Determinants of healthcare-seeking behavior among women with symptoms of pelvic organ prolapse in gurage zone  – Nature.com 23:11

Scientific Reports volume 15, Article number: 31948 (2025) Cite this article

Abstract

Pelvic organ prolapse (POP) is relatively common healthcare issue due to its high prevalence, various adverse effects, and challenges for the healthcare system. Women in developing nations are at a higher risk of experiencing this condition. Although POP and its risk factors are more common in low-resource settings, women in these settings often choose not to seek medical attention. Evidence of these women’s health-seeking behavior and its determinants is lacking in Ethiopia; particularly in the study area, no study was reported. The aim of this study was to asses determinants of healthcare-seeking behavior among women with symptoms of pelvic organ prolapse in the Gurage Zone in 2023. From March 1 to March 30, 2023, we conducted a community-based cross-sectional study in the Gurage Zone, utilizing a multi-stage systematic random sampling method to recruit participants. We collected data through structured questionnaires via face-to-face interviews and analyzed it using EpiData version 3.1 and the Statistical Package for the Social Sciences version 25. Logistic regression was employed to examine the relationship between independent variables and healthcare-seeking behavior among women experiencing pelvic organ prolapse symptoms. We incorporated variables with a p-value < 0.25 from the bivariate analysis into the multivariable model, identifying those with a p-value < 0.05 as statistically significant in the final analysis. We assessed the goodness of fit using the Hosmer and Lemeshow test. Results are presented as adjusted odds ratios with a 95% confidence interval. Out of 796 respondents, 248 (31.2%, 95% CI: 27.9, 34.7) of the women had reported symptoms of POP. The study showed that 73.4% (95% CI: [67.7–80.2%]) of women with symptomatic POP did not seek care. The factors associated with not seeking care included being a rural resident (AOR = 5.246; 95% CI [1.824, 13.282]), a lack of social support (AOR = 4.462; 95% CI [1.157, 6.692]), low income (AOR = 2.802; 95% CI [1.132, 7.634]), and fear of disclosure (AOR = 2.400; 95% CI [1.126, 6.261]). Around three quarters of women with symptoms of POP did not seek care. Factors such as residency, low income, lack of support, and fear of disclosure are significantly associated with the decision to seek care for POP symptoms. To address these challenges, it is crucial to implement targeted interventions aimed at improving healthcare access for rural populations, informing policymakers to consider implementing subsidized healthcare services, particularly for vulnerable populations, educational programs aimed at raising involvement of families, encouraging women to disclose their health issues and seek care are recommended by healthcare professionals and other concerned bodies.

Background of the study

Up to 40% of women globally suffer from some kind of anatomical prolapse, making POP a common disorder1. According to the limited number of population-based research studies on POP from low- and middle-income nations that are currently accessible, prevalence rates range from 3–56%1,2,3,4,5. In Ethiopia, the national prevalence of pelvic organ prolapse was 24.02%6.

Although a woman with POP has a variety of adverse results, many of them choose not to seek medical attention7,8. In developing countries, less than one in four women with pelvic floor disorders (PFDs) sought medical attention. Women in those countries often suffer in silence, delaying medical attention until their condition worsens9,10,11. Despite initiatives by non-governmental organizations and the Federal Ministry of Health in Ethiopia to offer free support, many women remain at home, hiding their issues even from close partners. This shows that raising awareness of the disorder and promoting health education are not prioritized12.

Delaying POP therapies essentially makes the situation in Ethiopia worse. Because they are afraid of societal stigma, many women who experience pelvic organ prolapse suffer in silence. A community-based study in the Dabat district of Gondar found that the prevalence of POP was 56.4%. From them, only 3.2% of the patients sought hospital care despite the availability of free services13.

Along with causing severe physical discomfort, POP also ruins romantic and sexual relationships. Because of the condition, women with vaginal prolapse frequently experience physical and verbal abuse from their husbands and mothers-in-law. Some husbands leave or threaten to leave their wives because of the symptoms of POP, while others mistakenly believe it to be a sign of venereal illness. Many women who have the symptoms of POP conceal their condition from others for years out of shyness and fear of the repercussions4,14,15,16.

Health-seeking behavior is influenced by a complex web of determinants (culture, economic status, perceptions, knowledge, belief in efficacy, age, gender roles, and social roles), and it is difficult to isolate the most influential determinants in the decisions to utilize health care. These determinants might be similar across the globe, but they have unique interactions, manifestations, and influences on individuals’ or groups’ lives depending on the individual’s or group’s peculiarities1,9,10,11,12,17,18,19,20. A limited number of studies investigating the reasons for treatment delays among women in Ethiopia indicate that contributing factors may include a lack of support, limited awareness and literacy, insufficient access to treatment centers, low income, and fears about disclosing their issues or facing social stigma15,21. Most POP patients experienced delays in receiving POP therapies. Factors like lack of support, low-income, and fear of losing social value/stigma were associated with treatment delay15,22,23,24.

Assessing healthcare-seeking behavior among women with symptoms of POP is crucial for identifying mothers who do not seek medical attention and understanding the associated consequences. In Ethiopia, POP appeared to be prevalent, but little published evidence exists regarding women’s healthcare-seeking behavior for symptomatic POP. Therefore, this study is aimed at determining the factors influencing healthcare-seeking behavior among women with pelvic organ prolapse symptoms in the Gurage Zone, Ethiopia.

Methods and materials

Study area and period

Our study was conducted in the Gurage Zone of central Ethiopia from March 1 to 30, 2023, which includes five town administrations and 16 districts, with Wolkite as its capital, 153 km from Addis Ababa. According to the 2007 census, the Gurage Zone has a population of 1,419,831, comprising 657,568 women and 62,078 men. According to the data obtained from the Zonal Health Department, there are seven public hospitals, 72 health centers and 412 Health posts in the zone.

Study design and population

We conducted a community-based cross-sectional study with sampled women who had POP in the Gurage zone and met the inclusion criteria during data collection via face-to-face interviews using structured questionnaire. The study included all ever-married women who are above 18 years with POP during the study period, while excluding those who unable to respond to the questionnaire due to severe illness and had a mental disability were excluded from the study.

Sample size and sampling procedure

The sample size was calculated using a single proportion formula, applying a 95% confidence interval (Z = 1.96) and a 5% margin of error. The proportion of women who sought care for POP in eastern Ethiopia is 40.3%12. A 10% non-response rate was considered and incorporated into the sample size calculation, resulting in an adjusted size of 407. The final sample size for this study was 814 due to design effect. The sample size was determined using a design effect of 2.

A multi-stage systematic random sampling procedure was employed to enroll the study population. From the woredas (administrative divisions in Ethiopia, similar to districts) and town administrations in the zone, four woredas were selected using a simple random sampling technique (SRST) through the lottery method: Edegagn woreda (17 kebeles), Geta woreda (16 kebeles), East Meskan woreda (15 kebeles), and South Sodo (17 kebeles). Subsequently, four kebeles (the smallest administrative units in Ethiopia) were chosen from each woreda, along with two kebeles from Wolkite town, also selected by SRST. Data collection was conducted through a house-to-house survey.

A Gurage zone is conveniently selected as a study area based on the study’s goals, feasibility, and the easy accessibility of participants. The sample was proportionally allocated to each woreda and kebele of the selected woredas according to household size.

Variables of the study

Dependent variable

Health care seeking behavior for POP.

Independent variable

Age of respondents, residency, religion, marital status, educational status, accessibility of health care services, behaviour of health care providers, social support, cultural influence, lack of transportation, and stigma.

Operational definition

POP: The presence of POP was identified by participants who responded “YES” to the question, “Do you have a bulge or something that you can see or feel in your vaginal area?”11.

Health-care seeking behavior for POP: Was assessed by the following question, “Have you ever sought care/help for POP?” “There were just two possible answers: “Yes” or “No”. Participants who gave a “yes” response were considered to have “sought care for disorder”, whereas those who gave a “no” response were considered to have “not sought care for disorder” for POP12.

Data collection tool and procedure

The data collection tool was developed by reviewing relevant literature. A group of researchers assessed the questionnaire to refine and enhance the items contained within it. The questionnaire used to assess the outcome variable (health-seeking behaviors among women with POP was adapted from different literature. Other explanatory variables, including socio-demography and other related conditions of study participants, were also collected using a structured questionnaire adapted from a health-related national survey25. We collected reasons for not seeking healthcare using close-ended questions in the questionnaire.

Ten data collectors and two supervisors were recruited. Two days of training were given on the study’s overall objective, questionnaire clarification, sampling strategy, and ethical considerations.

The English version of the original questionnaire was translated into local languages for data collection. At the interviewee’s home, the data collectors conducted the interviews quietly and without attracting attention.

Data quality management

To ensure data quality, we meticulously designed the questionnaire, ensuring that the questions were clear, the structure was logical, and the response options were suitable. We conducted a pre-test on 5% of the estimated total sample size outside the study area to enhance the tool’s alignment with social and cultural norms and to evaluate its clarity, sequence, and consistency. Subsequently, any ambiguities, complex words, and variations in understanding were addressed based on the pretest findings. Each questionnaire was assigned a unique identifying number.

We delivered comprehensive training to data collectors and supervisors covering the data collection procedures, ethical considerations for participants, potential risks to data validity if expectations were not met, and a detailed overview of each question in the study. To obtain informed consent and ensure reliable data, we offered participants a clear explanation of the study’s purpose, methods, confidentiality measures, and benefits. The principal investigator and supervisors closely monitored and reviewed all questionnaires on-site to ensure the completeness and consistency of the information collected. They took immediate corrective measures if any inconsistencies arose.

Finally, after verifying the completeness and clarity of the data, we assigned a unique identification number to the questionnaire and entered the data into the software. We used Epi-data for data entry because of its error detection capabilities. Two separate data clerks performed double data entry, and we cross-checked the consistency of the entered data by comparing the two sets. We kept the data in a secure location accessible only to the principal investigator. We conducted simple frequencies and cross-tabulations to detect missing values and outliers, and we confirmed these results by comparing them with the hard copies of the collected data.

Data processing and analysis

Following data collection, we checked the questionnaire for completeness, coded the responses, entered them into Epi-Data, and performed cleaning before exporting the data to SPSS Version 25 for analysis. We performed univariable, bivariable, and multivariable logistic regression analyses to investigate the relationships between the independent and dependent variables.

In the univariable analysis, we conducted a descriptive statistical analysis that included simple frequencies, measures of central tendency, and measures of variation to summarise and describe the characteristics of the study participants. The findings for categorical variables were displayed using frequencies with percentages, along with pie charts and bar graphs.

In the bivariable analysis, we utilized crude odds ratios with a 95% confidence interval to examine the associations between independent and dependent variables through binary logistic regression. The results were expressed as proportions and presented as crude odds ratios (COR) to indicate the strength of these associations. Independent variables with a p-value of less than 0.25 at a 95% confidence interval in the bivariable analysis, which were suitable for the regression model, were selected as candidates for multivariable logistic regression analysis to account for confounding factors.

We assessed multicollinearity to examine the linear relationships between the related independent variables using the variance inflation factor (VIF) and standard error. Variables with a VIF exceeding 10 or a standard error above 2 were excluded from the multivariable analysis. We conducted the Hosmer-Lemeshow test and the Omnibus test to evaluate the model’s fit.

We calculated the Adjusted Odds Ratio (AOR) with a 95% confidence interval (CI) to show the relationship between the independent and dependent variables while accounting for confounding factors. Variables with a P-value ≤ 0.05 were declared as having a statistically significant association with the outcome variable. Finally, results from SPSS were interpreted, the conclusion was drawn, and a recommendation was forwarded to the concerned bodies.

Results

Socio-demographic characteristics

The mean age of the participants was 34.74 years (± 7.971 SD). Among them, 430 individuals (54%) fell within the 25–34 age range. The largest group represented was from the Gurage ethnic community. Additionally, 457 participants (57.4%) identified as Muslim. A significant portion, 63.3%, resided in rural areas. Of the participants, 678 (85.2%) were married, while 584 (73.4%) were housewives. Furthermore, 465 participants (58.4%) had no formal education, and most earned a monthly income of less than 4000 (Table 1).Table 1 Distribution of the study participants by their Socio-demographic characteristics, gurage zone, central Ethiopia March 01 to March 30, 2023.

Full size table

Women’s response with an experience of distress symptoms

A bulge in the vaginal area was the leading pelvic organ distress as reported by 248 (31.2%) women, followed by incomplete bladder emptying after voiding, which was reported by 245 (30.8%) women (Table 2). .Table 2 Outcome distress symptoms responses related to POP of women in gurage zone, central Ethiopia March 01 to March 30, 2023.

Full size table

Prevalence of symptomatic POP among study participants

Two hundred forty-eight (31.2%, 95% CI: 27.9, 34.7) of the women had reported POP prolapse (Table 3).Table 3 Prevalence of symptomatic POP among study participants, gurage zone, central Ethiopia March 01 to March 30, 2023.

Full size table

Health care seeking behavior among study participants

From 248 of the women who had reported of POP; 182 (73.4%) did not seek healthcare (Table 4).Table 4 Health care seeking behavior among study participants, gurage zone, central Ethiopia March 01 to March 30, 2023.

Full size table

Reasons for not seeking health care among study participants

Out of 248 women who reported experiencing a POP, 182 (73.4%) did not seek healthcare (Table 4). Among these 182 participants, 116 (63.7%) indicated that low income was a reason for their decision, 67 (36.8%) attributed their avoidance to cultural influences, and 59 (32.4%) mentioned fear of disclosing their condition to healthcare providers.

Percent represents the percentage of women among the 182 women who did not seek medical advice. Some women might have reported more than one reason (Table 5).Table 5 Reasons for not seeking health care among study participants, gurage zone, central Ethiopia March 01 to March 30, 2023.

Full size table

Factors associated with care seeking for POP

In the bivariate analysis, respondents’ residency, social support, income, inaccessibility to health care services, fear of disclosure, and fear of stigma were associated with the outcome variables and were thus included in the multivariable model. In the multivariable model, residency, social support, income, and fear of disclosure were significantly associated with care-seeking behavior for POP as shown in the following table.

The factors associated with care-seeking for POP are presented in Table 6. The prevalence of not seeking care for POP was 3.282 times higher among women without social support compared to those with social support. Women with low income were more likely not to seek care for POP (AOR 2.802, 95% CI 1.132–7.634) compared to women with high income. Additionally, those who feared disclosing their condition were 2.4 times more likely not to seek care for POP than those who did not fear disclosure (AOR 2.400, 95% CI1.126–6.261) (see Table 6).Table 6 Factors associated with care seeking for POP among study participants, gurage zone, central Ethiopia March 01 to March 30, 2023.

Full size table

Discussion

Healthcare-seeking behavior for POP is poorly understood in Ethiopia due to a scarcity of research on this topic. This study is one of the few community-based cross-sectional studies conducted in the Gurage Zone, Ethiopia, aimed at assessing the determinants of healthcare-seeking behavior among women with symptoms of POP, using a pre-tested structured questionnaire.

This study revealed that three quarters of the participants did not seek care for POP, with a prevalence of 73.6% (95% CI: 67.7–80.2). Factors associated with care-seeking for POP included being a rural resident, lack of support, low income, and fear of disclosure.

The overall prevalence was consistent with a study conducted in Pakistan, where 20.5% of participants sought care. This finding is higher than that of a study conducted in eastern Ethiopia, which reported a prevalence of 59.6%, and a study in Nepal20. In contrast, this prevalence is lower than that reported in the Wolaita Zone (82.0%) and among participants in selected general and referral hospitals in Southern Ethiopia, where 84.6% experienced delays in receiving treatment for POP15. The differences in prevalence may be due to variations in study methodologies, such as sample sizes, the age groups of women involved, and the specific study settings.

Being a rural resident was a significant factor in care-seeking for POP. Our study found that women in rural areas were over five times more likely not to seek care compared to their counterparts. This supports previous research indicating that rural living is a major barrier to seeking care for POP18, likely due to lower education levels and a lack of prioritization of health among rural women in Ethiopia. The implications of this finding are profound. To address these challenges, it is crucial to implement targeted interventions aimed at improving healthcare access for rural populations.

Another important finding from this research is that women without family support were three times more likely not to seek care for POP compared to those with family support. This aligns with a study conducted in Southern Ethiopia15. This may be attributed to the family structure and decision-making processes prevalent in our society. The implications of this finding are significant. Women who lack support from their families may feel isolated and discouraged from seeking medical care, which can lead to worsened health outcomes. To address this, community health initiatives should focus on educating families about POP and the importance of supporting affected individuals. Additionally, healthcare providers should be trained to recognize the role of family dynamics in patient care. Ultimately, addressing the barriers posed by a lack of family support requires a multifaceted approach that includes education, community engagement, and policy interventions aimed at fostering supportive family structures.

Women with low income were less likely to seek care than those with higher income. A study conducted in Southern Ethiopia found that low-income women were nearly six times more likely to delay treatment for POP15. This finding is corroborated by a study conducted in Nepal20. The reluctance to seek care may arise from financial constraints, as low-income women often struggle to afford health services, transportation, and associated costs. In contrast, another study indicated that financial issues were not a significant barrier to seeking care, as their society provides free access to healthcare at various levels4. This highlights a critical need for targeted interventions. Policymakers should consider implementing subsidized healthcare services, particularly for vulnerable populations, ensuring that financial barriers do not prevent women from accessing necessary care.

We found that fear of disclosing their condition was associated with not seeking care for POP. Our findings align with studies conducted in Gondar, the UAE, and the Wolaita Zone4,14, which reported that shyness or fear of discussing POP symptoms with healthcare providers was one of the strongest determinants of care-seeking behavior. This may be attributed to social expectations, discrimination, and fear of rejection by husbands, and minimal social support following disclosure of their condition. Educational programs aimed at raising awareness about POP and its treatment options could empower women to seek help. Furthermore, involving families in these discussions may foster a supportive environment, encouraging women to disclose their health issues and seek care.

The strengths of our study include its community-based design, high response rate, large sample size, careful development of a pre-tested structured questionnaire, and quality control in data collection. A key limitation is that causality cannot be established due to the cross-sectional nature of the study. Recall and reporting bias may have occurred, as we assessed the outcome based on women’s self-reported symptoms. Additionally, the identification of POP symptoms by healthcare providers may have introduced bias. Future research should consider longitudinal designs to better establish causal relationships and employ both objective measures and self-reported data to minimize bias.

Conclusion

Although symptoms of POP affect quality of life in many ways, approximately three quarters of women experiencing these symptoms do not seek care. Factors such as residency, low income, lack of support, and fear of disclosure are significantly associated with the decision to seek care for POP symptoms.

To improve care-seeking for POP and enhance the quality of life for women, it is essential to address the factors significantly associated with seeking care. These findings will aid in designing an educational program and strategies aimed at raising awareness about the factors that facilitate care-seeking behavior.

Our findings emphasize the critical need for policies that educate women on improving healthcare-seeking behaviors in Ethiopia. It is also important to implement strategies such as increasing community income, providing free access to healthcare, enhancing social support, and raising awareness in rural areas. Healthcare professionals are vital in promoting understanding of modifiable risk factors.

Data availability

Data sets used in this study are available from the corresponding author upon reasonable request.

Abbreviations

AOR:

Adjusted Odds RatioCOR:

Crude Odds RatioETB:

Ethiopian birrCI:

confidence IntervalPFD:

Pelvic floor disorderPOP:

Pelvic Organ Prolapse SPSS-Statistical Package for Social ScienceWKUSH:

Wolkite University Specialized Hospital

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Acknowledgements

We express our gratitude to Wolkite University and the study settings for their cooperation. The clients who participated were the cornerstone of this study, and we thank them for their involvement. We also extend our appreciation to the data collectors and supervisors for their contributions.

Funding

Wolkite University provides us financial support.

Author information

Authors and Affiliations

  1. Department of Nursing, College of Medicine and Health Sciences, Wolkite University, Wolkite, EthiopiaAyana Benti Terefe, Tolesa Gemeda Gudeta & Girma Teferi Mengistu
  2. School of Medicine, College of Medicine and Health Sciences, Wolkite University, Wolkite, EthiopiaBethelhem Sileshy Ayalnew
  3. Department of Pharmacy, College of Medicine and Health Sciences, Wolkite University, Wolkite, EthiopiaGetu Habte Mamo
  4. Department of Midwifery, College of Medicine and Health Sciences, Wolkite University, Wolkite, EthiopiaMangistu Abera & Seboka Abebe Sori

Contributions

ABT: Think of the research idea and proposal development, supervise the data collection process, conduct the analysis, and write the manuscript. BSA: Involved in proposal development, and data analysis, and wrote the manuscript. TGG, GTM, SAS, MAM and GHM: involved in data analysis, result writing, and writing the manuscript. All authors read and approved the final.

Corresponding author

Correspondence to Ayana Benti Terefe.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethical approval

All methods were conducted in accordance with the relevant guidelines and regulations. The study protocol was approved by the [Wolkite University]. Informed voluntary consent was obtained from all study participants. The technical proposal for this study was submitted to the Institutional Health Research Ethics Review Committee (IHRERC) at Wolkite University, College of Health and Medical Sciences with reference number RCSUILC/022/15, where it received ethical clearance and approval. Following this, an official letter of cooperation was issued to the Gurage Zone Administration Health Office to facilitate the research. Subsequently, the Gurage Zone Administration Health Office sent letters of cooperation to the selected woredas. Written consent was obtained from all study participants.

Informed consent

Information about the study was provided to participants, including its potential disadvantages and benefits. They were informed of their right to refuse or withdraw from the study at any time without any negative consequences. Participants’ confidentiality was ensured by omitting names from the questionnaires, and the information collected was used solely for the stated purposes of the study. Data collection occurred only after obtaining written and signed voluntary consent from participants, and only those who signed the consent were included in the study.

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It is not relevant because this manuscript cannot hold a person’s data in any form (including individual details images or videos).

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Cite this article

Terefe, A.B., Ayalnew, B.S., Gudeta, T.G. et al. Determinants of healthcare-seeking behavior among women with symptoms of pelvic organ prolapse in gurage zone. Sci Rep 15, 31948 (2025). https://doi.org/10.1038/s41598-025-17194-9

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