Cervical Cancer Screening in Low Resource Settings Using Visual Inspection With Acetic Acid

Fighting cervical cancer in Africa: a cross-sectional study on prevalence and risk factors for precancerous lesions in rural Uganda

OBJECTIVE

To identify risk factors for precancerous cervical lesions and factors associated with treatment delay among women in the rural Busoga Region, Uganda.

STUDY DESIGN

A retrospective cross-sectional study from a regional cervical cancer screening program and from cervical cancer patients enrolled in a region-wide palliative care program.

METHODS

Logistic regression analysis was conducted to assess risk factors for screening positive for precancerous lesions. In a separate analysis, factors associated with treatment delay were assessed among women enrolled in the palliative care program.

RESULTS

Three thousand nine hundred forty-six women were included from the screening program and 334 from the palliative care program. In total, 7.6% of screening participants had precancerous lesions. Within Busoga Region, the highest positivity rate was found in Bugweri and Namayingo Districts. Abnormal vaginal bleeding (adjusted odds ratio [aOR] 1.60; 95% confidence interval [CI] 1.15-2.21; p = 0.005) and older age at first menstrual period (aOR 1.08; 95% CI 1.01-1.16; p = 0.03) were associated with having a precancerous lesion. Among palliative care patients, a history of previous contact with the health care system was associated with a delay in enrolment (≥12 months from first symptom presentation until commencement in palliative care; aOR 5.23; 95% CI 1.16-36.54; p = 0.047).

CONCLUSIONS

The results underline an unmet need for broad-scale cervical cancer screening focusing on all women in the reproductive age. Abnormal bleeding was the only substantial risk factor for precancerous lesions, indicating that specific algorithms to identify high-risk populations may not be applicable in this population. Increased awareness, resources, and funding are still necessary to achieve global cervical cancer elimination.

Mobile colposcopy by trained nurses in a cervical cancer screening programme at Battor, Ghana

OBJECTIVES

Cervical precancer screening programs are difficult to establish in low resource settings partly because of a lack of human resource. Our aiming was to overcome this challenge. We hypothesized that this could be done through task shifting to trained nurses.

DESIGN

Descriptive retrospective cross-sectional review.

SETTING

Training was at the Cervical Cancer Prevention and Training Center (CCPTC) and screening was carried out at the clinic and at outreaches / peripheral facilities.

PARTICIPANTS

All women who reported to the clinic for screening or were recruited during outreaches.

INTERVENTIONS

All 4 nurses were trained for at least 2weeks (module 1). A total of 904 women were screened by the trained nurses using the EVA system. Quality assurance was ensured.

MAIN OUTCOME MEASURES

Primary screening and follow-up were carried out by the trained nurses with quality assured through image sharing and meetings with peers and experienced gynaecologists.

RESULTS

828 women had primary screening and 76 had follow-up screening. 739 (89.3%) were screened at the clinic and 89 (10.7%) at outreaches/peripheral facilities. Of all screened, 130 (14.5%) had cervical lesions, and 25 (2.8%) were treated, 12 (48.0%) by Loop Electrosurgical Excision Procedure (LEEP) performed by a gynaecologist, 11 (44.0%) with thermal coagulation by trained nurses except one, and 2 (8.0%) with cryotherapy by trained nurses.

CONCLUSION

We demonstrate the utility of a model where nurses trained in basic colposcopy can be used to successfully implement a cervical precancer screening and treatment program in low-resource settings.

FUNDING

None indicated.

Understanding no-show behaviour for cervical cancer screening appointments among hard-to-reach women in Bogotá, Colombia: A mixed-methods approach

The global burden of cervical cancer remains a concern and higher early mortality rates are associated with poverty and limited health education. However, screening programs continue to face implementation challenges, especially in developing country contexts. In this study, we use a mixed-methods approach to understand the reasons for no-show behaviour for cervical cancer screening appointments among hard-to-reach low-income women in Bogotá, Colombia. In the quantitative phase, individual attendance probabilities are predicted using administrative records from an outreach program (N = 23384) using both LASSO regression and Random Forest methods. In the qualitative phase, semi-structured interviews are analysed to understand patient perspectives (N = 60). Both inductive and deductive coding are used to identify first-order categories and content analysis is facilitated using the Framework method. Quantitative analysis shows that younger patients and those living in zones of poverty are more likely to miss their appointments. Likewise, appointments scheduled on Saturdays, during the school vacation periods or with lead times longer than 10 days have higher no-show risk. Qualitative data shows that patients find it hard to navigate the service delivery process, face barriers accessing the health system and hold negative beliefs about cervical cytology.

Improving intervention design to promote cervical cancer screening among hard-to-reach women: assessing beliefs and predicting individual attendance probabilities in Bogotá, Colombia

Background

Despite being a preventable disease, cervical cancer continues to be a public health concern, affecting mainly lower and middle-income countries. Therefore, in Bogotá a home-visit based program was instituted to increase screening uptake. However, around 40% of the visited women fail to attend their Pap smear test appointments. Using this program as a case study, this paper presents a methodology that combines machine learning methods, using routinely collected administrative data, with Champion’s Health Belief Model to assess women’s beliefs about cervical cancer screening. The aim is to improve the cost-effectiveness of behavioural interventions aiming to increase attendance for screening. The results presented here relate specifically to the case study, but the methodology is generic and can be applied in all low-income settings.

Methods

This is a cross-sectional study using two different datasets from the same population and a sequential modelling approach. To assess beliefs, we used a 37-item questionnaire to measure the constructs of the CHBM towards cervical cancer screening. Data were collected through a face-to-face survey (N = 1699). We examined instrument reliability using Cronbach’s coefficient and performed a principal component analysis to assess construct validity. Then, Kruskal–Wallis and Dunn tests were conducted to analyse differences on the HBM scores, among patients with different poverty levels. Next, we used data retrieved from administrative health records (N = 23,370) to fit a LASSO regression model to predict individual no-show probabilities. Finally, we used the results of the CHBM in the LASSO model to improve its accuracy.

Results

Nine components were identified accounting for 57.7% of the variability of our data. Lower income patients were found to have a lower Health motivation score (p-value < 0.001), a higher Severity score (p-value < 0.001) and a higher Barriers score (p-value < 0.001). Additionally, patients between 25 and 30 years old and with higher poverty levels are less likely to attend their appointments (O.R 0.93 (CI: 0.83–0.98) and 0.74 (CI: 0.66–0.85), respectively). We also found a relationship between the CHBM scores and the patient attendance probability. Average AUROC score for our prediction model is 0.9.

Conclusion

In the case of Bogotá, our results highlight the need to develop education campaigns to address misconceptions about the disease mortality and treatment (aiming at decreasing perceived severity), particularly among younger patients living in extreme poverty. Additionally, it is important to conduct an economic evaluation of screening options to strengthen the cervical cancer screening program (to reduce perceived barriers). More widely, our prediction approach has the potential to improve the cost-effectiveness of behavioural interventions to increase attendance for screening in developing countries where funding is limited.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01800-3.

Performance of visual Inspection With Acetic Acid for Cervical Cancer Screening as Compared to Human papillomavirus Deoxyribonucleic acid Testing Among Women With HIV in Ethiopia: A Comparative Cross-sectional Study

Objectives

The aim of this study was to evaluate the performance of visual inspection with acetic acid compared with Human papillomavirus Deoxyribonucleic acid (HPV DNA) testing among women with HIV in Ethiopia.

Methods

A comparative cross-sectional study was conducted to address the aforementioned objective. Data were collected from January to October 2021, to compare the performance of these two screening modalities. Trained clinicians collected cervical specimens and immediately applied acetic acid for visual inspection. The HPV DNA testing was done using Abbott m2000rt/SP by trained laboratory professionals in accredited laboratories. A total of 578 women with HIV aged 25-49 years were included.

Results

Test positivity was 8.9% using visual inspection with acetic acid (VIA) and 23.3% using HPV DNA test. The sensitivity and specificity of the VIA test were 19.2% and 95.1%, respectively. The strength of agreement between the two screening methods was poor (k = .184). The burden of genetic distribution of high risk HPV16 was 6.1%, and HPV18 was 1.1%. Other high risk HPV types (ie non-HPV 16/18 high risk HPV genotypes) were predominant in this study (18.6%).

Conclusion

The higher positivity result using HPV DNA testing compared with VIA, and low sensitivity of VIA are indicating that the implementation of HPV DNA testing as the primary screening strategy is likely to reduce cervical cancer cases and deaths of women in the country.

Precancerous lesions of the cervix and its determinants among Ethiopian women: Systematic review and meta-analysis

Introduction

Precancerous lesions of the cervix are changes in cervical cells that make them more likely to develop into cancer. Understanding the prevalence and determinants of the precancerous lesions of the cervix among women helps to take an action like vaccination programs, improving screening coverage, and close management and follow-up which could decrease the morbidity and mortality caused by cervical cancer.

Materials and methods

The international databases, PubMed/MEDLINE, Web of Science, EMBASE, CINAHL, Google Scholar, Science Direct and Cochrane Library and unpublished reports were systematically searched. Two authors independently extracted all necessary data using a standardized data extraction format. STATA 14 statistical software was employed to analyse the data. The Cochrane Q test statistics and I² tests were used to assess the heterogeneity between the studies. A random-effect model was computed to estimate the pooled prevalence of precancerous lesions of the cervix in Ethiopia. Determinants of the precancerous lesion of cervix (early initiation of sexual intercourse, multiple sexual partners, and history of sexually transmitted infection) were analysed.

Results

Thirteen studies fulfilled the inclusion criteria and included in the meta-analysis. The I² test result showed high heterogeneity (I2, 93.2%, p = <0.001). Using the random effect analysis, the pooled prevalence of precancerous lesions of the cervix among women in Ethiopia was 14.21% (95% CI (10.49, 17.94). After adjusting of publication bias using trim-and-fill method, the pooled prevalence was 9.43% (95% CI (5.23, 13.62). Women who had multiple sexual partners in their lifetime (OR:2.67 CI: 1.49,4.79) and had a history of sexually transmitted infections (OR:6.22 CI: 2.99,12.92) were more likely to have a precancerous lesion of the cervix.

Conclusion

The pooled prevalence of the precancerous lesions of the cervix among Ethiopian women was 9.43%. It was associated with having multiple sexual partners and a history of sexually transmitted infections.

Knowledge, Belief and Practice of Cervical Cancer Screening and Prevention among Women of Taraba, North-East Nigeria

Objective:

The rising prevalence of cancer of the cervix especially in developing countries gives cause for concern. Fortunately, it can be prevented especially when the women at risk possess correct knowledge, have the right belief and access to screening and prevention services. Previous studies have reported poor knowledge and screening practices among women in developing countries raising the fear of continued spread. The aim of the study was to establish the cervical cancer knowledge, belief and prevention/screening practices among women in Taraba, North-East Nigeria.

Methods:

The study adopted a cross sectional survey design. A self-designed structured and validated questionnaire with a reliability index of .82 was employed to elicit information from 978 women of child bearing age. Data collected were analysed using percentage, mean, Chi-Square and ANOVA statistics.

Result:

The findings of the study revealed that the women of Taraba had appropriate knowledge about the nature of cervical cancer (73. 2%) signs and symptoms of cervical cancer (76.5%) risk factors of cervical cancer (88.0%), and prevention of cervical cancer (90.3%). The women did not have the right beliefs about the concept of cervical cancer and its preventive measures. They believed that the screening procedure is painful; they were too young to contract the disease and risk stigmatization if they went for screening. Only 45.2% of the women regularly engaged in screening and other prevention practices. Location of residence, and religion significantly determined knowledge and screening/prevention practices (P<0.05) while marital status and age (P<0.05) significantly affected the respondents’ beliefs about cervical cancer and prevention practices. Location of residence, and religion significantly determined knowledge and screening/prevention practices (P<0.05) while marital status and age (P<0.05) significantly affected the respondents’ beliefs about cervical cancer and prevention practices.

Conclusion:

It was concluded that knowledge about cervical cancer did not translate to right belief and good practice, and that belief and practice were affected by demographic variables of location of residence, religion, marital status and age.

Cervical Cancer Screening in HIV-Positive Farmers in South Africa: Mixed-Method Assessment

Background:

In 2015, a See and Treat cervical cancer screening program was implemented at a local HIV clinic in Limpopo, South Africa, where infrastructure limited adequate Pap smear usability.

Objectives:

The purpose of this evaluation was to determine the quality and sustainability of the implemented program.

Methods:

A mixed-methods program analysis was conducted at 18-months post implementation. Data collection techniques included in-depth interviews of staff and patients, observation of healthcare workers delivering screening, and review of charts and patient logs.

Findings:

Eighteen in-depth interviews revealed improved cervical cancer screening understanding and awareness. Privacy concerns and negative perceptions of medical care were barriers to screening. Informal observations revealed continued clinical competence among healthcare workers who had been previously trained. Review of charts demonstrated positive correlation between VIA and Pap smear results. In evaluating loss to attrition, about half of the first cohort of patients were lost to follow-up. VIAs and Pap smears were offered on an ongoing basis, and month-over-month change for overlapping four months of programming between 2015 and 2016 showed a 4.4% negative change in number of Pap smears and a 57% negative change in VIAs.

Conclusion:

Our evaluation reveals successful integration of See and Treat into current clinic services in rural South Africa and increased awareness of cervical cancer among health workers and participants. Program sustainability was challenging to assess as many patients were lost to follow-up, given the migrant and transient population attending this clinic. Acceptance by health workers and patients alike is vital for the long-term impact on cervical cancer incidence in this region.

Needs for Professional Education to Optimize Cervical Cancer Screenings in Low-Income Countries: a Case Study from Tanzania

Cervical cancer is a significant health problem in many developing countries. Due to limited treatment facilities for cancer in Tanzania, a screening referral program was developed between two urban clinics and Ocean Road Cancer Institute (ORCI), the only cancer treatment center in Tanzania. This study aimed to evaluate the effectiveness of the program and to identify opportunities for professional education. The study included 139 patients who were referred to ORCI from the screening clinics of Magomeni and Temeke between January 2015 and May 2016. Abstracted data from the medical records included patient age, screening results, and treatment. Eight nurses performing screening at the three locations were interviewed about their screening experience. Over half of the referrals (51.9%) were false positives. False positive diagnosis was more common among younger patients (35.68 ± 8.6 years) (p < 0.001) and those referred from Magomeni (59.8%) (p < 0.01) than referrals of older patients (42.46 ± 11.1 years) or those from Temeke (33.3%). Interviews of nurses showed differences among clinics, including resources, experience, and documentation of screening results. The high false positive rates and the variation of accuracy of screening between the two clinics showed a need for professional education of nurses and improvement in the health systems. Continuous education of nurses may increase the effectiveness of cervical screening. Health system enhancement of screening facilities such as provision of Lugol's iodine, more space for screening, and consistency and completion of screening records are needed to increase the accuracy of cervical screening and referrals in Tanzania and other similar low-income countries.

Qualitative Assessment of Cervical Cancer Awareness among Primary Health-Care Providers in Zaria, Nigeria

Background:

Cervical cancer is a major cause of cancer morbidity and mortality, especially in the developing countries. Preventive measures have helped in curbing the morbidity and mortality associated with the disease in the developed countries. Primary health-care centers provide opportunity for the primary prevention of cervical cancer, especially in environments where there are no standard protocols/programs for cervical cancer prevention.

Objective:

This study sought to assess the awareness of cervical cancer among primary health-care providers in Zaria.

Methodology:

The study was qualitative. Five primary health-care centers in Zaria local government were purposively selected for the study. Focus group discussions were conducted with the health-care providers in the selected facilities. The discussions were recorded on tape recorders and were transcribed verbatim. The transcripts were then analyzed into themes.

Results:

All participants were aware of cervical cancer. However, only few of the participants were aware of the cause of cervical cancer and the risk factors associated with the disease. None of the participants has had any training on the prevention of cervical cancer.

Conclusion:

Primary health-care providers can play a critical role in the prevention of cervical cancer in our environment. However, there is a need to train them on cervical cancer prevention for effective control of the disease.

Design and preliminary analysis of a vaginal inserter for speculum-free cervical cancer screening

Objective

Cervical cancer screening usually requires use of a speculum to provide a clear view of the cervix. The speculum is one potential barrier to screening due to fear of pain, discomfort and embarrassment. The aim of this paper is to present and demonstrate the feasibility of a tampon-sized inserter and the POCkeT Colposcope, a miniature pen sized-colposcope, for comfortable, speculum-free and potentially self-colposcopy.

Study design

We explored different designs using 3D computer-aided design (CAD) software and performed mechanical testing simulations on each. Designs were rapid prototyped and tested using a custom vaginal phantom across a range of vaginal pressures and uterine tilts to select an optimal design. Two final designs were tested with fifteen volunteers to assess cervix visualization, comfort and usability compared to the speculum and the optimal design, the curved-tip inserter, was selected for testing in volunteers.

Results

We present a vaginal inserter as an alternative to the standard speculum for use with the POCkeT Colposcope. The device has a slim tubular body with a funnel-like curved tip measuring approximately 2.5 cm in diameter. The inserter has a channel through which a 2 megapixel (MP) mini camera with LED illumination fits to enable image capture. Mechanical finite element testing simulations with an applied pressure of 15 cm H₂O indicated a high factor of safety (90.9) for the inserter. Testing of the device with a custom vaginal phantom, across a range of supine vaginal pressures and uterine tilts (retroverted, anteverted and sideverted), demonstrated image capture with a visual area comparable to the speculum for a normal/axial positioned uteri and significantly better than the speculum for anteverted and sideverted uteri (p<0.00001). Volunteer studies with self-insertion and physician-assisted cervix image capture showed adequate cervix visualization for 83% of patients. In addition, questionnaire responses from volunteers indicated a 92.3% overall preference for the inserter over the speculum and all indicated that the inserter was more comfortable than the speculum. The inserter provides a platform for self-cervical cancer screening and also enables acetic acid/Lugol’s iodine application and insertion of swabs for Pap smear sample collection.

Conclusion

This study demonstrates the feasibility of an inserter and miniature-imaging device for comfortable cervical image capture of women with potential for synergistic HPV and Pap smear sample collection.

Analysis of Factors Affecting Women of Childbearing Age to Screen Using Visual Inspection with Acetic Acid

Objectives

The purpose of this study was to evaluate patient factors such as knowledge, attitude, motivation, perception, socio-economic status and travel time to health facilities and assess how these factors affected patients’ decision to pursue cervical cancer screening with visual inspection with acetic acid (VIA).

Methods

A total of 80 women of childbearing age who visited Kenjeran and Balongsari Public Health Centers for health assessments were involved in this study. Patients who agreed to participate in the study underwent a verbal questionnaire to evaluate various factors.

Results

Bivariate analysis concluded that knowledge, attitude, motivation, perception, socioeconomic status, and travel time to health facilities were significantly different between women who received VIA screening and women who did not receive VIA screening (p < 0.05). The factors of knowledge, attitudes, motivation, perception, socio-economic status, and the travel time to health facilities accounted for 2.920-fold, 2.043-fold, 3.704-fold, 2.965-fold, 3.198-fold and 2.386-fold possibility, respectively, of patients to pursue cervical cancer screening with VIA. Multivariate analysis showed that perception, socio-economic status, and travel time to health facilities were the most important factors influencing whether or not women pursued VIA screening.

Conclusion

Knowledge, attitude, motivation, perception, socio-economic status, and travel time to health facilities appears to affect women’s’ decision to pursue cervical cancer screening with VIA, with the largest intake being the motivational factor.

Visual inspection with acetic acid and Lugol's iodine in cervical cancer screening at the general referral hospital Kayembe in Mbuji-Mayi, Democratic Republic of Congo

Introduction

Cervical cancer is the leading cause of morbidity and mortality of women from cancer in the developing World. It is the primary cause of reduced life expectancy in Sub-Saharan countries such as Democratic Republic of Congo. The aim of this work was to determinate the socio-demographic profile of women with precancerous and cancerous lesions of the cervix, to determinate the frequency of VIA and VILI positive cases and to show the challenges that can be faced in managing patients with abnormalities in the city of Mbuji-Mayi in the Democratic Republic of Congo.

Methods

As part of its activities, the “Association de Lutte contre le Cancer du Col utérin” (ALCC) organized a community outreach followed by free voluntary testing for cervical cancer for two weeks (26^thMarch to 10^th April 2011) at the General Referral Hospital Kayembe in Mbuji-Mayi (Democratic Republic of Congo).

Results

A total of 229 women were examined. 38% of tests (VIA + VILI) were positive with 6 clinically suspected cases of invasive cancer at stage 1 (7% of cases). Nearly 70% of patients were still of childbearing age and had started their first sexual intercourse before 18 years of age and 86% of cases were multiparous. Given the material, financial and technical constraints, 75% of patients were placed in a monitoring program of 9 months to 1 year (= expectation and another test) while 11% of them were selected for a biopsy to be locally practiced and sent to the pathologist. Nearly 8% of the cases were candidates for hysterectomy.

Conclusion

Given the difficulties encountered and the frequency of positive tests, we recommend another study with a larger sample, improved working conditions (mainly equipment) and the association of another test such as the Human Papilloma Virus (HPV) test.

Global women's health is more than maternal health: a review of gynecology care needs in low-resource settings

Women's health care efforts in low-resource settings are often focused primarily on prenatal and obstetric care. However, women all over the world experience significant morbidity and mortality related to cervical cancer, sexually transmitted infections, and urogynecologic conditions as well as gynecologic care provision including insufficient and ineffective family planning services. Health care providers with an interest in clinical care in low-resource settings should be aware of the scope of the burden of gynecologic issues and strategies in place to combat the problems. This review article discusses the important concerns both in the developing world as well as highlights similar disparities that exist in the United States by women's age, race and ethnicity, and socioeconomic status. Ultimately, this review article aims to inform and update health care providers on critical gynecologic issues in low-resource settings.

Underutilization of cervical cancer prevention services in low and middle income countries: a review of contributing factors

This review aims at identifying barriers to utilization of cervical cancer prevention services in low- and middle-income countries. An electronic search was conducted using the following key words, HPV vaccination, screening, barriers, utilization and low and middle income/developed countries. Using the Garrard (1999) Matrix method approach, a modified matrix was designed and used as a data collection tool and data related to each category listed on the tool were entered into a matrix containing columns reflecting the categories. Constant comparative analysis was used to identify thematic categories. 31 articles published between 2001 and 2014 were yielded from the search. Analysis of the contents of the articles showed that the underutilization of cervical cancer screening services in low and middle-income countries is the result of barriers in accessing and utilizing of the prevention services. Though not mutually exclusive, the barriers were categorized in three categories; individual, community and health system related. Individual barriers include lack of awareness and knowledge about risk factors and prevention of cervical cancer. Age, marital status, diffidence, social economic status, cultural and religious belief of the women also determine the women's' willingness to utilize the services. In some communities there is stigma attached to discussing reproductive health issues and this limits the young women's awareness of cervical cancer and its prevention. Understanding individual, community and health system barriers that hinder women's utilization of cervical cancer prevention services is very crucial in designing effective cervical cancer control programs in low- and middle-income countries.

Creating awareness and facilitating cervical and breast cancer screening uptake through the use of a Community Health Worker: a pilot intervention study

In South Africa, cervical cancer is the most common female cancer followed by breast cancer. Despite the high incidence of these cancers, population-based screening is limited to cervical screening available at primary health clinics. Cervical screening uptake is, however, low. In 2009 a new cancer prevention initiative was launched in a specific resource poor community in Tshwane, South Africa. The low cervical screening uptake as well as a potentially low breast screening uptake could have resulted in the failure of this initiative. The purpose of the study was to develop and pilot test an intervention to address this risk. A Community Health Worker was trained and tasked to raise awareness of cervical and breast cancer and motivate women to take up screening. The intervention was assessed in terms of three outcomes: screening uptake, awareness and the value of the Community Health Worker. Despite the fact that the Community Health Worker's role was valued, screening uptake was disappointing and the level of awareness remained low. Unfortunately this intervention failed and once again we are left with the challenge of improving screening uptake.

Awareness, perception and factors affecting utilization of cervical cancer screening services among women in Ibadan, Nigeria: a qualitative study

BACKGROUND

Over the years awareness and uptake of cervical cancer screening services has remained poor in developing countries. Problems associated with cervical cancer incidence include late reporting, ignorance and cultural issues relating to cervical cancer screening. This study sought to explore the awareness, perception and utilization of cervical cancer screening among women in Ibadan as well as factors that influence utilization.

METHOD

This is a qualitative study that utilized Eight Focus Group Discussions to collect information from women in selected health facilities in Ibadan, South West, Nigeria. The 82 participants were purposely recruited from women attending Antenatal clinics in 4 secondary and 4 primary health care facilities after approval was received from the Institutional Review Board in charge of the facilities. The focus group discussions were tape recorded and transcribed verbatim. The transcripts were analyzed into themes.

FINDINGS

The study provided qualitative information on the awareness, perception of the utilization of cervical cancer screening services among women in Ibadan. Participants were mainly married women (92.7%), mean age =27.6, SD =4.5, mainly traders (39%) and from Yoruba ethnic backgrounds (87.8%) and had secondary education (39%). The respondents reported not being aware of cervical cancer and were not utilizing the services. Though they did not know what cervical cancer screening entailed or the screening methods, they still believed that it is important since like for other diseases will help in early detection and treatment. The participants were eager to get more information from nurses on cervical cancer about cervical cancer screening. The major factors identified by the women that influence screening utilization were ignorance, Illiteracy, belief in not being at risk, having many contending issues, nonchalant attitude to their health, financial constraint and fear of having a positive result.

CONCLUSION

There is an urgent need for more enlightenment about cervical cancer especially by health workers. Also, cervical cancer services should be made available at very affordable cost so that women can easily access the services in order to reduce incidence of invasive cancer.

Acceptability of cervical cancer screening in rural Mozambique

In Zambézia province, Mozambique, cervical cancer (CC) screening was introduced to rural communities in 2010. Our study sought to determine whether women would accept screening via pelvic examination and visual inspection with acetic acid (VIA) at two clinical sites near the onset of a new CC screening program. A cross-sectional descriptive study of 101 women was undertaken in two rural communities in north-central Mozambique. We assessed a woman's willingness to be screened, knowledge about CC symptoms and treatment, and her recommendations for best methods to deliver information to other women. After the interview, we offered CC screening. Fully 86% of women accepted VIA screening when it was offered, but uptake was 100% at one clinic and only 68% at another. The cause of CC was thought to be associated with promiscuous activity (49%) and curses placed on the woman (42%). All women in one rural Mozambique clinic and two-thirds at a second clinic underwent CC screening. Knowledge about CC screening was significantly associated with uptake, suggesting educational campaigns need to be undertaken. However, educators need to be cautious about linking screening with high-risk behaviors, as women who understood the link trended toward refusing screening.

Cervical cancer screening in primary health care setting in Sudan: a comparative study of visual inspection with acetic acid and Pap smear

OBJECTIVE

To determine the feasibility of visual inspection with the use of acetic acid (VIA) as a screening method for cervical cancer, an alternative to the Pap smear used in primary health care setting in Sudan, and to compare sensitivity, specificity, positive and negative predictive values, and histological diagnosis of positive cases of both tests.

METHODS

A cross-sectional study of 934 asymptomatic women living in Khartoum, Sudan, was conducted during 2009-2010. A semi-structured questionnaire containing socio-economic and reproductive variables was used to collect data from each participant. Methods of screening used were VIA and conventional Pap smear, followed by colposcopy and biopsy for confirmation of the positive results of both screening tests.

RESULTS

The tests identified altogether 119 (12.7%) positive women. VIA detected significantly more positive women than Pap smear (7.6% versus 5.1%; P = 0.004), with an overlap between the two screening tests in 19% of positive results. There was no significant difference between VIA and Pap smear findings and sociodemographic and reproductive factors among screened women. Use of colposcopy and biopsy for positive women confirmed that 88/119 (73.9%) were positive for cervical intraepithelial neoplasia. VIA had higher sensitivity than Pap smear (74.2% versus 72.9%; P = 0.05) respectively. Out of 88 confirmed positive cases, 22 (25.0%) cases were invasive cervical cancer in stage 1, of which 19 versus three were detected by VIA and Pap smear respectively (P = 0.001). VIA had higher sensitivity and lower specificity than Pap smear (60.2% versus 47.7%) and (41.9% versus 83.8%) respectively. The combination of VIA/Pap has better sensitivity and specificity than each independent test (82.6% and 92.2%).

CONCLUSION

The findings of this study showed that VIA has higher sensitivity and lower specificity compared to Pap smear, but a combination of both tests has greater sensitivity and specificity than each test independently. It indicates that VIA is useful for screening of cervical cancer in the primary health care setting in Sudan, but positive results need to be confirmed by colposcopy and biopsy.

Cervical cancer risk factors and feasibility of visual inspection with acetic acid screening in Sudan

Objectives:

To assess the risk factors of cervical cancer and the feasibility and acceptability of a visual inspection with acetic acid (VIA) screening method in a primary health center in Khartoum, Sudan.

Methods:

A cross-sectional prospective pilot study of 100 asymptomatic women living in Khartoum State in Sudan was carried out from December 2008 to January 2009. The study was performed at the screening center in Khartoum. Six nurses and two physicians were trained by a gynecologic oncologist. The patients underwent a complete gynecological examination and filled in a questionnaire on risk factors and feasibility and acceptability. They were screened for cervical cancer by application of 3%–5% VIA. Women with a positive test were referred for colposcopy and treatment.

Results:

Sixteen percent of screened women were tested positive. Statistically significant associations were observed between being positive with VIA test and the following variables: uterine cervix laceration (odds ratio [OR] 18.6; 95% confidence interval [CI]: 4.64–74.8), assisted vaginal delivery (OR 13.2; 95% CI: 2.95–54.9), parity (OR 5.78; 95% CI: 1.41–23.7), female genital mutilation (OR 4.78; 95% CI: 1.13–20.1), and episiotomy (OR 5.25; 95% CI: 1.15–23.8). All these associations remained statistically significant after adjusting for age, educational level, employment, and potential confounding factors such as smoking, number of sexual partners, and use of contraceptive method. Furthermore, the VIA screening method was found to be feasible and acceptable to participants.

Conclusion:

This pilot study showed that women who have uterine cervix laceration, assisted vaginal delivery, female genital mutilation, or episiotomy are at an increased risk of cervical cancer. It also showed that VIA is a feasible and acceptable cervical cancer screening method in a primary health care setting.

Cryotherapy Treatment for Cervical Intraepithelial Neoplasia: Women's Experiences in Peru

Our objective was to examine cryotherapy experiences among women who received treatment for cervical intraepithelial neoplasia in a cervical cancer prevention project in rural Peru. The sample consisted of all women receiving cryotherapy during a 4-month period (July through October 2001). Structured interviews were conducted to collect information about the adequacy of information provision, women's satisfaction with cryotherapy, their ability to comply with postcryotherapy recommendations and condom use, their experience with cryotherapy side effects, and their satisfaction with cryotherapy follow-up. Of the 224 women who were interviewed, user satisfaction with cryotherapy treatment was generally good. A few women engaged in sex earlier than 30 days after treatment, primarily due to partner pressure to resume sex and the women's inability to successfully negotiate abstention from sex. These couples were not always able to use condoms. The percentage of women reporting vaginal discharge was within the range of responses reported in other studies. Cryotherapy appears to be acceptable to women in low-resource settings such as Peru.

Use of an expanded gold standard to estimate the accuracy of colposcopy and visual inspection with acetic acid

We estimate the accuracy of colposcopy and visual inspection with acetic acid (VIA) while minimizing the effects of misclassification bias, and maximizing ascertainment of disease. VIA was performed by experienced physicians on a population-based sample of women aged 30 to 49 years in rural Shanxi province, China. Each woman received VIA, liquid-based cytology (LBC) and hybrid capture 2 (hc2, QIAGEN, Gaithersburg, MD; formerly Digene Corporation). Any woman who tested positive on any test had colposcopy, endocervical curettage (ECC) with directed biopsies as necessary and 4-quadrant random biopsies from normal-appearing areas of the cervix. A standard diagnosis based on colposcopy and directed biopsy, and an expanded diagnosis including ECC and 4-quadrant random biopsy were generated for each woman. In 1,839 women, use of the expanded versus the standard diagnostic criteria increased the prevalence of histologically confirmed high-grade cervical intraepithelial neoplasia and cancer (CIN2+) from 3.2% (59/1,839) to 4.2% (77/1,839) and decreased the sensitivity of VIA for CIN2+ from 69.5% (95% CI: 56.8-79.8) to 58.4% (95% CI: 47.3-68.8%) with little change in specificity of approximately 89%. Compared with the expanded diagnostic criterion, the sensitivity of a visual diagnosis of high-grade CIN or cancer by a colposcopist was 49.4% (95% CI: 38.2-60.5). The use of an expanded diagnostic criterion in this study yielded more conservative estimates of the sensitivity of VIA and colposcopy.