Role of pre and post interventions on cervical cancer knowledge levels among women students at the University of Gondar, Gondar, Ethiopia

Background Cervical cancer is the second most common cancer in women aged 44 years and above in Ethiopia. Lack of awareness about the disease, lack of screening programs and inadequacy of vaccination in most regions of Ethiopia alarmingly increasing Human papillomavirus (HPV) infections and incidence of the disease. Educational intervention is a fast and effective primary preventive step to reduce the cervical cancer burden. Objective The present study was carried out to understand the impact of knowledge-based intervention and factors influencing the knowledge levels on young women attending college education at University of Gondar (UoG), Gondar. Method A cross-sectional comparative study was conducted and data was collected using a standardized self-administered questionnaire in both English and Amharic (Ethiopian main official language) and analysed using the Statistical Package for the Social Sciences software (SPSS ver.23, IBM). Results There was an increase in overall awareness about cervical cancer (symptoms, risk factors, screening methods, and vaccination) in all post intervened students compared to baseline knowledge levels (before education intervention) statistically at p<0.001 significance level. The mean age of the study participants was 20.86 years (SD, 1.86). Out of total 283 women student participants, overall baseline awareness about cervical cancer symptoms (81.6%, p<0.002), risk factors (94.8%, p<0.001), HPV (60.6%, p<0.001), screening (84.3%, p<0.001) and HPV vaccines (42.1%, p<0.001) was more in 4th year and above over other respondents. After the intervention, knowledge levels increased in students 3rd and above years over 1st and 2nd-year students irrespective of the branch they belong. Initial awareness on various broad issues was 8.77 and after education intervention, it was 30.39 with mean overall knowledge increase of 21.62. However, baseline awareness was better on risk factors and poor on vaccination. After education intervention, an increase of 246% in overall knowledge about cervical cancer including symptoms, risk factors, HPV, screening and vaccination. Age, year of study, branch of study and family income were the explanatory variables significant on overall baseline knowledge levels and after education intervention, year of study was the only independent variable significant for the overall increase in knowledge levels. Conclusion The present study suggests that educational intervention as the primary preventive method is effective and young trained women volunteers belong both rural and urban areas will be important stakeholder to increase positive attitude to reduce the cervical cancer burden in Ethiopia.


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categories as follows (i) <2000 birr (ii) >=2000-5000 birr (iii) >5000 birr and above. Knowledge levels of 139 respondents regarding symptoms, risk factors, HPV and its relationship with cervical cancer, prevention methods 140 like screening and vaccination was measured using a 42 item instrument. A score of 1 was allocated for a 141 good/correct answer and 0 for a wrong answer or "Do not know". The maximum possible score was 42. Mean 142 score used to estimate the cumulative mean score of knowledge levels of cervical cancer. The total score was 143 divided into, those scored above 31 or more were categorized as having very good ("sufficient") knowledge; the 144 others were categorized "good NK" with 23 to 31, fair with score 13-22 and poor NK was 1-12 and zero score 145 categorized as "no" knowledge. Source of information, awareness and perception, concern and acceptability, 146 health-seeking behaviour and choice of venue for screening and vaccination were measured before and after 147 educational intervention and descriptive statistics were used to measure the change in response. as changes in scores after the educational intervention. Odds ratio and 95% confidence interval were also used to 161 identify the presence and strength of association wherever appropriate. All tests of significance were two-tailed 162 at 5% level. For regression analysis, the reference category was the most common category of an independent 163 variable (IV).

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A total of 283 study participants, both from biological and non-biological sciences attended the educational 166 training on cervical cancer general awareness and responded to both pre-intervention and post-intervention 167 questionnaires (Table 1). The dependent variables (DVs) were compared descriptively with respect to socio-168 demographic characteristics. The categorical variables were expressed as percentages. Pre-post education 169 intervention differences for knowledge scores and the proportion of correct responses for each question 170 summarized (Table 2). Baseline knowledge was low among all groups, with scores better among older 171 participants. The baseline knowledge about awareness, symptoms, risk factors, HPV, screening and vaccination 172 were low among non-biological science students (Table 3). A brief, structured presentation increased cervical 173 cancer awareness knowledge among all groups. On average, knowledge scores significantly improved from 8 to 174 26 after the presentation (maximum possible score 42; P < .001), irrespective of region, year of study, branch of 175 study, and age. The baseline average score of 9 for students age 20 and above and 7 in students below 20 years, 176 and after education intervention score increased to 24 and 28 in age 20 years below and above groups respectively.

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Fourth-year and above students showed a baseline score of 11 and first-year students had the lowest baseline score

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(7.4%) students were married. Study participants father's educational levels were, illiterates 83 (29.3%), up to 190 10 th grade 156 (55.1%) and above 10 th grade 44 (15.5%) and mother's educational levels were, illiterate 108 191 (38.2%), up to 10 th grade 144 (50.9%) and above 10 th grade 31(11.0% increase in awareness about symptoms compared to students belong to biological sciences (Table 3). Overall mean 227 level knowledge about the symptoms of cervical cancer before the intervention was 1.74 after education 228 intervention was 6.81 with a mean increase of 5.07 (Table 5).      To assess knowledge about the cervical cancer risk factors, nine questions including multiple sexual partners, poor 295 hygiene, no knowledge on cervical cancer and cigarette smoking could promote cervical cancer were asked to 296 study participants (Table 2). About 35.6 % (n=101) study respondents had no idea about risk factors associated 297 with the disease before educational intervention and only 7.4% (n=21) students could not identify any of the risk 298 factors even after educational intervention. Before the intervention, 43 (15.2%) students felt high parity could be 299 a risk factor and after the educational intervention, 137 (48.4%) could felt high parity could be a risk factor and it 300 was the least correctly responded question among the nine risk factors were asked. One hundred and eighty-two showed the highest increase in awareness about risk factors compared to students from non-biological sciences 305 (Table 3). More than 95 (33%) students identified, multiple sex partners, poor hygiene, no awareness of cervical 306 cancer, unprotected intercourse could be risk factors (Table 2). Mean baseline awareness about the risk factors 307 was 2.71, which was highest compared to other categories of the questionnaire and after intervention an overall 308 increase of 6.7.  (Table 2). 102 (36.04%) respondents from non-biological sciences and 62 (21.9%) biological sciences had no 320 baseline awareness about HPV and its relationship with different diseases. After educational intervention, non-321 biological science students showed the highest increase in awareness about HPV compared to students belong to 322 biological sciences (Table 3). Overall mean knowledge level before the intervention was 1.37, and after the 323 intervention was 5.61 with an increase of 4.24 (Table 5).  (Table 3). However, before the intervention, 11.3% each from biological and non-biological sciences 335 were heard of cervical cancer screening and after the intervention, it was increased to 32.1% and 43.8% in 336 biological and non-biological sciences. 8% and 5.3% before and after 39.2% and 43.1% of biological and non-337 biological sciences from total respondents reported that they were heard of Pap smear test. After educational 338 intervention, increase in awareness about cervical cancer screening was good in respondents from non-biological 339 sciences over biological sciences (Table 3). Overall mean level of knowledge before the intervention was 1.95 340 after the intervention was 6.93 with a mean increase of 4.98 (Table 4).

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Awareness regarding the target population for HPV vaccination.

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There were eight different questions like availability of HPV vaccine, the age of vaccination, availability of HPV 343 vaccine both for girls and boys, a vaccine for non-cervical cancers were asked before and after the educational 344 intervention. 48.5% of total respondents before and 91.5% after education intervention were aware of HPV 345 vaccination ( showed the highest increase of awareness that students belong to biological sciences (Table 3). Overall mean 355 knowledge level before the intervention was 1.0, and after the intervention was 4.34 with a mean increase of 3.34

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To understand the health-seeking behaviour, respondents were been asked if they have a symptom of cervical 398 cancer, how soon they visit a doctor and in response to this, 58% of respondents could not decide before 399 intervention and 25.8% could not understand the importance of health check even after education intervention.

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1.4% of respondents before and 9.9% after intervention said, they never visit any medical help. Before 401 intervention, 23.7% and after intervention, 39.2% respondents reported, they will visit medical hospital within a 402 few days. 18.3% before and 34.9% after education intervention felt they will visit hospital from a couple of weeks 403 to a couple of months (Table 9).

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Bivariate analysis showed six socio-demographic characteristics were found to be significantly associated with 425 knowledge levels about cervical cancer: age, educational level, branch of study, fathers and mother's education 426 levels, and family size (Table 12).   year of study significantly predict levels of awareness of cervical cancer.

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The main objective of this study was to assess knowledge levels at baseline and after education intervention about

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48.5% of total respondents before and 91.5% after the educational intervention were aware of HPV vaccination.

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There is a wide global variation on cervical cancer awareness and HPV vaccination acceptability is reported in 604 several reports [133][134][135]. In our study participants, HPV vaccination was the least improved category even after

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We declare no conflict of interest

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The