Precancerous Lesion of the Cervix and Associated Factors Among Women of West Wollega, West Ethiopia, 2022.

A precancerous cervical lesion, which is also called an intraepithelial lesion, is an abnormality in the cells of the cervix that could eventually develop into cervical cancer. 1 Cervical cancer is a crucial point of action for any cancer control program because of the burden of the disease, and the possibilities for effective prevention via screening. 2 It is historically classified as adenocarcinoma and squamous cell carcinoma in 99% of women with squamous cervical carcinoma caused by Humans Papillomavirus (HPV) infection. 3 Cervical cancer is the leading cause of death in women. Worldwide, cervical cancer is the fourth leading cause of death in women. 4 By 2020, an estimated 604000 women have been diagnosed with cervical cancer worldwide and an estimated 342,000 women have died of the disease. 3 Globally, cervical cancer has an occurrence rate of 371,000 cases and a death rate of 190,000 with 80% of the cancer of the cervix death occurring in resource-limited countries. The maximum rates are found in Central and South America, East Africa, South, and South-East Asia, and the Western Pacific. The problem is mainly worse in sub-Saharan Africa. 1 In Africa, 80,400 women were diagnosed with cervical cancer each year and it is the second most common cancer in the region. Furthermore, 50,300 women die each year from the disease and it is the leading cause of death from cancer. In sub-Saharan Africa, cervical cancer accounts for 22.5% of all women with cancer, and the majority of women with cervical cancer live in rural areas. 5 , 6 Ethiopia ranked 14th led by Malawi among the East African Countries. In Ethiopia, about 7095 new cervical cancer cases are diagnosed annually which makes it the 2nd leading cause of female cancer and the 2nd most common female cancer in women aged 15-44 years according to an estimate 2012. 7 , 8 According to World Health Organization (WHO) estimates, cervical cancer is expected to kill more than 443,000 women by 2030, with a high rate (over 98% of deaths) believed to occur in developing countries (especially in Sub-Saharan Africa (SSA). 9 Non-communicable diseases such as cervical cancer cause devastating effects in developing countries. 5 Cervical cancer is the most common cancer in 23 countries and is the leading cause of death in 36 countries. Most of these countries are in sub-Saharan Africa, Melanesia, South America, and Southeast Asia. 10 Precancerous lesions can be progressed to cervical cancer and the risk for the development of cervical cancer if there is missed the chance of early identification of the precancerous lesion and its risk factor. 11 It can be prevented, unlike other reproductive cancers through effective screening programs. 12 According to an estimate in 2012, there were about 4732 cervical cancer deaths which occurred annually making cervical cancer the 2nd leading cause of female cancer deaths in Ethiopia. As well as being the 2nd leading cause of cancer mortality in women aged 15-44 years. This implies there will excessive life loss due to the disease unless prompt intervention like screening and vaccination is undertaken. 8 Early screening and vaccination are some prevention strategies for cervical cancer. However, the risk of death from complications related to cancer of the cervix may be mainly affiliated to health problems over the course of a woman’s life in low income countries. 13 Vaccination can be viewed as primary prevention, with screening as secondary prevention. 12 Even though the cause for many cancers remains unknown, established cancer causes include external factors like lifestyle, such as tobacco use and excess body weight, and non-modifiable judged as internal factors, including inherited genetic mutations, hormones, and immune conditions are contributors. 14 The peak age of incidence was between 40 and 49 years. Most of the cases were found in Addis Ababa, where the hospital is situated. An increase in the trend of cervical cancer cases was observed. 2 In addition, in Ethiopia, early sexual activity, high HIV prevalence, and low socioeconomic status may place women at risk for cervical cancer. 15 It is estimated that about 1-2% of women have CIN2 + each year. This rate is reported to be higher for HIV-positive women, at 10%. 1 - 5 , 16 In high-income countries, regular Pap smear tests have been shown to reduce the risk of developing cervical cancer, by detecting malignant mutations. 17 As the problem is escalating in low and mid-income countries, interventions like using visual inspection with acetic acid has been revealed to be effective for screening in precancerous lesion low resource settings. 18 Cervical cancer is preventable, however many women in low-income countries do not have access to effective screening programs. Ethiopia has no standard policy or protocol for cervical cancer screening, rather it is patchy or inconsistent. Ethiopian women typically present for cancer care at a late stage in the disease, where treatment is likely ineffective. 19 There are no specific symptoms and no clinical features indicating the presence of a CIN. Many of these lesions, however, may become white when 3-5% acetic acid is added and possibly iodine-negative in the use of Lugol’s iodine solution, as the CIN epithelium contains little or no glycogen. 20 Like that of colorectal cancer screening, this procedure can help to prevent cervical cancers by giving opportunity for early identification and removal of precancerous lesions. It also provides the chance to identify as early as possible, when treatment is less extensive and more likely to be successful. Furthermore, screening is known to contribute in decrement of death from cancers including cervical cancer. 14 However, lack of funding for diagnostic services, low awareness of testing, and lack of trained health professionals are also major challenges in diagnosing and treating cervical cancer. 21 Reducing the magnitude and tackling the factors related with precancerous lesion is very important. As it is very crucial to produce significant decreases in incidence and mortality from precancerous lesion, barriers should be identified. Therefore, this study is aimed at determining the magnitude of this lesion within the study area and factors contributing to the problem. 22 Every woman has the right to be screened for cervical cancer at least once in her lifetime. However, in resource-poor settings, 30–49-year-old women comprise the target audience because cervical cancer is rare in women under 30 and most common in women over 40 years. Screening younger women will detect many lesions that will never develop into cancer, will lead to considerable overtreatment, and is not cost-effective. 1 , 23 In the same manner, the World Health Organization set priority to be given to screening women aged 30-49 years in the general population of women. 23 In Ethiopia according to the population census of 2013 EFY/2020/21 G.C projected estimate of women aged 30-49 years comprises approximately 19.2% of the total population. 1 To the best of author’s knowledge, prevalence, and factors for precancerous cervical lesions, have not been studied yet in study area. Therefore, this study will serve for clinicians, policy makers, and program planner’s designers as a resource for the design of appropriate interventions to decrease cervical cancer in areas like vaccination, early screening, and awareness creation. Further, the results of the study may serve as baseline information for future research.

A total of 339 women were interviewed during the study period with a response rate of 100%. The mean (±SD) age of the respondents were35.22± 6.32. Most of the participants were married, 295(87%) in marital status and about 228(67.3%) of them were Protestant religion followers in religion. Most of them were rural in residence 215(63.4%) and the majority of them, 282 (83.2%), were unemployed in occupation. One hundred sixty-one (47.5%) of the interviewed women had health insurance. Among those interviewed, 41% of the study participants’ educational status was primary level followed by non-formal education ( Table1 ). Table 1. Sociodemographic Characteristics of Study Participants, West Wollega, Ethiopia, 2022. Variable(n = 339) Variable categories Frequency Percent Age of respondents 15-34 140 41.3 35-54 199 58.7 Marital status Married 295 87.0 Single 6 1.8 Divorced 14 4.1 Widowed 24 7.1 Religion Protestant 228 67.3 Orthodox 65 19.2 Adventist 13 3.8 Muslim 33 9.7 Ethnicity Oromo 320 94.4 Amhara 16 4.7 Others 3 0.9 Residence Urban 215 63.4 Rural 124 36.6 Occupational status Employed 57 16.8 Unemployed 282 83.2 Educational status No formal education 93 27.4 Primary level 139 41 Secondary level 61 18 College and above 46 13.6 Member of health insurance Yes 161 47.5 No 178 52.5 Monthly income (in ETB) 0-600 253 74.6 601-12000 86 25.4 Sociodemographic Characteristics of Study Participants, West Wollega, Ethiopia, 2022. Of the total study participants, 323(95.3%) had pregnant history and 317(93.5%) had given birth in their life. The mean age at first birth of the respondents with SD was 19.73 +2.58. Ninety-nine (29.2%) of the study participants reported they have experienced at least one episode of abortion and 132(38.9%) had a history of the irregular menstrual cycle. Forty-four (13%) of the study participants reported as they have a history of multiple sexual partners and 127(37.5%) had a history of STI. Around thirty-five percent of the study participants had been sero-positive for HIV. Regarding family history, the precancerous cervical lesion was diagnosed in 36(10.6%) of the study participant’s family members. Almost thirty-one percent of the interviewed study participants utilized OCP as a method of family planning ( Table 2 ). Table 2. Obstetrics and Gynecological Related History of Study Participants, West Wollega, Oromia, Ethiopia, 2022. Variable(n = 339) Variable categories Frequency Percent Ever became pregnant Yes 323 95.3 No 16 4.7 Ever given birth Yes 317 93.5 No 22 6.5 Age at first intercourse <18 yrs 97 28.6 ≥18 yrs 242 71.4 Age at first birth 15-18 104 32.8 19-49 213 67.2 Number of pregnancies 0-4 262 77.3 5-10 77 22.7 Number of deliveries 0-4 268 79.1 5-10 71 20.9 History of abortion Present 99 29.2 Not present 240 70.8 Menstrual cycle Regular 207 61.1 Irregular 132 38.9 History of bleeding after sexual intercourse Present 59 17.4 Not present 280 82.6 History of multiple sexual partners Present 44 13.0 Not present 295 87.0 History of STI Present 127 37.5 Not present 212 62.5 Family diagnosed with precancerous cervical lesion? Yes 36 10.6 No 303 89.4 History of cigarette smoking Present 1 .3 Not present 338 99.7 History of Alcohol Consumption Present 18 5.3 Not present 321 94.7 History of chronic steroid use Present 26 7.7 Not present 313 92.3 HIV status Positive 117 34.5 Negative 222 65.5 Family planning use OCP 104 30.7 Injectable 189 55.8 Implant 113 33.3 IUCD 30 8.8 Obstetrics and Gynecological Related History of Study Participants, West Wollega, Oromia, Ethiopia, 2022. Among the study participants interviewed, only 217 (64%) had ever heard about precancerous cervical lesions of which 56.6% replied media is a source of their information, and 75(34.2%) reported health care workers. Around three fourth (77.3%) claimed as having multiple sexual partners as a risk for precancerous cervical lesions. Early sexual practice (<18 years) and cigarette smoking as risk factors for precancerous cervical lesions were reported by 67% and 60.8% of respondents, respectively. In general, 215(63.4%) of the study participants were regarded as having good knowledge of precancerous cervical lesions Table 3 . Table 3. Knowledge Status of Respondents Regarding Precancerous Cervical Lesion, West Wollega, 2022. Variable(n = 339) Variable categories Frequency Percent Heard about precancerous cervical lesions? No 122 36.0 Yes 217 64.0 Source of information Media 124 56.6 Health workers 75 34.2 Family 6 2.7 Neighbors/Community 12 5.5 HPV infection is a risk for precancerous cervical lesions? No 188 55.5 Yes 151 44.5 Having multiple sexual partners is a risk for precancerous cervical lesions? No 77 22.7 Yes 262 77.3 Performing early sexual practice 6 years is a risk for precancerous cervical lesion? No 200 59.0 Yes 139 41.0 Does cigarette smoking expose precancerous cervical lesions? No 133 39.2 Yes 206 60.8 Do precancerous cervical lesion symptoms gradually appear? No 98 28.9 Yes 241 71.1 Abnormal vaginal bleeding is a sign of precancerous cervical lesion? No 76 22.4 Yes 263 77.6 Bleeding or pain after coitus is a sign of precancerous cervical lesion? No 81 23.9 Yes 258 76.1 CC screening used to prevent precancerous cervical lesions? No 52 15.3 Yes 287 84.7 The HPV vaccine is used to prevent precancerous cervical lesions? No 122 36.0 Yes 217 64.0 Women with untreated precancerous cervical lesions can die? No 26 7.7 Yes 313 92.3 Advanced stage of precancerous cervical lesion causes infertility? No 47 13.9 Yes 292 86.1 Does the precancerous cervical lesion cause reproductive organ disability? No 25 7.4 Yes 314 92.6 The advanced stage of CC causes psychosocial problems in women’s life? No 34 10.0 Yes 305 90.0 The precancerous cervical lesion is easily cured if detected at an early stage? No 41 12.1 Yes 298 87.9 Are women aged 30-49 recommended to take the precancerous cervical lesion screening? No 45 13.3 Yes 294 86.7 Overall, knowledge level (good knowledge) Yes 215 63.4 No 124 36.6 Knowledge Status of Respondents Regarding Precancerous Cervical Lesion, West Wollega, 2022. Among the study participants, 145(42.8%), 143(42.2%), and 157(46.3%) had strongly agreed that cancer of the cervix is highly prevalent in Ethiopia, precancerous cervical lesion affects any woman, and precancerous cervical lesion can be prevented, respectively. Almost 50% of the study participants strongly agreed that having precancerous cervical lesion screening is not harmful and that the service is given free of charge. In general, 229(67.6%) of the respondents had a favorable attitude toward pre-cancerous cervical lesion screening, prevention, and control methods ( Table 4 ). Table 4. Attitude Level of the Study Participants, West Wollega, 2022. Variables Strongly disagree (#/%) Disagree (#/%) Neutral (#/%) Agree (#/%) Strongly agree (#/%) Cancer of the cervix is highly prevalent in Ethiopia 33(9.7) 12(3.5) 58(17.1) 91(26.8) 145(42.8) Precancerous cervical lesion affects any women 20(5.9) 22(6.5) 64(18.9) 90(26.5) 143(42.2) Any adult woman including you can acquire precancerous cervical lesion 14(4.1) 37(10.9) 45(13.3) 77(22.7) 166(49) Cancer of the cervix cannot be transmitted 58(17.1) 34(10) 90(26.5) 62(18.3) 95(28) The precancerous cervical lesions can be prevented 21(6.2) 16(4.7) 57(16.8) 88(26) 157(46.3) Having precancerous cervical lesion screening has no harm 18(5.3) 18(5.3) 43(12.7) 84(24.8) 176(51.9) Precancerous cervical lesion screening is free of charge 17(5) 17(5) 40(11.8) 81(23.9) 184(54.3) You should recommend your friends be screened 11(3.2) 12(3.5) 45(13.3) 88(26) 183(54) The precancerous cervical lesion is fatal 14(4.1) 12(3.5) 53(15.6) 67(19.8) 193(56.9) Your husband allows and supports you to be screened for precancerous cervical lesion 8(2.4) 16(4.7) 80(23.6) 90(26.5) 145(42.8) You should personally support precancerous cervical lesion patients 9(2.7) 18(5.3) 52(15.3) 76(22.4) 184(54.3) The overall level of attitude Frequency Percent Favorable attitude 229 67.6 Unfavorable attitude 110  32.4 Attitude Level of the Study Participants, West Wollega, 2022. Visual Inspection of Acetic Acid was made to identify presence of cervical lesion. Accordingly, 27.4% of the were judged as having cervical lesion (positive for the test) at time of data collection. Accordingly, overall precancerous cervical lesions in the study area was 93 (27.4%) with (95% CI: 22.7%-32.1%). Table 5. Crude and Adjusted Odds Ratios of Factors Associated with the Precancerous Cervical Lesion, West Wollega, Ethiopia, 2022. Variables (n = 339) Categories Precancerous cervical lesion (VIA) results OR (95% CI) Negative Positive Crude OR P-value Adjusted OR P-value Menstrual cycle Regular 168(81.1%) 39(18.9%) .001 a 2.29(1.29-4.04) .004 a Irregular 78(59.1%) 54(40.1%) 2.98(1.82-4.89) 1 Family Hx of dx for cx ca No 225(74.3%) 78(25.7%) 2.06(1.01-4.19) .046 1.65(.69-3.93) .257 Yes 21(58.3%) 15(41.7%) 1 History of STI No 177(83.5%) 35(16.5%) 1 <.001 3.46(1.94-6.18) <.001 a Yes 69(54.3%) 58(45.7%) 4.25(2.57-7.03) Bleeding after intercourse Yes 220(78.6%) 60(21.4%) 4.65(2.59-8.34) <.001 2.88(1.43-5.78) .003 a No 26(44.1%) 33(55.9%) 1 Number of pregnancies ≤4 199(76%) 63(24%) 1 .015 .47(.10-2.25) .347 ≥5 47(61%) 30(39%) 2.01(1.18-3.46) Parity 0-4 196(76%) 62(24%) 1 .003 2.41(1.23-4.75) .011 a 5-10 35(53%) 31(47%) 2.8(1.37-4.35) Attitude Favorable attitude towards screening for cervical cancer 180(78.6%) 49(21.4%) 1 <.001 2.15(1.21-3.83) .009 a Unfavorable attitude towards screening for cervical cancer 66(60%) 44(40%) 2.45(1.49-4.02) Use of steroids No 234(74.8%) 79(25.2%) 1 .003 3.5(1.32-9.34) .012 a Yes 12(46.2%) 14(53.8%) 3.46(1.54-7.79) 1=Reference a Statically significant Crude and Adjusted Odds Ratios of Factors Associated with the Precancerous Cervical Lesion, West Wollega, Ethiopia, 2022. 1=Reference a Statically significant In multivariable analysis, participants with a diagnosis of menstrual irregularity had a two folds higher odds of being diagnosed with the precancerous cervical lesion when compared with counterpart at, [AOR=2.29(95%CI:1.29-4.04]. Women with history of STI had 3.5 times higher odds of developing precancerous cervical lesion compared to women with no history of STI [AOR)=3.46(95%CI:1.94-6.18)]., Women having bleeding after sexual intercourse were 2.88 times more likely to have precancerous cervical lesion compared to those without it at [AOR=2.88(95%CI:1.43-5.78)]. Women with parity greater than or equal to five had 2.4 times higher odds of developing precancerous cervical lesions compared to women with parity less than five at [AOR=2.41(95%CI:1.23-4.75)]. Participants who had a history of steroid use had 3.5 times higher odds of developing precancerous cervical lesion compared to participants with no history of steroids use at [AOR=3.5(95%CI:1.32-9.34) and women with an unfavorable attitude towards screening for cervical cancer screening, prevention, and control methods had 2.2 times higher odds of developing precancerous cervical lesion compared to women with favorable attitude towards screening, prevention, and control methods [AOR=2.15(95%CI:1.21-3.83)] ( Table 5 ).

The findings of this study are in line with the results of a study from the city of Arba Minch and the Zuria region (27.7%) and are higher than those reported in Easter Ethiopia, Harar (18.5%), three referral hospitals of Amhara region 20.2%, and Jimma (12.9%). 3 , 5 , 10 , 13 Furthermore, the findings were significantly higher than systematic reviews conducted in Ethiopia, 24 Southern Ethiopia 22%, 25 - 26 Dessie 6.9%, Waldia and Dessie 9.9%, 27 Almeda textile factory in North Ethiopia 6.7% 28 and Rwanda. 18 This reveals that the findings recommend raising of a screening strategy for cervical intraepithelial neoplasia for all women. 13 In this study, 63.4% of study participants were well-informed about cervical cancer. The findings were higher than the study results in Butajira and Wolita of Ethiopia. On the other hand, the study also revealed that 67.6% of women interviewed had a positive attitude toward cervical smear screening under the results reported in Bishoftu town. 16 , 17 , 29 Participants with a diagnosis of menstrual irregularity had a statistically significant higher odds of association [AOR=2.29(95%CI: 1.29-4.04] for being diagnosed with a precancerous cervical lesion of the cervix, which is in line with research done in Debre -Berhan University. 22 This might be a reason of other causes of abnormal menstruation including uterine cancer or cervical cancer. 20 As well, sometimes cervical cancer mimics menstrual bleeding. The patient may notice a longer or heavier menstrual cycle than usual or spotting or bleeding between periods 24 Women having STI had 3.5 times higher odds of developing precancerous cervical lesions compared to women with no history of STI [AOR) = 3.46(95%CI:1.94-6.18)], which is similar to research conducted in the Debre Markos town, 30 Southern Ethiopia, 25 and three referral hospital in Amhara region. 5 This association might be due to that the fact that cervical cancer occurs in the cervix, which is the entrance to the uterus. More than 90% of cervical cancers develop due to persistent infection of the human papillomavirus (HPV), which is most often transmitted through sexual intercourse. 21 It is clear that STI are a result of having sexual partners. In another way, having multiple sexual partners escalates the risk of getting HPV, and in turn, can lead to the development of cervical pre-cancer lesions. 13 As well, it is clear that nearly all cases of cervical cancer result from infection with HPV, and the prevention of cervical cancer includes screening and vaccination. 12 Women having a history of bleeding after sexual intercourse were more likely to have precancerous cervical lesions [AOR=2.88(95%CI: 1.43-5.78)] compared to their counterparts. This is in line with a study in Beijing. 31 Bleeding during or after sex can be alarming, especially if the mothers were not menstruating. 32 The most likely causes include a sexually transmitted infection, benign polyps, cervical ectropion, atrophic vaginitis, endometriosis, trauma, and cancer. 33 The results suggest that to prevent precancerous cervical lesions one must consider changes of lifestyle and sexual behavior. 34 Women with parity greater than or equal to five had 2.4 times higher odds of developing precancerous cervical lesion compared to women with parity less than five [AOR=2.41(95%CI: 1.23-4.75)], which is in line with Johannesburg South Africa, 35 this might be due to that high parity increases the risk of squamous-cell carcinoma of the cervix among HPV-positive women. A general decline in parity might therefore partly explain the reduction in cervical cancer recently seen in most countries. 36 Women with an unfavorable attitude had 2.2 times higher odds of developing precancerous cervical lesions compared to women with a favorable attitude [AOR=2.15(95%CI:1.21-3.83)]. This is in line with research done in Hawassa town 36 and an overall score of attitudes was 67.6%. This finding was lower than research conducted among Adama Science and Technology University Female Students which was (71.7 %). This discrepancy might be due to the fact that the study area was urban and also might be due to the educational status of study participants. 37

Precancerous cervical lesions continue to be a significant public health concern in Ethiopia. It will remain a cause of death of women unless effective screening methods like VIA and vaccination to HPV are scaled up. Furthermore, having history of menstrual irregularities, STI, bleeding after coitus, parity greater ≥5, steroid use, and having unfavorable attitude towards screening factors are significantly associated with occurrence of precancerous lesion. This implies that clinicians can play a pivotal role in the prevention of advancement of the lesion to cancer as majority of the factors can be identified during early. Therefore, effective prevention approaches have to consider these factors for the control of cervical cancer in early phase of lesions. ASIR-Age-Standardized Incidence Rate, CIN 2 and CIN 3_Cervical Intraepithelial Neoplasia, CC- Cervical Cancer, DNA –Deoxyribose Nucleic Acid, DALYs -Disability-Adjusted Life-Years, WHO-World Health Organization, HIV- Human Immune-Virus, LSES-Low Socioeconomic Status, OR-Odd Ratio, SSA-Sub-Saharan Africa, STI-Sexually Transmitted Infection, STD-Sexually Transmitted Diseases, NGO- Non-Governmental Organization, HPV-Human Papilloma Virus, VIA- Visual Inspection with Acetic acid

This study was conducted in selected hospitals of West Wollega, which is found in Oromia National Regional State, located at a distance of 441 km from Addis Aba. It has a total population of 1,951,933 (Urban %13 Rural 87%). Five government hospitals, two NGO hospitals, 67 health centers, and 560 public health facilities are currently functional. Data were collected from January 1-February 20/2022. The participants were selected from all women of age 30-49 years’ living in the West Wollega zone, while all selected women of age between 30 and 49 years attending pre-cervical cancer screening at West Wollega Hospitals and selected health centers were studied by institutional-based prospective analytic cross-sectional study design was employed. The sample size was calculated using a single population proportion formula; considering 27.7% as the prevalence of pre-cervical cancer among clients screened in Southern Ethiopia, 3 5% margin of error, and a 10% estimated non–response rate.Where, n = the sample size required.N= Number of householdsP = 27.7% prevalence of pre-cervical cancer among clients screened in Southern Ethiopiad = margin of sampling error tolerated Zα/2 = the standard normal variable at (α-1) or 95% confident level = 1.96 Since the total population is >10,000 no need for a correction formula: The sample size was found to be 308. By adding a 10% non-response rate the final sample size is 339.Hospitals and health centers providing routine cervical cancer screening and treatment using VIA and cryotherapy services were purposively selected . Women aged 30-49 years in four hospitals and five selected health centers were 125,250 (Gimbi General Hospital=24,011, Gimbi Adventist Hospital=19,583, Nedjo General Hospital=22,539, and Aira General Hospital=18,474) (five selected health center =40,643. The calculated sample size was allocated using probability proportional to size (PPS) and finally convenient sampling was used to select the study subjects. Data were collected through face-to-face interviews with a structured questionnaire that was initially adapted from previous studies. 4 The questionnaire was prepared in English, translated to Afan Oromo, and then back to English to check the consistency. Ten BSc nurses and five supervisors were assigned for data collection and supervision. One-day orientation was given for data collectors and supervisors to ensure the quality of the field operation by principal investigators. Supervisors supervised the data collection process on daily bases and check the quality of collected data. The data collection tool was pre-tested on 5% of the sample at Arjo health center. Based on the findings and feedback obtained from the pre-testing process, a modification was made to the questionnaire. The data were entered into Epi-data version 3.2 and analyzed by SPSS version 25.0 for further analysis and interpretation. Descriptive analysis was carried out for each of the variables to check frequency, distribution, and missing values. Variable with a p-value of <.25 on bi-variable analysis were entered into a multivariable logistic regression to identify predictors of pre-cancerous lesion of the cervix. The odds ratio at 95% confidence intervals was used to quantify the degrees of association. Results with a p-value ≤.05 were considered as being statistically significant A positive VIA - as “sharp, distinct, well-defined, dense (opaque, dull, or, oyster white) acetowhite areas with or without raised margins, abutting the squamocolumnar junction in the transformation zone” or “strikingly dense acetowhite areas in the columnar. 1 Good Knowledge : Respondents who scored >the mean value of 75 from total 22 knowledge assessing questions. Poor Knowledge: Respondents who scored ≤ the mean value of 75 from total 22 knowledge assessing questions. Favorable Attitude: respondents who scored>than the mean value of 67 from total 12 attitude assessing questions Unfavorable Attitude : respondents who scored ≤ than the mean value of 67 from total 12 attitude assessing questions Ethical Clearence letter was obtained from the West Wollega Zonal Health Department research, ethics review committee with reference number 199/WEFGL/13, Date-12/12/13, and then a formal letter was written to all Hospitals and health centers included within the study before data collection. All study participants were provided information about the study purpose and confidentiality of information. The participants were informed to withdraw participation at any point if they felt discomfort. Written informed consent was obtained from each study participant.