Are not the orthodox part of the Christian community? Would it be clearer, given a worldwide readership likely unfamiliar with Ethiopian religion to refer to the Orthodox as Ethiopian Christian Orthodox? This would avoid confusion with Jewish Orthodox.

All study participants … telephone about the source of information after two months of time from the recruitment period: This sentence is problematic. The study has two arms where patients received specific one-on-one counseling and brochures, or little other than the general information provided by the clinic. But now a third arm is suggested, where the patients receive new sources of information during the subsequent telephone calls. Does this mean some clients in the interventional or control groups learn from a third source and were acting on that new information? Do we now have a murky third arm? Please explain.

Discussion

This study was conducted in an urban area where most people can read and write or have someone around to read for them : Useful in methods to help describe the population clientele.

Paragraph:

In this study, women who were screened for cervical cancer reported that the health education they have received from one-to-one health education and the educational brochure had helped them to decide in screening for cervical cancer. : Was there anything the healthcare professionals learned when giving advice to getting the clients attention and having the client follow through with testing? If so, please add in the results section and comment in the discussion section.

Paragraph: This study also found a significant association between history of STI

. This could be related to the fact that HIV screening is a routine procedure that is provided for all pregnant women at all health facilities hence: I was unaware of this fact, which explains my comment related to table 1. Please comment about routine HIV screening in pregnant women much earlier.

References

: Please refer the Journal’s instructions; Most references are incomplete

#2 : Who is the author, what is the journal or book etc.

#3 : Is this a web reference. Need URL & Date access

#4 : Web site note proper – too many periods.

#5 : Citation incomplete

Etc.

**********

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Reviewer #3: No

Reviewer #4: Yes: Stanley J Robboy, MD

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Decision Letter 2

Stanley J Robboy

10 Sep 2020

The Role of Health Education on Cervical Cancer Screening Uptake at Selected Health Centers in Addis Ababa

PONE-D-19-25303R2

Dear Dr. Abu,

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

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Kind regards,

Stanley J. Robboy, MD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The revisions submitted are good.

Attached is a file the Academic Editor has made as suggested changes to the manuscript.

As the Journal does not make changes to submitted manuscripts, I have made some suggested wording changes that the authors may wish to include.

Attachment

Submitted filename: PONE-D-19-25303R2.1] in Word.docx

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Acceptance letter

Stanley J Robboy

22 Sep 2020

PONE-D-19-25303R2

The Role of Health Education on Cervical Cancer Screening Uptake at Selected Health Centers in Addis Ababa

Dear Dr. Abu:

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

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

If we can help with anything else, please email us at plosone@plos.org.

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

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Stanley J. Robboy

Academic Editor

PLOS ONE

Associated Data

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    The data are all contained within the manuscript. If any details are needed, I can provide all the data without restriction.

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