A scoping review: Facilitators and barriers of cervical cancer screening and early diagnosis of breast cancer in Sub-Saharan African health settings

Baseline assessment of cervical cancer screening and treatment capacity in 25 counties in Kenya, 2022

Background

Cervical cancer is the leading cause of cancer deaths among women in Kenya. In the context of the Global strategy to accelerate the elimination of cervical cancer as a public health problem, Kenya is currently implementing screening and treatment scale-up. For effectively tracking the scale-up, a baseline assessment of cervical cancer screening and treatment service availability and readiness was conducted in 25 priority counties. We describe the findings of this assessment in the context of elimination efforts in Kenya.

Methods

The survey was conducted from February 2021 to January 2022. All public hospitals in the target counties were included. We utilized healthcare workers trained in preparation for the scale-up as data collectors in each sub-county. Two electronic survey questionnaires (screening and treatment; and laboratory components) were used for data collection. All the health system building blocks were assessed. We used descriptive statistics to summarize the main service readiness indicators.

Results

Of 3,150 hospitals surveyed, 47.6% (1,499) offered cervical cancer screening only, while 5.3% (166) offered both screening and treatment for precancer lesions. Visual inspection with acetic acid (VIA) was used in 96.0% (1,599/1,665) of the hospitals as primary screening modality and HPV testing was available in 31 (1.0%) hospitals. Among the 166 hospitals offering treatment for precancerous lesions, 79.5% (132/166) used cryotherapy, 18.7% (31/166) performed thermal ablation and 25.3% (42/166) performed large loop excision of the transformation zone (LLETZ). Pathology services were offered in only 7.1% (17/238) of the hospitals expected to have the service (level 4 and above). Only 10.8% (2,955/27,363) of healthcare workers were trained in cervical cancer screening and treatment; of these, 71.0% (2,097/2,955) were offering the services. Less than half of the hospitals had cervical cancer screening and treatment commodities at time of survey. The main health system strength was presence of multiple screening points at hospitals, but frequent commodity stock-outs was a key weakness.

Conclusion

Training, commodities, and diagnostic services are major gaps in the cervical cancer program in Kenya. To meet the 2030 elimination targets, the national and county governments should ensure adequate financing, training, and service integration, especially at primary care level.

Integration of cervical cancer screening into healthcare facilities in low- and middle-income countries: A scoping review

Cervical cancer is a prevalent disease among women, especially in low- and middle-income countries (LMICs), where most deaths occur. Integrating cervical cancer screening services into healthcare facilities is essential in combating the disease. Thus, this review aims to map evidence related to integrating cervical cancer screening into existing primary care services and identify associated barriers and facilitators in LMICs. The scoping review employed a five-step framework as proposed by Arksey and O'Malley. Five databases (MEDLINE, Maternity Infant Care, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science) were systematically searched. Data were extracted, charted, synthesized, and summarised. A total of 28 original articles conducted in LMICs from 2000 to 2023 were included. Thirty-nine percent of the reviewed studies showed that cervical cancer screening (CCS) was integrated into HIV clinics. The rest of the papers revealed that CCS was integrated into existing reproductive and sexual health clinics, maternal and child health, family planning, well-baby clinics, maternal health clinics, gynecology outpatient departments, and sexually transmitted infections clinics. The cost-effectiveness of integrated services, promotion, and international initiatives were identified as facilitators while resource scarcity, lack of skilled staff, high client loads, lack of preventive oncology policy, territorial disputes, and lack of national guidelines were identified as barriers to the services. The evidence suggests that CCS can be integrated into healthcare facilities in LMICs, in various primary care services, including HIV clinics, reproductive and sexual health clinics, well-baby clinics, maternal health clinics, and gynecology OPDs. However, barriers include limited health system capacity, workload, waiting times, and lack of coordination. Addressing these gaps could strengthen the successful integration of CCS into primary care services and improve cervical cancer prevention and treatment outcomes.

Drivers of cervical cancer prevention and management in sub-Saharan Africa: a qualitative synthesis of mixed studies

BACKGROUND

Cervical cancer is a public health concern in the sub-Saharan Africa region. Cervical cancer screening is one of the strategies for detecting early precancerous lesions. However, many women have poor access to and utilization of screening services in the region. This review aimed to synthesize evidence on the challenges and opportunities of screening, early detection and  management of cervical cancer in sub-Saharan Africa.

METHODS

We conducted a structured narrative review of studies published in English. We included studies published from 1 January 2013 to mid-2022. Studies were selected following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Key search terms (detractors and enablers, cervical cancer screening, sub-Saharan Africa) were employed to identify studies from three electronic databases (HINARI, Science Direct, and PubMed). We also conducted searches on Google Scholar to identify relevant grey literatures. A thematic analysis was conducted and themes were identified, then explained using a socio-ecological framework (intrapersonal, interpersonal, organizational, community, policy levels).

RESULTS

We identified 60 studies in the final review. Cervical cancer screening and early detection and management programmes are influenced by drivers at multiple levels. Individual-level drivers included a lack of knowledge about cervical cancer and screening literacy, and a low risk in perception, attitude, susceptibility and perceived fear of test results, as well as sociodemographic characteristics of women. Interpersonal drivers were community embarrassment, women's relationships with health workers, support and encouragement, the presence of peers or relatives to model preventive behaviour, and the mothers' networks with others. At the organizational level, influencing factors were related to providers (cervical cancer screening practice, training, providers' profession type, skill of counselling and sex, expert recommendation and work commitments). At the community level, drivers of cervical cancer screening included stigma, social-cultural norms, social networks and beliefs. System- and policy-level drivers were lack of nearby facilities and geographic remoteness, resource allocation and logistics management, cost of screening, promotion policy, ownership and management, lack of decentralized cancer policy and lack of friendly infrastructure.

CONCLUSIONS

There were several drivers in the implementation of cervical cancer screening programmes at multiple levels. Prevention and management of cervical cancer programmes requires multilevel strategies to be implemented  across the individual level (users), community and organizational levels (providers and community users), and system and policy levels. The design and implementation of policies and programmes need to address the multilevel challenges.

Cervical Cancer Screening Uptake and Experiences of Black African Immigrant Women in Canada

Cervical cancer is one of the leading causes of cancer-related death among African women. Unfortunately, in most sub-Saharan African nations, women are vulnerable if they are unaware that cervical cancer is preventable with frequent screening and early treatment. The aim of this study was to examine Black African immigrant women's perceptions and experiences of cervical screening in British Columbia, Canada. Twenty Black African immigrant women were interviewed using the qualitative research method Interpretive Description. Data collection approaches included indepth interviews and analytic memos. Data were analyzed using a constant comparative technique guided by a socioecologic framework to capture subjective experiences and perceptions. Four key themes were identified, including confusing conceptualizations about cancer and cancer screening, competing priorities, concerns for modesty, and commitment to culture. The study findings point to the need for more active approaches to promoting cervical screening for this population.

Stigma and Social Determinants of Health Associated With Fidelity to Guideline-Concordant Therapy in Patients With Breast Cancer Living With and Without HIV in Botswana

BACKGROUND

Patients with breast cancer in sub-Saharan Africa (SSA) experience a disproportionate burden of mortality. Fidelity to treatment guidelines, defined as receiving optimal dose and frequency of prescribed treatments, improves survival. We sought to identify patient factors associated with treatment fidelity and how this may differ for people with HIV (PWH) and breast cancer.

METHODS

We conducted a qualitative study of women who initiated outpatient treatment for stages I-III breast cancer in Botswana, with deviance sampling of high- and low-fidelity patients. One-on-one interviews were conducted using semi-structured guides informed by the Theory of Planned Behavior. The sample size was determined by thematic saturation. Transcribed interviews were double coded with an integrated analytic approach.

RESULTS

We enrolled 15 high- and 15 low-fidelity participants from August 25, 2020 to December 15, 2020, including 10 PWH (4 high, 6 low fidelity). Ninety-three percent had stage III disease. Barriers to treatment fidelity included stigma, social determinants of health (SDOH), and health system barriers. Acceptance and de-stigmatization, peer and other social support, increased knowledge and self-efficacy were identified as facilitators. The COVID-19 pandemic amplified existing socioeconomic stressors. Unique barriers and facilitators identified by PWH included intersectional stigma, and HIV and cancer care integration, respectively.

CONCLUSION

We identified multilevel modifiable patient and health system factors associated with fidelity. The facilitators provide opportunities for leveraging existing strengths within the Botswana context to design implementation strategies to increase treatment fidelity to guideline-concordant breast cancer therapy. However, PWH experienced unique barriers, suggesting that interventions to address fidelity may need to be tailored to specific comorbidities.

Patients' experiences undergoing breast evaluation in Rwanda's Women's Cancer Early Detection Program

PURPOSE

There is urgent need for interventions to facilitate earlier diagnosis of breast cancer in low- and middle-income countries where mammography screening is not widely available. Understanding patients' experiences with early detection efforts, whether they are ultimately diagnosed with cancer or benign disease, is critical to optimize interventions and maximize community engagement. We sought to understand the experiences of patients undergoing breast evaluation in Rwanda's Women's Cancer Early Detection Program (WCEDP).

METHODS

We conducted in-person semi-structured interviews with 30 patients in two districts of Rwanda participating in the WCEDP. Patients represented a range of ages and both benign and malignant diagnoses. Interviews were recorded, transcribed, translated, and thematically analyzed.

RESULTS

Participants identified facilitators and barriers of timely care along the breast evaluation pathway. Community awareness initiatives were facilitators to care-seeking, while persistent myths and stigma about cancer were barriers. Participants valued clear clinician-patient communication and emotional support from clinicians and peers. Poverty was a major barrier for participants who described difficulty paying for transport, insurance premiums, and other direct and indirect costs of hospital referrals in particular. COVID-19 lockdowns caused delays for referred patients. Although false-positive clinical breast exams conferred financial and emotional burdens, participants nonetheless voiced appreciation for their experience and felt empowered to monitor their own breast health and share knowledge with others.

CONCLUSION

Rwandan women experienced both benefits and burdens as they underwent breast evaluation. Enthusiasm for participation was not reduced by the experience of a false-positive result. Reducing financial, logistical and emotional burdens of the breast diagnostic pathway through patient navigation, peer support and decentralization of diagnostic services could improve patients' experience.

Knowledge about Cervical Cancer Prevention and Screening in Women with Cervical Cancer Attending Gynecological Services in Southern Mozambique

BACKGROUND

Mozambique has high rates of cervical cancer and cancer-related deaths among women. A high rate of refusal and low acceptance of treatment is observed among cervical cancer patients. The extent of their knowledge of the disease is unknown.

OBJECTIVES

To assess knowledge about this disease (prevention, risk factors, and the possibilities of early diagnosis) in women with cervical cancer attended in gynecological services in Gaza province, Mozambique.

MATERIALS AND METHODS

This cross-sectional study took place in the city of Xai-Xai at the Provincial Hospital of Xai-Xai (HPXX) in the southern province of Gaza (Mozambique). Non-probability convenience sampling was used. Eligible patients (women) aged 35-50 years, diagnosed with cervical cancer and followed at the HPXX in the second quarter of 2021 (n = 60), took part in the survey during their scheduled consultations. Descriptive statistics were calculated using SPSS statistical software (version 16).

RESULTS

The study included 60 women, 39 (65%) HIV positive. More than half (55.0%) believed that having a single sexual partner was an effective form of prevention; 50.0% reported that excessive alcohol consumption and having many sexual partners could cause the disease, and 46.7% affirmed that having many children increased the risk. Thirty-eight (63.3%) women reported that early diagnosis of cervical cancer was important for receiving prompt treatment, and 54 (90.0%) said regular visits to the gynecologist were important for an early diagnosis. Thirty-five (58.3%) mentioned acetic acid screening as a diagnostic test.

CONCLUSIONS

There are significant gaps in awareness of cervical cancer among high-risk groups.

Barriers and enablers of breast cancer screening among women in East Africa: a systematic review

BACKGROUND

Breast cancer is among the most common cancers globally with a projected increase in incidence and mortality in low- and middle-income countries. The majority of the patients in East Africa present with advanced disease contributing to poor disease outcomes. Breast cancer screening enables earlier detection of the disease and therefore reduces the poor outcomes associated with the disease. This study aims to identify and synthesize the reported barriers and enablers of breast cancer screening among East African women.

METHODS

Medline, Embase, SCOPUS, and Cochrane library were searched for articles published on the subject from start to March 2022 using PRISMA guidelines. Also, forward citation, manual search of references and searching of relevant journals were done. A thematic synthesis was carried out on the "results/findings" sections of the identified qualitative papers followed by a multi-source synthesis with quantitative findings.

RESULTS

Of 4560 records identified, 51 were included in the review (5 qualitative and 46 quantitative), representing 33,523 women. Thematic synthesis identified two major themes - "Should I participate in breast cancer screening?" and "Is breast cancer screening worth it?". Knowledge of breast cancer and breast cancer screening among women was identified as the most influencing factor.

CONCLUSION

This review provides a rich description of factors influencing uptake of breast cancer screening among East African women. Findings from this review suggest that improving knowledge and awareness among both the public and providers may be the most effective strategy to improve breast cancer screening in Eastern Africa.

The roles of chaplains in dispelling cancer myths in Nigeria: A narrative review

Background and Aims

The epidemiological burden of cancer in Africa, and Nigeria in particular, has been increasing significantly over the past few decades due to exposure to numerous risk factors as well as belief in various myths and misconceptions. Chaplains can play crucial roles in dispelling these myths and misconceptions about cancer among people. Therefore, this study seeks to review the epidemiological burden, risk factors, and myths relating to cancer and the roles of chaplains in dispelling cancer myths in Nigeria.

Methods

This paper is a narrative review that relied on secondary sources obtained through a thorough literature search of relevant articles on multiple electronic databases including PubMed, Google Scholar, and Web of Science. Published books, journal articles, and other published materials that were written in English were consulted in line with the objectives of this study. Both theoretical and empirical papers were used for this review.

Results

Cancers are associated with risk factors including exposure to chemicals, ultraviolet radiation, harmful tobacco and alcohol use, exposure to human papillomavirus (HPV), and these factors may vary with age, cultural beliefs (myths and misconceptions), and socioeconomic factors among others. Chaplains, however, have crucial roles to play in dispelling cancer myths in Nigeria. These roles include counseling, advocacy, education, and psycho-social support which may be limited by challenges such as spiritual ambiguity, inadequate training of healthcare providers and limited time/resources. These challenges can be addressed by training healthcare providers and incorporating chaplain practice in Nigerian healthcare.

Conclusion

The role of chaplains in dispelling cancer myths in Nigeria is crucial despite the numerous challenges. Hence, an urgent address of these challenges will be instrumental in ensuring effective chaplain practice in Nigeria.

Early cervical cancer screening: The influence of culture and religion

BACKGROUND

Screening for cervical cancer at an early stage is essential for providing women with a better chance of receiving effective treatment for both precancers and cancer. Delaying screening until cancer has advanced can be detrimental, resulting in late presentation of cervical cancer and, as a result, cancer metastasis.

AIM

The purpose of this study was to assess the extent to which culture and religion influence early cervical cancer screening in women.

SETTING

The research was conducted in one of the rural districts in Manicaland Province of Zimbabwe.

METHODS

A qualitative exploratory and contextual design was utilised, and data were gathered by means of semistructured interviews. At 17 semistructured interviews, data saturation was reached and further data collection terminated. Data were thematically analysed.

RESULTS

Five themes that described participants' perceptions on culture and religion as barriers to early cervical cancer screening emerged from the data. These included a lack of knowledge, stigmatisation, cultural beliefs and values, religion and a lack of resources. These all negatively affected participants' motivation to seek early screening services.

CONCLUSION

According to the study findings, culture and religion constitute impediments to early cervical cancer screening for rural women. Interventions that encourage screening, such as targeted health education and health promotion materials, must consider cultural and religious views if behaviour change in diverse groups is to be accomplished.Contribution: The study has the potential to inform Zimbabwean health policy and contribute to prospective interventions or health education that encourage women to attend early cancer screening.

A qualitative study to explore healthcare providers' perspectives on barriers and enablers to early detection of breast and cervical cancers among women attending primary healthcare clinics in Johannesburg, South Africa

Low-and-middle income countries (LMICs) contribute approximately 70% of global cancer deaths, and the cancer incidence in these countries is rapidly increasing. Sub-Saharan African (SSA) countries, including South Africa (SA), bear some of the world's highest cancer case fatality rates, largely attributed to late diagnosis. We explored contextual enablers and barriers for early detection of breast and cervical cancers according to facility managers and clinical staff at primary healthcare clinics in the Soweto neighbourhood of Johannesburg, South Africa. We conducted qualitative in-depth interviews (IDIs) between August and November 2021 amongst 13 healthcare provider nurses and doctors as well as 9 facility managers at eight public healthcare clinics in Johannesburg. IDIs were audio-recorded, transcribed verbatim, and entered into NVIVO for framework data analysis. Analysis was stratified by healthcare provider role and identified apriori around the themes of barriers and facilitators for early detection and management of breast and cervical cancers. Findings were conceptualised within the socioecological model and then explored within the capability, opportunity and motivation model of behaviour (COM-B) for pathways that potentially influence the low screening provision and uptake. The findings revealed provider perceptions of insufficient South African Department of Health (SA DOH) training support and staff rotations resulting in providers lacking knowledge and skills on cancer, screening policies and techniques. This coupled with provider perceptions of poor patient cancer and screening knowledge revealed low capacity for cancer screening. Providers also perceived opportunity for cancer screening to be undermined by the limited screening services mandated by the SA DOH, insufficient providers, inadequate facilities, supplies and barriers to accessing laboratory results. Providers perceived women to prefer to self-medicate and consult with traditional healers and access primary care for curative services only. These findings compound the low opportunity to provide and demand cancer screening services. And because the National SA Health Department is perceived by providers not to prioritize cancer nor involve primary care stakeholders in policy and performance indicator development, overworked, unwelcoming providers have little motivation to learn screening skills and provide screening services. Providers reported that patients preferred to go elsewhere and that women perceived cervical cancer screening as painful. These perceptions must be confirmed for veracity among policy and patient stakeholders. Nevertheless, cost-effective interventions can be implemented to address these perceived barriers including multistakeholder education, mobile and tent screening facilities and using existing community fieldworkers and NGO partners in providing screening services. Our results revealed provider perspectives of complex barriers to the early detection and management of breast and cervical cancers in primary health clinic settings in Greater Soweto. These barriers together appear potentially to produce compounding effects, and therefore there is a need to research the cumulative impact but also engage with stakeholder groups to verify findings and create awareness. Additionally, opportunities do exist to intervene across the cancer care continuum in South Africa to address these barriers by improving the quality and volume of provider cancer screening services, and in turn, increasing the community demand and uptake for these services.

Regional and country-level trends in cervical cancer screening coverage in sub-Saharan Africa: A systematic analysis of population-based surveys (2000-2020)

BACKGROUND

Sub-Saharan Africa (SSA) has the highest cervical cancer (CC) burden globally-worsened by its HIV epidemics. In 2020, the World Health Organization (WHO) introduced a CC elimination strategy with goals for vaccination, screening, and treatment. To benchmark progress, we examined temporal trends in screening coverage, percent screened at least twice by the age of 45, screening coverage among women living with HIV (WLHIV), and pre-cancer treatment coverage in SSA.

METHODS AND FINDINGS

We conducted a systematic analysis of cross-sectional population-based surveys. It included 52 surveys from 28 countries (2000 to 2020) with information on CC screening among women aged 25 to 49 years (N = 151,338 women). We estimated lifetime and past 3-year screening coverage by age, year, country, and HIV serostatus using a Bayesian multilevel model. Post-stratification and imputations were done to obtain aggregate national, regional, and SSA-level estimates. To measure re-screening by age 45, a life table model was developed. Finally, self-reported pre-cancer treatment coverage was pooled across surveys using a Bayesian meta-analysis. Overall, an estimated 14% (95% credible intervals [95% CrI]: 11% to 21%) of women aged 30 to 49 years had ever been screened for CC in 2020, with important regional and country-level differences. In Eastern and Western/Central Africa, regional screening coverages remained constant from 2000 to 2020 and WLHIV had greater odds of being screened compared to women without HIV. In Southern Africa, however, screening coverages increased and WLHIV had equal odds of screening. Notably this region was found to have higher screening coverage in comparison to other African regions. Rescreening rates were high among women who have already been screened; however, it was estimated that only 12% (95% CrI: 10% to 18%) of women had been screened twice or more by age 45 in 2020. Finally, treatment coverage among 4 countries with data was 84% (95% CrI: 70% to 95%). Limitations of our analyses include the paucity of data on screening modality and the few countries that had multiple surveys.

CONCLUSION

Overall, CC screening coverage remains sub-optimal and did not improve much over the last 2 decades, outside of Southern Africa. Action is needed to increase screening coverage if CC elimination is to be achieved.

Barriers to uptake of cervical cancer screening services in low-and-middle-income countries: a systematic review

OBJECTIVES

Low-and-middle-income countries (LMICs) bear a disproportionate burden of cervical cancer mortality. We aimed to identify what is currently known about barriers to cervical cancer screening among women in LMICs and propose remedial actions.

DESIGN

This was a systematic review using Medical Subject Headings (MeSH) terms in Google Scholar, PubMed, Scopus, and Web of Science databases. We also contacted medical associations and universities for grey literature and checked reference lists of eligible articles for relevant literature published in English between 2010 and 2020. We summarized the findings using a descriptive narrative based on themes identified as levels of the social ecological model.

SETTING

We included studies conducted in LMICs published in English between 2010 and 2020.

PARTICIPANTS

We included studies that reported on barriers to cervical cancer screening among women 15 years and older, eligible for cervical cancer screening.

RESULTS

Seventy-nine articles met the inclusion criteria. We identified individual, cultural/traditional and religious, societal, health system, and structural barriers to screening. Lack of knowledge and awareness of cervical cancer in general and of screening were the most frequent individual level barriers. Cultural/traditional and religious barriers included prohibition of screening and unsupportive partners and families, while social barriers were largely driven by community misconceptions. Health system barriers included policy and programmatic factors, and structural barriers were related to geography, education and cost. Underlying reasons for these barriers included limited information about cervical cancer and screening as a preventive strategy, poorly resourced health systems that lacked policies or implemented them poorly, generalised limited access to health services, and gender norms that deprioritize the health needs of women.

CONCLUSION

A wide range of barriers to screening were identified across most LMICs. Urgent implementation of clear policies supported by health system capacity for implementation, community wide advocacy and information dissemination, strengthening of policies that support women's health and gender equality, and targeted further research are needed to effectively address the inequitable burden of cervical cancer in LMICs.

Mobilizing stakeholders to drive the cervical cancer elimination agenda in Kenya: The national cervical cancer stakeholders' forum 2022

Background

Kenya is among the nineteen countries in Sub-Saharan Africa with the highest burden of cervical cancer globally. The high burden of cervical cancer in developing countries reflects the absence of effective cervical cancer prevention programs with limited resources invested to provide comprehensive services.

Objective

We aimed to engage stakeholders in a structured consultative forum, to gain insights and forge effective partnerships to drive the cervical cancer elimination agenda in Kenya.

Methods

The National Cervical Cancer Stakeholders Consultative Forum was organized as a part of activities to commemorate the National Cervical Cancer Awareness Month on 19th January 2022 in Nairobi, Kenya. The overall goal of the meeting was to provide a forum to sensitize stakeholders on the National Cervical Cancer Prevention and Control Program (NCCP) with a view to strengthen partnerships, increase coordination for improved service delivery and to provide a forum for resource mobilisation and alignment of key stakeholders towards elimination of cervical cancer in Kenya. Nominal group technique was adopted for structured discussions, and the findings analysed to derive key themes.

Findings

Key challenges to primary and secondary prevention of cervical cancer were identified as low awareness, stigma and misinformation, high unmet need for treatment of early lesions, few health care providers with capacity to screen and treat, inadequate supplies, inefficient health information systems and poor referral pathways. Championing integration of cervical cancer screening and treatment services into routine health programs, strengthening policy implementation and robust monitoring and evaluation were identified as critical interventions.

Conclusion

The National Cervical Cancer Stakeholders Forum 2022 provided insights for enabling Kenya to progress on the 2030 elimination targets. Such forums can be useful in bringing all actors together to evaluate achievements and identify opportunities for more effective national cervical cancer prevention and control programs.

Poor knowledge and awareness of human papillomavirus and cervical cancer among adult females in rural Ghana

Cervical cancer (CC) continues to be a global burden, and a disease of public health interest, especially in low- and middle-income countries. This study explored the knowledge and awareness of human papillomavirus (HPV) infection and CC and the risk-behavioural characteristics of an adult female population in rural Ghana. A total of 274 women, aged 21 years and above were recruited through multi-stage sampling. A questionnaire was used to obtain data on their socio-demographic and socio-economic characteristics and assess their knowledge and awareness of HPV and CC through face-to-face interviews. In all, 187 (68.2%) participants had poor knowledge of HPV and CC with 87 (31.8%) having good knowledge. Only 18.2% and 48.9% of them had prior awareness of HPV infection and CC, respectively. Their primary source of information was the broadcast media (TV and Radio stations) (60.1%). Regarding risky lifestyle behaviours, the mean age at sexual debut was 18.52 ± 2.39 years, 82.8% have had more than one lifetime sexual partner, 81.0% were multiparous with 51.5% using oral contraceptives. Women with higher educational attainment (cOR = 0.41; 95%CI = 0.20-0.81), monthly income (cOR = 0.31; 95%CI = 0.10-1.02), and lifetime sexual partners (aOR = 0.46; 95%CI = 0.21-1.00) were less likely to have poor CC and HPV knowledge compared to their counterparts. In conclusion, adult females in the rural population have limited knowledge and awareness of HPV infection and CC with low CC screening. Intensive educational campaigns should be organised and spearheaded on multiple platforms by the Ghana Health Service and civil societies to sensitise and educate women, in the rural parts of the country, on CC and its related preventive measures.

Designing a Pro-Equity HPV Vaccine Delivery Program for Girls Who Have Dropped Out of School: Community Perspectives From Uttar Pradesh, India

India experiences a substantial burden of cervical cancer and accounts for nearly one third of cervical cancer deaths worldwide. While human papillomavirus (HPV) vaccines have been introduced subnationally in some states, HPV has not yet been rolled out nationally. Given the target age group, schools are the most common delivery channel for HPV vaccines, but this fails to account for local girls who never attended or no longer attend school. We conducted a qualitative, design-informed, community-based study conducted in Uttar Pradesh, India. We assessed facilitators and barriers among out-of-school girls and proposed program characteristics to inform the design of pro-equity HPV vaccine delivery programs for out-of-school girls. Programs should improve parental knowledge of the risk of cervical cancer, engage vaccinated girls as vaccine champions, utilize varied media options for low-literacy populations, and ensure that HPV vaccine services are accessible and flexible to accommodate out-of-school girls. In areas with poor or irregular school attendance among adolescent girls, HPV vaccine coverage will remain suboptimal until programs can effectively address their needs and reach this priority population. Our findings present a meaningful opportunity for program planners to purposefully design HPV vaccination programs according to these parameters, rather than modifying existing programs to include HPV vaccine. Adolescent girls, their parents, and other community members should be involved in program design to ensure that the program can effectively meet the needs of adolescent girls who are not in school.

A Review of the Nucleic Acid-Based Lateral Flow Assay for Detection of Breast Cancer from Circulating Biomarkers at a Point-of-Care in Low Income Countries

The current levels of breast cancer in African women have contributed to the high mortality rates among them. In South Africa, the incidence of breast cancer is also on the rise due to changes in behavioural and biological risk factors. Such low survival rates can be attributed to the late diagnosis of the disease due to a lack of access and the high costs of the current diagnostic tools. Breast cancer is asymptomatic at early stages, which is the best time to detect it and intervene to prevent high mortality rates. Proper risk assessment, campaigns, and access to adequate healthcare need to be prioritised among patients at an early stage. Early detection of breast cancer can significantly improve the survival rate of breast cancer patients, since therapeutic strategies are more effective at this stage. Early detection of breast cancer can be achieved by developing devices that are simple, sensitive, low-cost, and employed at point-of-care (POC), especially in low-income countries (LICs). Nucleic-acid-based lateral flow assays (NABLFAs) that combine molecular detection with the immunochemical visualisation principles, have recently emerged as tools for disease diagnosis, even for low biomarker concentrations. Detection of circulating genetic biomarkers in non-invasively collected biological fluids with NABLFAs presents an appealing and suitable method for POC testing in resource-limited regions and/or LICs. Diagnosis of breast cancer at an early stage will improve the survival rates of the patients. This review covers the analysis of the current state of NABLFA technologies used in developing countries to reduce the scourge of breast cancer.

Cervical cancer screening-related knowledge among community health workers in Eswatini: a cross-sectional survey

Eswatini has the highest age-standardized incidence and second highest mortality rate related to cervical cancer globally. In Eswatini, community health workers educate communities about cervical cancer screening. They need to have accurate knowledge about cervical cancer and screening to do this effectively. Therefore, the current study aimed to assess knowledge regarding cervical cancer screening among community health workers in Eswatini. A telephone survey of 172 community health workers from eight selected constituencies was conducted. Descriptive analyses were performed to assess participants' socio-demographic and service-related characteristics. Linear regression was applied to investigate factors associated with cervical cancer screening-related knowledge. One hundred and seven (62%) participants answered at least 80% of the questions correctly. However, knowledge regarding cervical cancer risk factors, the meaning of screening results and Eswatini cervical cancer screening guidelines was suboptimal. Community health workers aged 46-55 were more likely (β = 1.27, 95% confidence interval [CI]: 0.39-2.15, p < 0.01) to have a higher cervical cancer screening knowledge score than those aged 30-45 years. Community health workers from Lubombo were marginally less likely (β = -0.83, 95% CI: -1.80 to -0.04, p = 0.05) to have a higher knowledge score than those from Hhohho. This study suggests knowledge deficits amongst community health workers in Eswatini. Knowledge deficits may result in inaccurate information being communicated to clients. While increasing knowledge of these vital health workers may not be sufficient to increase cervical cancer screening rates in Eswatini, it is an essential first step that should be the focus of future educational efforts.

Barriers and Facilitators to Cervical Cancer Screening in Western Kenya: a Qualitative Study

About nine out of 10 cervical cancer deaths occur in low-resource countries, with a particularly high burden in sub-Saharan Africa. The objectives of this study were to assess barriers and facilitators to cervical cancer screening in western Kenya from the perspectives of community members and healthcare providers. We conducted two focus groups with female community members (n = 24) and one with providers (n = 12) in Migori County, Kenya. Discussion guides queried about knowledge and awareness of cervical cancer prevention; structural, social, and personal barriers; and facilitators towards cervical cancer screening uptake. Group discussions were recorded, transcribed, and analyzed for emerging themes. Participants in both groups reported low awareness of HPV and cervical cancer screening in the community, and identified that as a main barrier to screening. Community members reported fear of pain and embarrassment as significant barriers to a screening pelvic exam. They also reported that providers' lack of knowledge and discomfort with a sensitive subject were significant barriers. A personal connection to cervical cancer and/or screening was associated with willingness to screen and awareness. Providers reported workload and lack of supplies and trained staff as significant barriers to offering services. Based on these findings, we identified three intervention components to address these facilitators and barriers to screening. They include utilizing existing social networks to expand awareness of cervical cancer risk and screening, training non-physician health workers to meet the demand for screening, and employing female-driven screening techniques such as self-collection of specimens for HPV testing. Cervical cancer prevention programs must take into account the local realities in which they occur. In low-resource areas in particular, identifying low-cost, effective, and culturally appropriate strategies for addressing poor screening uptake is important given limited funding. This study took a formative approach to identify facilitators and barriers to cervical cancer screening based on focus groups and interviews with community members and healthcare providers.

Explaining socioeconomic inequality in cervical cancer screening uptake in Malawi

Background

Cervical cancer is a prevalent public health concern and is among the leading causes of death among women globally. Malawi has the second highest cervical cancer prevalence and burden in the world. Due to the cervical cancer burden, the Malawi government scaled up national cancer screening services in 2011, which are free for all women. This paper is the first study to examine the socioeconomic inequality in cervical cancer screening uptake using concentration indices, in Malawi. Furthermore, it decomposes the concentration index to examine how each factor contributes to the level of inequality in the uptake of cervical cancer screening.

Methods

The data used in this paper were obtained from the nationally representative Malawi Population HIV Impact Assessment (MPHIA) household survey, which was conducted in 2015. Concentration curves were constructed to explore whether there was any socioeconomic inequality in cervical cancer screening and, if so, its extent. This was complemented by concentration indices that were computed to quantify the magnitude of socioeconomic inequality. A decomposition analysis was then conducted to examine the factors that explained/were associated with greater socioeconomic inequality in cervical cancer screening. The methodology in this paper followed that of previous studies found in the literature and used the wealth index to measure socioeconomic status.

Results

The results showed that the concentration curves lay above the line of equality, implying a pro-rich inequality in cervical cancer screening services. Confirming the results from the concentration curves, the overall concentration index was positive and significant (0.142; %95 CI = 0.127, 0.156; p < 0.01). The magnitude was lower in rural areas (0.075; %95CI = 0.059, 0.090; p < 0.01) than in urban areas (0.195; %95CI = 0.162, 0.228 p < 0.001). After undertaking a decomposition of the concentration index, we found that age, education, rural or urban location, and wealth status account for more than 95% of the socioeconomic inequality in cervical cancer uptake.

Conclusion

Despite the national scale-up of free cancer care at the point of use, cervical cancer screening uptake in Malawi remains pro rich. There is a need to implement parallel demand-side approaches to encourage uptake among poorer groups. These may include self-testing and mobile screening centres, among others.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13750-4.

[Early detection and prevention of cervical cancer: knowledge, attitudes and practices of FHS professionals]

The study aimed to investigate the knowledge, attitudes and practices of professionals of the Family Health Strategy (FHS) on the control of uterine cervical cancer (CCU) recommended by the Ministry of Health (MS). This is a cross-sectional study, which used a self-administered questionnaire with the doctors and nurses of the FHS of Juiz de Fora, MG, in 2019. For analysis, the chi-square and Fisher's exact test were used, 5% level of significance. Among the 170 surveyed, which corresponded to 93% of FHS professionals in the city, the prevalence of adequate knowledge was 39.4% and had association with younger age and female gender. The prevalence of an adequate attitude was 59.5% and of appropriate practices 77.6%, both associated with a longer time since graduation. The presence of the Ministry of Health guidelines in the units was associated with the outcomes, knowledge and adequate practice, confirming the importance of support material for consultation by professionals. Only 28.2% of professionals reported having received training in the last 3 years and 50.3% carried out educational actions for users. The need for permanent education actions with professionals is highlighted, aiming at a more effective action to confront and eradicate CCU.

Gene therapy access: Global challenges, opportunities, and views from Brazil, South Africa, and India

Gene and cell therapies for a variety of life-limiting illnesses are under investigation, and a small number of commercial products have successfully obtained regulatory approval. The cost of treatment is high, and clinical studies evaluating safety and efficacy are performed predominately in high-income countries. We reviewed the current status of gene and cell therapies in low- and middle-income countries and highlighted the need and current barriers to access. The state of product development in Brazil, South Africa, and India is discussed, including lessons learned from American Society of Gene and Cell Therapy (ASGCT)-sponsored virtual symposia in each of these countries.

Developing a culturally tailored short message service (SMS) intervention for improving the uptake of cervical cancer screening among Ghanaian women in urban communities

Background

There has been extensive research across the globe to understand the barriers and facilitators of cervical cancer (CC) screening. However, few studies have focused on how such information has been used to develop text messages for mHealth screening programs, especially in resource-poor countries. This study elicited information on barriers and facilitators, the preferences of women regarding the modalities for delivery of health SMS messages on screening for cervical cancer, and demonstrates how this information was used to create a health screening program among women in the Greater Accra Region of Ghana.

Methods

Four main activities were carried out, including (1) a total of five focus group discussions, (2) a baseline survey involving 62 female bankers and 68 women from the communities, (3) a stakeholder meeting involving experts in cervical cancer research and clinical care, and (4) pilot testing of the text messages. Focus group discussions and the baseline survey data were collected concurrently between February and May 2017 and the results were used to develop 5 specific communication objectives during the stakeholder engagements held in June 2017.

Results

In all, 32 text messages were developed and pretested in July 2017(13 addressed knowledge on CC; 6 highlighted the importance of early detection; 5 allayed fear as a barrier to CC screening; 5 encouraged women to have time for their health, and 3 messages contained information on where to go for screening and the cost involved). Although awareness about the disease was high, knowledge of CC screening was low. For two-thirds of respondents (22/33), perceived lack of time, high cost, and fear (of cc, screening procedure, and potential for negative outcome) accounted for the reasons why respondents will not go for screening, while education on CC, especially from health workers and the mass media enabled uptake of CC screening.

Conclusion

Several factors prevent women from accessing screening services for CC, however, barriers such as low levels of education on CC, lack of time, and fear can be targeted in SMS messaging programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01719-9.

Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low-income and middle-income countries: a systematic review

OBJECTIVES

To systematically synthesise available evidence on the nature and effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low and middle-income countries (LMICs).

DESIGN

A systematic review of published evidence. The review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses.

DATA SOURCES

A comprehensive search of published literature was conducted. In addition, relevant grey literature sources and bibliographical references of included studies were searched for potentially eligible evidence.

STUDY SELECTION

Studies published between January 2010 and November 2020 were eligible for inclusion. To be eligible, studies had to report on interventions/strategies targeted at women, the general public or healthcare workers, aimed at improving the timely diagnosis of breast and/or cervical cancers in LMIC settings.

DATA EXTRACTION AND SYNTHESIS

Literature search, screening, study selection, data extraction and quality appraisal were conducted by two independent reviewers. Evidence was synthesised and reported using a global taxonomy framework for early cancer diagnosis.

RESULTS

From the total of 10 593 records identified, 21 studies conducted across 20 LMICs were included in this review. Most of the included studies (16/21) focused primarily on interventions addressing breast cancers; two focused on cervical cancer while the rest examined multiple cancer types. Reported interventions targeted healthcare workers (12); women and adolescent girls (7) and both women and healthcare workers (3). Eight studies reported on interventions addressing access delays; seven focused on interventions addressing diagnostic delays; two reported on interventions targeted at addressing both access and diagnostic delays, and four studies assessed interventions addressing access, diagnostic and treatment delays. While most interventions were demonstrated to be feasible and effective, many of the reported outcome measures are of limited clinical relevance to diagnostic timeliness.

CONCLUSIONS

Though limited, evidence suggests that interventions aimed at addressing barriers to timely diagnosis of breast and cervical cancer are feasible in resource-limited contexts. Future interventions need to address clinically relevant measures to better assess efficacy of interventions.

PROSPERO REGISTRATION NUMBER

CRD42020177232.

Progress and challenges in human papillomavirus and cervical cancer in southern Africa

PURPOSE OF REVIEW

Although cervical cancer is preventable, it is the leading cancer among women in southern Africa. The association of high-risk human papillomavirus (HR-HPV) with almost all invasive cervical cancers has led to the development of effective primary and secondary prevention measures. This review focuses on updated and new evidence of the epidemiology of HPV and HPV-based secondary prevention in southern Africa.

RECENT FINDINGS

HR-HPV prevalence in southern Africa differs between regions, and varies most by HIV prevalence and age. HR-HPV prevalence among women living with HIV (WLWH) is reported between 29 and 59.7%, and between 16.2 and 25.2% among women without HIV. HPV16 is the most common HR-HPV type present in invasive cervical cancers in the region; and vaccination may potentially prevent approximately 80% of these cancers. Concerning preliminary data suggests faster development of new cervical precancer within a short follow-up period.

SUMMARY

We need tools that identify the small number of women with precancer from the many with transient HR-HPV infection in southern Africa. The high-volume of test-positive women leads to challenges in managing triage in a HR-HPV-based screening program. Longitudinal data from the entire region is urgently needed to guide effective implementation of HPV-based screening programs.

Implementing community-based human papillomavirus self-sampling with SMS text follow-up for cervical cancer screening in rural, southwestern Uganda

BACKGROUND

Self-collected HPV screening may improve cervical cancer screening coverage in low resource countries, yet data guiding implementation and follow-up of abnormal results are sparse.

METHODS

This is a prospective cohort implementation study of HPV self-testing program in Mbarara, Uganda with mobile phones to facilitate result notification and referral for treatment at a regional hospital. The effectiveness of the interventions was analyzed using Proctor's model of implementation. Women were interviewed following screening and at 6 months to assess acceptability and barriers to follow-up. Data were analyzed using descriptive statistics.

RESULTS

159 of 194 (82%) of eligible women underwent HPV self-sampling; of these, 27 (17%) returned positive for high-risk HPV subtypes. We sent SMS messages providing test results and follow-up instructions to all participants. Seventeen (63%) hrHPV-positive participants reported receiving SMS text instructions for follow-up, of whom 6 (35%) presented for follow-up. The most common reasons for not returning were: lack of transportation (n = 11), disbelief of results (n = 5), lack of childcare (n = 4), and lack of symptoms (n = 3). Confidence in test results was higher for self-screening compared to VIA (Likert score 4.8 vs 4.4, P = 0.001).

CONCLUSIONS

Despite the use of SMS text-based referrals, only one-third of women presented for clinical follow-up after abnormal HPV testing.

Knowledge, awareness, attitudes and screening practices towards breast and cervical cancer among women in Nepal: a scoping review

Aim

Breast and cervical cancers have emerged as major global health challenges and disproportionately affect women in low- and middle-income countries, including Nepal. This scoping review aimed to map the knowledge, attitudes and screening practices for these cancers among Nepali women to improve cancer outcomes and reduce inequality.

Methods

Five electronic databases (CINAHL, Embase, Global Health, PsycINFO and PubMed), grey literature, and reference and citation lists were searched for articles published in English up to June 2021. Articles were screened against inclusion/exclusion criteria, and data from eligible studies were extracted. Results were summarised narratively.

Results

The search yielded 615 articles, 38 of which were included in this scoping review (27 cervical cancer, 10 breast cancer, 1 both cancers). Levels of knowledge regarding breast and cervical varied widely. The main knowledge gaps were misconceptions about symptoms and risk factors, and poor understanding of screening behaviours. Screening practices were mostly inadequate due to socio-cultural, geographical or financial barriers. Positive attitudes towards cervical screening were associated with higher education and increased knowledge of screening modalities. Higher levels of knowledge, (health) literacy and participation in awareness campaigns facilitated breast cancer screening.

Conclusion

Knowledge and screening practices for breast and cervical cancer among Nepali women were poor and highlight the need for awareness and education programmes. Future research should explore community health worker-led awareness and screening interventions for cervical cancer, and programmes to increase the practice of breast self-examination and clinical breast examinations to support early diagnosis of breast cancer.

Association between cervical dysplasia and female genital schistosomiasis diagnosed by genital PCR in Zambian women

BACKGROUND

Female genital schistosomiasis (FGS) is a neglected tropical gynaecological disease that affects millions of women in sub-Saharan Africa (SSA). FGS is caused by Schistosoma haematobium, a parasitic carcinogen involved in the pathogenesis of squamous cell carcinoma of the bladder. Cervical cancer incidence and mortality are highest in SSA, where pre-cancerous cervical dysplasia is often detected on screening with visual inspection with acetic acid (VIA). There are no studies evaluating the association between VIA positivity and FGS diagnosed by genital PCR.

METHODS

Women were recruited from the Bilharzia and HIV (BILHIV) study in Zambia a community-based study comparing genital self-sampling to provider obtained cervicovaginal-lavage for the diagnosis of FGS in women aged 18-31. FGS was defined as positive Schistosoma DNA from any genital PCR. Urogenital schistosomiasis diagnostics included urine circulating anodic antigen, urine microscopy and portable colposcopy. Participants were offered cervical cancer screening using VIA at Livingstone Central Hospital. Associations of PCR confirmed FGS and other diagnostics with VIA positivity were assessed using multivariable logistic regression.

RESULTS

VIA results were available from 237 BILHIV participants. A positive Schistosoma PCR in any genital specimen was detected in 14 women (5.9%), 28.6% (4/14) of these women had positive VIA compared to 9.0% without PCR evidence of schistosome infection (20/223). Schistosoma PCR positivity in any genital specimen was strongly associated with VIA positivity (OR: 6.08, 95% CI: 1.58-23.37, P = 0.02).

CONCLUSIONS

This is the first study to find an association between FGS and positive VIA, a relationship that may be causal. Further longitudinal studies are needed.

Challenges and opportunities associated with cervical cancer screening programs in a low income, high HIV prevalence context

Background

Cervical cancer is a leading cause of death among Cameroon women. The burden of cervical cancer is in part traceable to the inadequate understanding of socio-contextual determinants of access to screening and prevention opportunities. We explored multilevel individual, community and structural factors that facilitate or inhibit cervical cancer prevention in women at risk in a low-income, high HIV prevalence context.

Methods

We utilized an exploratory qualitative approach to obtain data through focus group discussions and in-depth interviews from May to August, 2018. A two-stage purposive sampling strategy was used to select 80 women and 20 men who participated in 8 focus group discussions and 8 in-depth interviews. The socio-ecological model guided data analyses to identify micro-, meso-, and macro-level determinants of cervical cancer screening.

Results

Micro-level factors including lack of awareness and knowledge about cervical cancer, lack of access to information, excessive cost of cervical cancer screening, low risk perceptions, and poor health seeking behaviors were major barriers for women seeking cervical cancer screening. Meso-level factors, such as social networks, socio-cultural norms, perceptions of the role of men and HIV-related stigma when screening is integrated into HIV care, also engender negative attitudes and behaviors. Macro-level barriers to cervical cancer screening included poorly equipped health facilities and a lack of national cancer prevention policies and programs.

Conclusion

In the context of the call for elimination of cervical cancer as a public health problem, our findings highlight challenges and opportunities that should be considered when implementing interventions to increase uptake of cervical cancer screening in low-middle income settings.

Mapping the cervical cancer screening cascade among women living with HIV in Johannesburg, South Africaa

OBJECTIVE

To map the cervical cancer screening cascade among women living with HIV attending a public-sector cytology screening program in Johannesburg, South Africa.

METHODS

We conducted a retrospective cohort study of routinely collected clinical data captured in an electronic medical record system. Women (≥18 years) living with HIV with an abnormal Pap result between January 2013 and May 2018 were included. The proportion of women who received follow-up consistent with extant clinical guidelines, stratified by their initial Pap smear result, was examined.

RESULTS

The study included 2072 women: 1384 (66.8%) with a low-risk Pap result, 681 (32.9%) with a high-risk Pap result, and 7 (0.3%) with suspected cancer. Only 174 (25.6%) women with a high-risk Pap result underwent guideline-indicated management within 18 months. Among women with a low-risk Pap result, 375 (27.1%) received follow-up within 1 year; the cumulative incidence of follow-up increased to 63.1% at 3 years. All women with suspected cancer either received a colposcopic biopsy or were referred for further treatment.

CONCLUSION

Attrition among South African women living with HIV who attended cervical screening in an urban public-sector program was high. Developing tailored interventions to address bottlenecks in the care cascade and improve cervical screening outcomes will be central to eliminating cervical cancer.