The magnitude of precancerous cervical lesions and its associated factors among women screened for cervical cancer at a referral center in southern Ethiopia, 2021: a cross-sectional study

Background Cervical cancer is the most prevalent gynecologic cancer in women and the second leading cause of cancer death worldwide. Africa's southern, eastern, and western regions have the highest rates of cervical cancer. Cervical cancer is treatable and curable when detected early, but it is nonetheless fatal in low- and middle-income (LMIC) nations where screening and early detection are not widely accessible. Objective The objective of this study is to assess the magnitude of precancerous cervical lesions and their associated factor among women screened for cervical cancer at a referral center in southern Ethiopia, in 2021. Methods A retrospective institution-based cross-sectional study was conducted from February 21 to April 14, 2022, among randomly selected 372 records of women screened for cervical cancer at Hawassa University Specialized Hospital. Data were extracted from clients' charts using a data extraction checklist. Statistical Package for Social Sciences version 26 and logistic regression analysis were applied to determine the association between dependent and independent variables, and significance was declared at p-value <0.05. Results The magnitude of abnormal cervical dysplasia in this study was 18.3% of which 14% were precancerous cervical lesions and 4.3% were cervical cancer. Early coitarche: Adjusted odds ratio (AOR) = 5.6 [95% (confidence interval) CI = 1.87–16.78], having more than one sexual partner: AOR = 2.6 [95% CI = 1.2–5.68], being HIV positive: AOR = 3.56 [95% CI = 1.53–8.29], and having sexually transmitted infections: AOR = 4.64 [95% CI = 2.08–10.35] were independent predictors of precancerous cervical lesions. Conclusion The magnitude of precancerous cervical lesions in the study setting is 18% and the magnitude of cervical cancer is 14%, which is higher than the pooled prevalence of precancerous cervical lesions in Ethiopia. Having multiple sexual partners, being HIV positive, having sexual intercourse before 21 years, and new STI diagnosis was independently associated with abnormal precancerous cervical lesions.


Introduction
Columnar cells undergo modifications in a precancerous stage of the cervix, increasing their propensity to develop into cancer.Although this stage has not yet developed into cancer, if it is not treated quickly, it is quite likely to do so in 10 years or more (1,2).The area of the cervix that contains epithelium that has undergone a squamous metaplastic transition is known as the transformation zone.There is an area of squamous metaplasia between the ectocervix and the squamocolumnar junction.The majority of anomalies are assumed to start in this region (3).
Cervical cancer is the most common gynecologic cancer in women.The human papillomavirus is the primary cause of the majority of these malignancies, while other hosts and behavioral variables also play a role in the development of the tumors after the first infection.Serology is also inconsistent and unable to differentiate between past and present infections.Consequently, the only way to be certain of a diagnosis is through the direct detection of HPV DNA or cytologic examination.The absence of routine pap smear screening is the biggest risk factor for cervical cancer (2).
Sub-Saharan Africa has the highest global incidence and mortality rates for cervical cancer, with rates particularly high in Eastern Africa (Malawi has the highest incidence and mortality rate in the world), Southern Africa, and Middle Africa.In Northern America, Australia/New Zealand, and Western Asia (Saudi Arabia and Iraq), mortality rates can vary by up to 18 times, while incidence rates are 7-10 times lower (4,5).
Africa's southern, eastern, and western regions have the greatest rates of cervical cancer.Cervical cancer is still fatal in low-and middle-income countries (LMIC), where screening and early detection are not easily accessible although it is a preventable illness that can be cured when discovered early.Almost 90% of cervical cancer fatalities occur in LMICs.LMICs frequently struggle with a lack of resources and funds to offer proper treatment (4)(5)(6).
Cervical cancer is thought to be a concern for 29 million Ethiopian women, with 7,095 new cases and 4,752 fatalities reported annually.Cervical cancer is the main cause of cancerrelated deaths among women aged 15-44 in the nation and the second most common malignancy among all women (7,8).
By 2020, the Federal Ministry of Health in Ethiopia aimed to have at least 80% of the eligible target groups screened and treated for cases of pre-invasive cervical cancer.Yet, a community-based cross-sectional survey of nine districts and two city administrations in Ethiopia (Addis Ababa and Dire Dawa) reveals a shockingly low percentage of cervical screening (2.9%), and only 10% of patients had visited the cancer center in the early stages of their illness (7,8).
Though several studies concentrating on north and central Ethiopia are conducted, most of these studies are conducted focusing on women with HIV.Besides assessing all women screened for cervical cancer, this study is conducted in the biggest referral center in southern Ethiopia which encompasses not only urban but also women from rural and pastoral areas of the south.Therefore, this study aimed to determine the magnitude of precancerous cervical lesions and their predictors among women screened for cervical cancer in Hawassa University Comprehensive Specialized Hospital Southern Ethiopia.
After identifying the prevalence of precancerous cervical lesions and associated factors in the study area, this study aims to provide the finding of the study to Sidama, SNNPR, and Oromia regional health bureaus to enact strategies helpful for reducing contributors of the infection.

Study setting
The Sidama area, one of the three densely populated coffeeproducing regions in the nation, has Hawassa as its capital.HUCSH is a teaching hospital in Hawassa that has been providing health services since 2006.It provides services for more than 20 million people from all over southern Ethiopia.Currently, it has over 450 beds and cares for clients in a broad range of services to over 90,200 outpatients, 181,116 inpatients, and 1,092 emergency cases annually.The hospital gives cervical cancer screening services with VIA for women aged 30-49 years.

Study period and study design
A retrospective institution-based cross-sectional method was employed from February 21 to April 14, 2022, to determine the magnitude of cervical cancer and its associated factors among women screened for cervical cancer at HUCSH in 2021.

Study population
Medical records of all women who were screened for cervical cancer in the gynecologic department of HUCSH in 2021.

Eligibility criteria
Medical records of women who were screened for cervical cancer available during the study period with complete information were recruited into the study including date of VIA examination, HIV status, and result of the VIA examination.

Sample size determination
From the total number of 454 women screened for cervical cancer in 2021 at Hawassa University Comprehensive Specialized Hospital, 42 medical records were unavailable at the record center and 40 had incomplete information which resulted in the reduction of the sample size of the study to 372 charts of women screened for cervical cancer.

Variables of the study Dependent variables
The prevalence of precancerous cervical lesions.

Independent variables
Socio-demographic characteristics (age, marital status, occupation, and educational status), sexual activity (number of sexual partners), age at first sexual intercourse, parity, status of HIV infection, STI status, use of contraceptives, and history of smoking.

Operational definition Positive for cervical cancer
Women who have been screened using visual inspection with acetic acid (VIA) and tested positive.

Data collection
Data was collected by investigators from the HUCSH precervical cancer screening unit of the client assessment form and the registry book as a form of the checklist.It contains means of identification (age, educational status, and other sociodemographic statuses like marital status and occupation), reproductive history (marital status, parity, contraceptive use, age at first intercourse, and pregnancy), menstrual bleeding pattern (regularity and postcoital bleeding), risk factors (history of smoking, number of sexual partners, previous abnormal pap smear, chronic corticosteroid use, and HIV status), examination result, VIA result, and intervention done, if any.

Data processing and analysis
Statistical Package for Social Science (SPSS) Version 26 was used to code, enter, clean up, and update the data before analysis.The statistical relationship between each independent variable and the result variable was examined using a logistic regression model.Variables with a p-value of 0.25 or less were added to the multivariable logistic regression model.Tables and texts were used to display the results.Using adjusted odds ratios (AOR) with a 95% confidence interval, the strength of associations was evaluated, and significance was determined at a p-value of 0.05.

Data quality control
Training and orientation were provided for data collectors and supervisors for 2 days on the objective of the study, confidentiality of information, and data collection tools.Day-to-day supervision was carried out by the principal investigator and trained supervisor for the entire length of the data collection period.
Using the variance inflation factor and standard error, multicollinearity was examined to determine whether there was a linear correlation between the independent variables.The multivariate analysis excluded variables having a standard error of >2 and a variance inflation factor >10 from consideration.To assess the model's fitness, a Hosmer-Lemeshow test was conducted.The test yielded a value >0.05, and the fit was assumed.

Ethical considerations
Ethical approval was obtained from the institutional review board (IRB) of Hawassa University College of Medicine and Health Sciences.A formal letter was written to Hawassa University's comprehensive specialized hospital to access data of women screened for cervical cancer during the study period.Data were kept confidential, the anonymity of the respondents was assured, and data were used only for research purposes.

Sociodemographic characteristics of the respondents
Out of 454 women screened for a precancerous lesion at HUCSH by VIA in the year 2021, a total of 372 medical records were reviewed in this study.The mean age of the participants was 38.68 (SD ± 9.07) years.Nearly 46.8% of participants had an educational level of elementary school and the majority of the participants were married (317) (85.2%) (Table 1).

Reproductive history and related variables of the respondents
The participants' average starting age for sexual activity was 19.64 years (SD: 2.95).The majority of participants, 363 (97.6%), had at least one child, and 193 (51.8%) of them had more than three.A history of STI was present in nearly one-fifth of the individuals [73 (19.6%)], and 82 (22.04%) had several partners.More than a fourth-fifth of the participants 308 (82.79%) had been tested for HIV and forty-seven (12.6%) of them were reactive of which 44 (93.6%) were on highly active antiretroviral therapy (HAART) (Table 2).

The magnitude of abnormal cervical lesions
Among 372 women's medical records, 18.3% of participants had abnormal cervical lesions, of which 14% were found to be positive and 4.3% had lesions suspected to be cervical cancer (Figure 1).
Of the 372 women screened for cervical cancer in the duration of the study, 96.8% had a normal pelvic exam, 86.3% were screened for the first time, 4.6% had a suspicious lesion upon examination, 14% had a positive VIA result, and 13.7% received cryotherapy (Table 3).

Factors associated with precancerous cervical lesion
The multivariable logistic regression analysis showed that early age coitarche, having more than one sexual partner, being HIV positive, and new STI history were independently associated with abnormal cervical lesions.The odds of the abnormal cervical lesion were 5.6 times higher among women whose age at first sexual intercourse was <21 years old, AOR = 5.6 [95% CI = 1.87-16.78].Women who had more than one sexual partner were 2.6 times more likely than women who had only one partner to acquire abnormal cervical lesions, AOR = 2.6 [95% CI = 1.2-5.68].Those who were HIV+ had a higher chance of developing atypical cervical lesions, AOR = 3.56 [95% CI = 1.53-8.29].The odds of the abnormal cervical lesion were 4.64 times higher among women who had new sexually transmitted infections (STI) AOR = 4.64 [95% CI = 2.08-10.35](Table 4).

Discussion
This study assessed the prevalence of precancerous cervical lesions and associated factors among women screened for cervical cancer at HUCSH in 2021.In this study, women were screened with visual inspection with acetic acid (VIA) for precancerous cervical lesions.Because VIA is less expensive and uses resources that are readily available locally, it is preferred in low-resource nations like Ethiopia.In this study, 18% had a The magnitude of precancerous cervical lesions by VIA screening among women screened for cervical cancer at HUCSH, 2021.suspicious precancerous cervical lesion, 14% were positive for precancerous cervical lesions tested by visual inspection with acetic acid, and 4.3% had lesions suspected to be cervical cancer.The magnitude of precancerous cervical lesions in this study (14%) is consistent with the finding of a study in the Amhara region of northern Ethiopia (13.1%), and a systematic review and meta-analysis pooled the prevalence of cervical precancerous lesions among women in Ethiopia (13.4%) (9,10).
Compared to other previous studies, the finding of the study is less than what was reported in a study conducted at Gandhi memorial hospital, Ethiopia, (23.5%) and a study conducted among women greater than 30 years of age in southern Ethiopia (27.7%) (11,12).The discrepancy between our study and the one conducted in Addis Ababa can be due to the nature of the center in Addis Ababa where the study was conducted.Which is one of the main referral centers in the country for screening for cervical cancer for suspected cases from different parts of the country.On the other hand, the discrepancy with the findings of the second study can be attributed to the fact that the study was conducted among women older than 30 years of age in the urban areas of southern Ethiopia, whereas our study encompasses women from both rural and pastoral areas of the region.
On the other hand, this study's outcome is higher than studies from Cameroon (3.33%), Ghana (3.7%), India (1%), and Northeast Ethiopia (6.9%) (3,(13)(14)(15).This difference in the magnitude of the condition can be attributed to the fact that these studies are done among a large population in the community, including women not screened for cervical cancer, and over extended years.
In this study, women who had more than one sexual partner were found to have a 2.6 times higher risk for cervical precancerous lesion than those who reported having one sexual partner.This finding is supported by a result from a study conducted in Addis Ababa, Ethiopia, Northeast Ethiopia, southern Ethiopia, Addis Ababa, and other African countries (11,12,(15)(16)(17)(18)(19)(20).Sexual contact is the primary method of transmission for the human papillomavirus, which causes precancerous cervical lesions.As with other sexually transmitted diseases, the risk of acquiring the virus increases with having sexual intercourse with multiple partners as it increases the chance of having more frequent and unprotected coitus (1,2).
In the study, women who were HIV positive were found to have 3.56 times greater odds of having precancerous cervical lesions than women who were HIV negative.This finding is supported by a study on the global burden of the disease and a study in northeast Ethiopia which shows that the pooled risk of cervical cancer was increased by sixfold in women living with HIV (15,21).HIV and cervical cancer are inextricably linked.HIV-positive women are commonly assumed to have more risky sexual behavior than their counterparts.The immune system is crucial for eliminating cancer cells and reducing their development and dissemination.HIV-infected women have impaired cell-mediated immunity that makes them more prone to the cancerous effect of HPV; this sequence of risks exposes

TABLE 1
Socio-demographic characteristics of women screened for cervical cancer at HUCSH, 2021.

TABLE 2
Reproductive health history and related characteristics of women screened for cervical cancer at HUCSH, 2021.

TABLE 3
Screening result of women screened for cervical cancer at HUCSH, 2021.

TABLE 4
Bivariable and multivariable logistic regression analysis of factors associated with precancerous cervical lesions among women screened for cervical cancer at HUCSH, 2021.
a The variables which were adjusted to get the odds ratios were smoking history, history of STI, contraception use, and age.*p value <0.05.