Understanding the role of embarrassment in gynaecological screening: a qualitative study from the ASPIRE cervical cancer screening project in Uganda

Barriers and facilitators of cervical cancer screening literacy among rural women with HIV attending rural public health facilities in East Central Uganda: a qualitative study using the integrated model of health literacy

BACKGROUND

Several rural public health facilities in East Central Uganda have sub-optimal, below 50%, levels of uptake of cervical cancer screening services among women with HIV. This is attributed to low cervical cancer screening literacy: limited ability to access, understand, appraise, and apply cervical cancer screening information. This research identified multi-level (health facility, community, interpersonal and individual) barriers, and facilitators of accessing, understanding, and applying cervical cancer screening information among rural women with HIV attending rural public health facilities in East Central Uganda to inform interventions.

METHODS

We conducted ten Focus Group Discussions with rural women aged 25-49 years with HIV attending four selected rural public health facilities: thirty women who had ever screened for cervical cancer and thirty women who had never screened for cervical cancer across different age categories. Data was collected using a guide based on the Integrated model of health literacy. Thematic analysis was used for analysis. Competences (accessing, understanding and applying cervical cancer screening information) and categories of factors (health system, community, interpersonal and individual factors) of the integrated model of health literacy were deductively derived whereas barriers and facilitators were deductively derived from women's statements.

RESULTS

Lack of communication materials and inability to access information were health facility and individual barriers of accessing cervical cancer screening information respectively. Facilitators of accessing information were access to information at health facility, community, and interpersonal levels and women's ability to access information. Barriers and facilitators of understanding cervical cancer information were related to communication materials, provision of health education and women's concentration during health education. Barriers and facilitators of applying cervical cancer screening information were related to communication and provision of cervical cancer screening services at health facility level, and interpersonal level from peers, partners and other family members as well as women's ability to: understand information and access to cervical cancer screening services at individual level.

CONCLUSIONS

This study emphasizes the influence of multi-level factors on cervical cancer screening literacy among rural women with HIV attending rural public health facilities in East Central Uganda. Improving uptake of cervical cancer screening services among these women requires multi-level interventions.

Understanding women's and men's perspectives on cervical cancer screening in Uganda: a qualitative study

BACKGROUND

Cervical cancer remains a significant but preventable threat to women's health throughout much of the developing world, including Uganda. Cervical cancer screening and timely treatment of pre-cancerous lesions is a cost-effective means of mitigating cervical cancer morbidity and mortality. However, only 5% of women in Uganda have ever been screened. Barriers to screening, such as social stigma and access to safe conditions, have been previously identified, but insights into the role of male spouses in encouraging or discouraging screening have been limited. To our knowledge, no studies have compared barriers and facilitators among women who had or had not yet been screened and male partners of screened and unscreened women.

METHODS

To resolve this gap, we conducted 7 focus groups- 3 among women who had been screened, 3 among those who had not been screened, and 1 among men whose female partners had or had not been screened. We performed qualitative thematic analysis on the focus group data.

RESULTS

We identified several important factors impacting screening and the decision to screen among women, ranging from stigma, availability of screening, false beliefs around the procedure and side effects, and the role of spousal support in screening promotion. Male spousal perspectives for screening ranged from full support to hesitancy around male-performed exams and possible prolonged periods without intercourse.

CONCLUSION

This exploratory work demonstrates the importance of dialogue both among women and their male partners in enhancing screening uptake. Efforts to address screening uptake are necessary given that it is an important means of mitigating the burden of cervical cancer. Interventions along these lines need to take these barriers and facilitators into account in order to drive up demand for screening.

Evaluating human papillomavirus (HPV) self-sampling among Latinas in the United States: A systematic review

BACKGROUND

Latinas experience the greatest cervical cancer incidence compared with other ethnic/racial groups in the United States (US) due in part to significant disparities in screening uptake. Social and structural conditions that impede access to and participation in screening include language barriers, concerns about documentation status, logistical issues (e.g., transportation, limited clinic hours), and cultural beliefs regarding modesty and promiscuity. To overcome these challenges, self-sampling for human papillomavirus (HPV) DNA testing has emerged as a potentially promising method for promoting cervical cancer screening among this population. Thus, this systematic review aimed to assess the acceptability of HPV self-sampling among US Latinas.

METHODS

Using EBSCOhost and PubMed databases, we searched for studies published in the past two decades (2003-2023) that described participation in HPV self-sampling among Latinas. Eleven articles met inclusion criteria.

RESULTS

The majority of studies were conducted in Florida, California, and Puerto Rico, were single-arm designs, and involved the use of community health workers and Spanish-language materials (e.g., brochures). Across studies, the majority of participants reported that self-sampling was acceptable with respect to ease of use, comfort (lack of pain), privacy, and convenience; however, some women were concerned about the accuracy of self-sampling or whether they had performed sample collection correctly.

CONCLUSION

Given the high acceptability, self-collection of cervicovaginal samples for HPV testing may offer a feasible option for enhancing participation in cervical cancer screening in this population that encounters significant barriers to screening.

Providers and women's perspectives on opportunities, challenges and recommendations to improve cervical cancer screening in women living with HIV at Mbarara Regional Referral Hospital: a qualitative study

BACKGROUND

Cervical cancer screening uptake remains low despite being a critical prevention method for adult women living with HIV(WLHIV). These women experience greater incidence and persistence of high-risk human papillomavirus (HPV) and severe outcomes, including cervical cancer comorbidity and death.

OBJECTIVE

We explored the opportunities, challenges, and recommendations of clinical care providers and WLHIV to improve cervical cancer screening uptake among WLHIV in Southwestern Uganda.

METHODS

In a cross-sectional qualitative study from January to June 2021 at Mbarara Regional Referral Hospital, we interviewed six key informant clinical care providers and held four focus group discussions with women living with HIV. Data was coded using Atlas ti software and analysed using thematic inductive analysis.

RESULTS

The participants identified several prevailing opportunities for cervical cancer screening, including skilled clinical care workers, public awareness for demand creation, optimized clinic flow, provider-led referrals, and peer-led information sharing that ease clinic navigation and shorten participant throughput. However, challenges occurred due to standalone services resulting in double queuing, longer clinic visit hours, missed chances for screening alongside unsupported lower health facilities leading to crowding at the referral hospital, and inadequate patient privacy measures leading to shame and stigma and the misconception that cervical cancer is incurable. Integrating HPV-DNA testing in HIV services was perceived with ambivalence; some participants worried about the quality of sample collection, while others valued the privacy it offered. Optimising self-collected DNA testing and sufficient counselling were recommended to improve cervical cancer screening uptake.

CONCLUSION

Opportunities for cervical cancer screening included trained clinical care professionals, increased public awareness, improved clinic flow, provider referrals, and peer education. Challenges, such as unsupported lower-level health facilities, misconceptions, inadequate patient privacy, and uncertainty about integrating HPV-DNA screening into HIV services, were cited. Adequate counselling and self-sample collection were recommended to foster screening. Our findings may guide healthcare programs integrating cervical cancer screening into HIV clinics to reach the 70% World Health Organisation targets by 2030.

Experiences and perspectives regarding human papillomavirus self-sampling in sub-Saharan Africa: A systematic review of qualitative evidence

Introduction

Cervical cancer screening coverage remains low in sub-Saharan Africa (SSA) due to limited access and low uptake of available services by women. The use of HPV-based self-sampling intervention for cervical cancer screening has the potential to increase screening coverage in the region. This study aimed to analyse qualitative evidence on the experiences and perspectives of women, healthcare workers, and policymakers regarding HPV self-sampling.

Methods

We reviewed qualitative studies from January 2011 to March 2023 in PubMed, Scopus, Medline Ovid, Cochrane, and WEB of Science databases for articles with qualitative data on HPV self-sampling from different countries in SSA. The socio-ecological model was used to guide data analysis and the study findings.

Results

Thirteen qualitative studies were included for analysis, and they revealed themes under the intrapersonal, interpersonal, community, and health systems constructs of the Socio-ecological model. Intrapersonal themes included the acceptability of self-sampling, self-efficacy, and the perceived value of self-sampling. The interpersonal construct had themes such as women's spousal relationships, peer support, and the health worker's relationship with the women. The community construct had two themes: social stigma and misinformation, and the influence of cultural norms and religion. Finally, the health systems construct had themes such as the setting for self-sampling, follow-up availability of treatment services and education and awareness.

Conclusion

This study highlights the factors influencing the acceptability and uptake of an HPV-based self-sampling intervention for cervical cancer screening in SSA. Considering these findings when designing interventions in SSA is crucial to ensure acceptance and demand among end-users. Self-sampling interventions offer the potential to reach many unscreened women and increase cervical cancer screening coverage in SSA, which is an essential strategy towards achieving the World Health Organisation's cervical cancer elimination targets by the close of the century.

Practitioners support and intention to adopt universal access to self-collection in Australia's National Cervical Screening Program

OBJECTIVE

Primary care practitioners are crucial to engaging people in Australia's national cervical screening program. From July 2022, practitioners have been able to offer all screen-eligible people the choice to collect their own self-collected sample; an option introduced to increase equity. This study explored how practitioners are intending to incorporate universal access to self-collection into their clinical care.

METHODS

Semi-structed interviews with 27 general practitioners, nurses, and practice managers from 10 practices in Victoria, Australia conducted between May and August 2022. Interviews were deductively coded, informed by the Consolidated Framework for Implementation Research. The Diffusion of Innovations theory was used to categorise intention to provide self-collection.

RESULTS

Participants were supportive of universal access to self-collection, citing benefits for screen-eligible people and that it overcame the limited adaptability of the previous policy. Most participants' practices (n = 7, 70%) had implemented or had plans to offer the option for self-collection to all. Participants deliberating whether to provide universal access to self-collection held concerns about the correct performance of the self-test and the perceived loss of opportunity to perform a pelvic examination. Limited time to change practice-level processes and competing demands within consultations were anticipated as implementation barriers.

CONCLUSIONS

The extent to which self-collection can promote equity within the program will be limited without wide-spread adoption by practitioners. Communication and education that addresses concerns of practitioners, along with targeted implementation support, will be critical to ensuring that self-collection can increase participation and Australia's progression towards elimination of cervical cancer.

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.

Acceptability of Integrated Community-Based HIV and Cervical Cancer Screening in Mayuge District, Uganda

PURPOSE

To assess the acceptability of integrated screening for cervical cancer and HIV in the community setting.

METHODS

We developed surveys for patients and community health workers (CHWs) who participated in the Advances in Screening and Prevention in Reproductive Cancers (ASPIRE) Mayuge trial that compared self-collected human papillomavirus testing at home versus community health meetings in Mayuge district, Uganda. Quantitative data were summarized using descriptive statistics. Open-ended questions were analyzed using an inductive approach with thematic content analysis.

RESULTS

We conducted 102 patient surveys and 31 CHW surveys between June and August 2021. Ninety-nine percent of patients and 100% of CHWs indicated that they would find the addition of an HIV test to their self-collected cervical cancer test acceptable. The most frequently stated reasons in favor of adding an HIV test to the ASPIRE Mayuge cervical cancer screening pathways were time-saving, privacy, and support from other women and CHWs. The most frequently stated reasons against integrated screening were related to concerns about confidentiality, most often in reference to women's family members and other women in their village.

CONCLUSION

Integrated community-based cervical cancer and HIV testing would be highly acceptable to both women and CHWs.

Exploring the sources of cervical cancer screening self-efficacy among rural females: A qualitative study

AIM

Evidence showed self-efficacy was relevant to rural females' cervical cancer screening behaviour. However, little is known about sources of self-efficacy in cervical cancer screening among rural females. This study aimed to explore sources of self-efficacy in cervical cancer screening among rural females.

DESIGN

A qualitative descriptive study was conducted. Both users and providers of cervical cancer screening services in rural areas of China were recruited through maximum variation sampling.

METHODS

Individual semi-structured interviews through telephone calls were conducted. Data were analysed via six main stages of the framework method, with the social cognitive theory as a reference.

RESULTS

Four main sources were identified, including personal screening experience, hearing about other women's screening experiences, professional health education and consultation, and emotional status. Personal screening experience included enactive mastery of completing the screening behaviour and cognitive mastery of internalisation of the screening. Only the experience of completing cervical cancer screening behaviour was not strong enough to improve self-efficacy. Cognitive mastery showed more critical influence.

CONCLUSION

These four sources of rural females' cervical cancer screening self-efficacy matched with the major sources of self-efficacy of the social cognitive theory. Cognition was critical to influencing the screening self-efficacy. Intervention strategies aimed at enhancing rural females' cervical cancer screening self-efficacy can be developed from these four major sources.

PUBLIC CONTRIBUTION

A registered nurse with rich experience in cervical cancer-related research and qualitative study was the interviewer of this study. Rural females and cervical cancer screening services providers (healthcare professionals and village staff) were recruited as interviewees. The interview guides were developed by the research team and evaluated by an expert panel including two nurse leaders of gynaecological cancer, one doctor specialised in cervical cancer, and one medical director in a local rural hospital.

Precancerous cervical lesion screening acceptance among women in Eastern Ethiopia

OBJECTIVE

This study assessed perceived barriers, precancerous cervical lesion screening acceptance, and associated factors among women in Eastern Ethiopia.

SETTING

This study was conducted in Hiwot Fana Specialized Hospital and Jugal Hospital.

STUDY DESIGN

This study is a facility-based cross-sectional study.

STUDY PARTICIPANTS

This study included 1181 women aged 25-49 years. Bivariate and multivariable logistic regression was used to evaluate the relationship between variables and control confounders.

RESULTS

Nearly half of the participants (587 or 49.7%) agreed to be screened for precancerous cervical lesions. Seventy-six per cent of those checked were negative for visual inspection with acetic acid, 18.5% were positive, and 5.7% had cancer-like lesions. In multivariable analysis, fear of discomfort from the screening procedure, having a male screener, and embarrassment were the perceived barriers that were inversely associated with screening acceptance.

CONCLUSIONS

The uptake of the screening service in the study area was not satisfactory, indicating that the programme was underutilised in the area.

Comparison of Cervical Cancer Screening Used between Individuals with Disabilities and Individuals without Disabilities

OBJECTIVE

Cervical cancer is the fourth most prevalent cancer in women worldwide. It is vital to achieve a high cervical cancer screening rate among women. We compared the Pap smear test (PST) used between individuals with disabilities and those without disabilities in Taiwan.

METHODS

Individuals registered in the Taiwan Disability Registration File and the National Health Insurance Research Database (NHIRD) were screened for this nationally representative retrospective cohort study. Women aged 30 and above in 2016 and who were still alive in 2016 were matched in a 1:1 ratio via propensity score matching (PSM); 186,717 individuals with disabilities and 186,717 individuals without disabilities were included. Controlling for relevant variables, the odds of receiving PST were compared using conditional logistic regression analysis.

RESULTS

A lower percentage of individuals with disabilities (16.93%) received PST than those without disabilities (21.82%). The odds of individuals with disabilities receiving PST were 0.74 times that of individuals without disabilities (OR = 0.74, 95% CI = 0.73-0.76). Compared to individuals without disabilities, individuals with intellectual and developmental disabilities had the lower odds of receiving PST (OR = 0.38, 95% CI = 0.36-0.40), followed by individuals with dementia (OR = 0.40, 95% CI = 0.33-0.48) or multiple disabilities (OR = 0.52, 95% CI = 0.49-0.54).

CONCLUSIONS

We highly recommend that healthcare practitioners recognize the unique needs of individuals with different types of disabilities, especially those with cognitive impairments.

Community-integrated self-collected HPV-based cervix screening in a low-resource rural setting: a pragmatic, cluster-randomized trial

Effective approaches to improve coverage of self-collected human papillomavirus (HPV)-based cervix screening (SCS) as well as attendance at treatment for HPV-positive participants are needed to inform policy on optimal integration of cervical cancer screening programs within existing infrastructure in low-resource settings. ASPIRE Mayuge was a pragmatic cluster-randomized trial in rural Mayuge district, Uganda, comparing the superiority of two recruitment implementation strategies for SCS: Door-to-Door versus Community Health Day. Villages were randomized (unblinded) to a strategy, and participants aged 25-49 years with no previous history of hysterectomy or treatment for cervical cancer or pre-cancer were eligible. Participants completed a survey and participated in SCS. The primary outcome was rate of attendance at treatment after a positive SCS. The trial randomized 31 villages and 2,019 participants included in these analyses (Door-to-Door: 16 clusters, 1,055 participants; Community Health Day: 15 clusters, 964 participants). Among HPV-positive participants, attendance at treatment rates were 75% (Door-to-Door) and 67% (Community Health Day) (P = 0.049). Participants in the Community Health Day intervention were less likely to attend treatment compared to Door-to-Door (risk ratio = 0.78, 95% confidence interval: 0.64-0.96). No adverse events were reported. Policymakers in low-resource settings can use these results to guide implementation of SCS programs. ISRCTN registration: 12767014 . ClinicalTrials.gov registration: NCT04000503 .

Misconceptions About Female Cancers Contributing to Late Presentation to Health Facilities in Ethiopia: A Qualitative Study

Introduction

Morbidity and mortality from female cancers is a major public health problem in low- and middle-income countries, including Ethiopia. More than three quarters of women visiting health facilities are diagnosed with late-stage cervical and breast cancer. Evidence reveals that misconception affects timely health seeking behavior which could have averted expensive treatment and poor survival. This study aimed to explore misconceptions about female cancers that may have contributed to late presentation of the problem to health facilities in Sidama region, Ethiopia.

Methods

A descriptive qualitative study was carried out in June 2021. Nine focus group discussions (six with women and three with men) and 14 key informants were conducted. Data were collected using interview guide until all information get saturated. Data were inductively coded and qualitative content analysis was applied.

Results

A total of 63 (24 men and 39 women) people participated in this study. Nearly all (12) key informant interviewees have awareness about cervical and breast cancer, yet reported that their community members clearly lack awareness and they are working to improve misconceptions regarding cervical and breast cancer. The focus group discussion participants (15 men and 36 women) reported lack of detailed information related to cervical and breast cancer. Women believe that cervical and breast cancer mainly resulted from poor hygiene, trauma, having multiple sexual partners, early marriage, breast exposure to heat, not breast feeding, birth complication, urinating in the sun, hereditary, devil's intrusion and God's punishment.

Conclusion

There were misconceptions among the community on what cervical and breast cancer mean, how they could happen, what the symptoms are, why and when to screen, when to seek health care and how to use modern treatment options. Therefore, we recommended the design of social and behavioral change strategies to address the misconceptions among different population groups.

Cancer-Related Stigma in Malawi: Narratives of Cancer Survivors

PURPOSE

Stigma is an impediment across the cancer care continuum, leading to delayed presentation to care, elevated morbidity and mortality, and reduced quality of life. The goal of this study was to qualitatively examine the drivers, manifestations, and impacts of cancer-related stigma among individuals who received cancer treatment in Malawi, and to identify opportunities to address stigma.

METHODS

Individuals who had completed treatment for lymphoma (n = 20) or breast cancer (n = 9) were recruited from observational cancer cohorts in Lilongwe, Malawi. Interviews explored the individual's cancer journey, from first symptoms through diagnosis, treatment, and recovery. Interviews were audio-recorded and translated from Chichewa to English. Data were coded for content related to stigma, and thematically analyzed to describe the drivers, manifestations, and impacts of stigma along the cancer journey.

RESULTS

Drivers of cancer stigma included beliefs of cancer origin (cancer as infectious; cancer as a marker of HIV; cancer due to bewitchment), perceived changes in the individual with cancer (loss of social/economic role; physical changes), and expectations about the individual's future (cancer as death sentence). Cancer stigma manifested through gossip, isolation, and courtesy stigma toward family members. The impacts of cancer stigma included mental health distress, impediments to care engagement, lack of cancer disclosure, and self-isolation. Participants suggested the following programmatic needs: community education about cancer; counseling in health facilities; and peer support from cancer survivors.

CONCLUSION

The results highlight multifactorial drivers, manifestations, and impacts of cancer-related stigma in Malawi, which may affect success of cancer screening and treatment programs. There is a clear need for multilevel interventions to improve community attitudes toward people with cancer, and to support individuals along the continuum of cancer care.

Women's acceptability of a self-collect HPV same-day screen-and-treat program in a high burden setting in the Pacific

BACKGROUND

A field trial to evaluate a self-collect point-of-care HPV screen-and-treat (HPV S&T) program was implemented in two Well Women Clinics in Papua New Guinea (Papua New Guinea). Assessing the acceptability of a health intervention is a core element of evaluation. In this study, we examined women's acceptability of both self-collection and HPV S&T intervention in Papua New Guinea.  METHODS: Sixty-two semi-structured interviews were conducted with women who had undergone cervical screening in the same-day self-collected HPV screen-and-treat program in Madang and Western Highlands Provinces, Papua New Guinea. Data were thematically analysed using the Theoretical Framework of Acceptability (TFA) and managed using NVivo 12.5.

RESULTS

Most women agreed that self-collection was transformative: it helped circumvent the culturally embarrassing pelvic examination and increased their self-efficacy, especially due to the provision of health education, instructions, and pictorial aids. The availability of same-day results, and treatment if indicated, was particularly valued by the women because it reduced the financial and temporal burden to return to the clinic for results. It also meant they did not need to wait anxiously for long periods of time for their results. Women also appreciated the support from, and expertise of, health care workers throughout the process and spoke of trust in the HPV-DNA testing technology. Most women were willing to pay for the service to ensure its sustainability and timely scale-up throughout Papua New Guinea to support access for women in harder to reach areas.

CONCLUSION

This study reported very high levels of acceptability from a field trial of self-collection and HPV same-day screen-and-treat. The program was deemed culturally congruent and time efficient. This innovative cervical screening modality could be the 'solution' needed to see wider and more immediate impact and improved outcomes for women in Papua New Guinea and other high-burden, low-resource settings.

Social network-based group intervention to promote uptake of cervical cancer screening in Uganda: study protocol for a pilot randomized controlled trial

INTRODUCTION

Cervical cancer (CC) is the most common cancer and accounts for one quarter of all cancer-related deaths among women in Uganda, where lifetime CC screening is estimated to be as low as 5%. This study will evaluate the feasibility, acceptability, and preliminary efficacy of a social network-based group intervention designed to empower women who have received CC screening to encourage women in their social network to also screen.

METHODS

Forty adult women (index participants) who have recently screened for CC will be recruited, 20 of whom will be randomly assigned to take part in the intervention and 20 to the wait-list control. Each index participant will be asked to recruit up to three female social network members (i.e., alters; maximum total = 120 alters) who have not screened for CC to participate in the study. Assessments (survey and chart abstraction) will be administered at baseline and month 6 to index and alter participants. The primary outcome is CC screening among participating alters, with a secondary outcome being engagement in CC prevention advocacy among index participants. Repeated-measure multivariable regression analyses will be conducted to compare outcomes between the intervention and control arms.

DISCUSSION

If successful, this intervention model has the potential not only to impact uptake of CC screening and treatment but also to establish a paradigm that can be applied to other health conditions.

TRIAL REGISTRATION

NIH Clinical Trial Registry NCT04960748 (clinicaltrials.gov).

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.

Sexual Modesty in Sexual Expression and Experience: A Scoping Review, 2000 - 2021

Sexual modesty is the social, cultural, interpersonal, and psychological systems - defined by the tenets of Script Theory - that regulate individuals' sexual expression and experience at the social, legal, and interpersonal boundaries of acceptable/not-acceptable, private/public, and personal/social. Almost all aspects of sexual expression and experience are touched by the pervasive modesty standards for sexual communication, sexual display, sexual relations, and sexual behaviors. Sexual modesty influences an array of sexual and reproductive health outcomes. Many aspects of sexual modesty are enforced by legal as well as social, cultural, and religious proscriptions, including social shaming and ostracism as well as corporal and capital punishments. The purpose of this paper is to summarize a diverse literature related to sexual modesty from the years 2000 to 2021 in order to clarify its role in sexual health and sexual wellbeing and to identify directions for new research.

Qualitative factors influencing breast and cervical cancer screening in women: A scoping review

Breast and cervical are top cancers for women globally, but few studies have summarised how gender norms influence screening uptake, given sexual connotations and physical exposure. These beliefs may play a central role in decision-making, and understanding them is crucial to improving screening rates and services. This review scopes international literature for gender-based qualitative factors influencing women’s screening uptake. A systematic search of peer-reviewed English articles in PubMed, Scopus, and CINAHL was conducted from inception until December 2019. Articles were included if they were about breast or cervical cancer screening, had mixed or qualitative methodology, and sampled women from the general population. 72 studies spanning 34 countries were analysed. Eight studies also included healthcare providers’ views. Our narrative thematic analysis summarised primary themes extracted from each study into first-level subthemes, then synthesising second-level and third-level themes: (I) gender socialisation of women, (II) gender inequality in society, and (III) lack of empowerment to women in making screening decisions. Women tended to face sociocultural/role-based constraints, were expected to prioritise family, and keep bodily exposure to their husbands. Women showed low awareness and had fewer opportunities for health education compared to men. Male relations were often gatekeepers to financial resources needed to pay for screening tests. Screening risked community norms about women’s or husbands’ perceived embarrassing sexual behaviours. These findings suggest that interventions targeting unhelpful stigmatising beliefs about women’s cancer screening must concurrently address community general norms, familial role-based beliefs, as well as at male relations who hold the purse-strings.

Utilisation of cervical cancer screening among women living with HIV at Kenya's national referral hospital

Background

In 2009, Kenyatta National Hospital (KNH) integrated cervical cancer screening within HIV care using visual inspection with acetic acid (VIA) and Pap smear cytology.

Objectives

We evaluated utilisation of cervical cancer screening and human papillomavirus (HPV) vaccination among women living with HIV (WLHIV) receiving HIV care at KNH.

Method

From November 2019 to February 2020, WLHIV aged ≥ 14 years were invited to participate in a survey following receipt of routine HIV services. We assessed awareness of cervical cancer, uptake of cervical cancer screening, uptake of the HPV vaccine, and barriers to utilisation of these services. In a subset of survey participants, focus group discussions (FGDs) were also conducted to identify screening barriers.

Results

Overall, 305 WLHIV participated in the survey. Median age was 36 years (interquartile range [IQR]: 28-43), 41% were married, and 38% completed secondary education. Most (90%) had HIV RNA < 1000 copies/mL. Awareness of cervical cancer was high (84%), although only 45% of WLHIV had screened for cervical cancer at the referral hospital and only 13% knew how to prevent high-risk HPV. No participants had received an HPV vaccination. Older age, higher education, and knowledge of the HPV vaccine were associated with higher likelihood of cervical cancer screening (P < 0.05). In FGDs, barriers to utilising the services included user fees, fear of the procedure impacting fertility, age and gender of the provider, and long waiting times.

Conclusion

Despite integration with HIV services, the utilisation of cervical cancer screening was low among WLHIV and implementation barriers contributed to low utilisation.

Exploring Factors Associated with Patients Who Prefer Clinician-Sampling to HPV Self-Sampling: A Study Conducted in a Low-Resource Setting

Human papillomavirus (HPV) self-sampling (Self-HPV) is a promising strategy to improve cervical cancer screening coverage in low-income countries. However, issues associated with women who prefer conventional HPV clinical-sampling over HPV self-sampling may affect screening participation. To address this issue, our study assessed factors associated with women's preferences related to Self-HPV. This study was embedded in a large clinical trial recruiting women aged 30-49 years in a primary HPV-based study termed "3T-Approach" (for Test-Triage-Treatment), launched in 2018 at Dschang District Hospital, West Cameroon. Participants were invited to perform a Self-HPV. After the sampling and before receiving the results, participants completed a questionnaire about cervical cancer screening and their preferences and perceptions around Self-HPV. The median age of the 2201 participants was 40.6 (IQR 35-45) years. Most (1693 (76.9%)) preferred HPV self-sampling or had no preference for either method, and 508 (23.1%) preferred clinician-sampling. Factors associated with an increased likelihood of reporting a clinician-sampling preference were tertiary educational level (29.4% CI: 25.6-33.6 vs. 14.4% CI: 12.8-16.1) and being an employee with higher grade professional or managerial occupations (5.5% CI: 3.8-7.9 vs. 2.7% CI: 2.0-3.5). The main reported reason for women preferring clinician-sampling was a lack of "self-expertise". Most women (>99%) would agree to repeat HPV self-sampling and would recommend it to their relatives. HPV self-sampling in the cultural context of central Africa was well accepted by participants, but some participants would prefer to undergo clinician sampling. Health systems should support well-educated women to increase self-confidence in using HPV self-sampling.

Barriers to follow-up after an abnormal cervical cancer screening result and the role of male partners: a qualitative study

INTRODUCTION

Cervical cancer is the leading cause of cancer deaths among women in Malawi, but preventable through screening. Malawi primarily uses visual inspection with acetic acid (VIA) for screening, however, a follow-up for positive screening results remains a major barrier, in rural areas. We interviewed women who underwent a community-based screen-and-treat campaign that offered same-day treatment with thermocoagulation, a heat-based ablative procedure for VIA-positive lesions, to understand the barriers in accessing post-treatment follow-up and the role of male partners in contributing to, or overcoming these barriers.

METHODS

We conducted in-depths interviews with 17 women recruited in a pilot study that evaluated the safety and acceptability of community-based screen-and-treat programme using VIA and thermocoagulation for cervical cancer prevention in rural Lilongwe, Malawi. Ten of the women interviewed presented for post-treatment follow-up at the healthcare facility and seven did not. The interviews were analysed for thematic content surrounding barriers for attending for follow-up and role of male partners in screening.

RESULTS

Transportation was identified as a major barrier to post-thermocoagulation follow-up appointment, given long distances to the healthcare facility. Male partners were perceived as both a barrier for some, that is, not supportive of 6-week post-thermocoagulation abstinence recommendation, and as an important source of support for others, that is, encouraging follow-up attendance, providing emotional support to maintaining post-treatment abstinence and as a resource in overcoming transportation barriers. Regardless, the majority of women desired more male partner involvement in cervical cancer screening.

CONCLUSION

Despite access to same-day treatment, long travel distances to health facilities for post-treatment follow-up visits remained a major barrier for women in rural Lilongwe. Male partners were identified both as a barrier to, and an important source of support for accessing and completing the screen-and-treat programme. To successfully eliminate cervical cancer in Malawi, it is imperative to understand the day-to-day barriers women face in accessing preventative care.

Spillovers and Social Interaction Effects in the Demand for Preventive Healthcare: Evidence from the PROGRESA program

This paper exploits the randomized research design of a large welfare program-PROGRESA-to study the existence in rural Mexico of spillover effects in the propensity to screen for gender- and non-gender-specific conditions. I find significant evidence of increased demand for Papanicolaou cervical-cancer screening among women ineligible for the Conditional Cash Transfer, yet no evidence of similar externalities in non-gender specific tests, such as blood-pressure and blood-sugar checks. Certain pieces of evidence are suggestive of the weakening of the social norm related to husbands' opposition to screening of their wives as one of the possible drivers of the indirect effect.

Cancer and severe mental illness in low- and middle-income countries: The challenges and outlook for the future

OBJECTIVE

Patients with severe mental illness (SMI) face health inequalities that lead to under treatment of diseases such as cancer and result in increased mortality. There is literature addressing this issue for SMI patients in high-income countries but few for those in low- and middle-income countries. This review aims to draw attention to the health inequalities and the compounding factors faced by SMI patients in low- and middle-income countries. The relevance of integration of psycho-oncology in the care of SMI patients with cancer is integral to reduce disparities and address varied contributory factors.

METHODS

The literature review was conducted by searching through two databases which includes PubMed and Google Scholar. We searched for articles using keyword search terms: severe mental illness, SMI, schizophrenia, bipolar disorder, cancer, low- middle-income countries, low- and middle-income countries, psycho-oncology, HPV vaccine, cancer incidence, cancer mortality, cancer control, cancer screening, cancer treatment and palliative care.

RESULTS

A total of 80 research articles were included in our literature review. We found that there was an increased requirement for adapting to the changing disease landscape in low- and middle-income countries. An improvement on aspects such as vaccination, screening and prevention is necessary, and also efforts to change social stance towards SMI is crucial.

CONCLUSION

There is an increase incidence of cancer in low- and middle-income countries, and the number of patients with SMI in low- and middle-income countries is also rising. This is due to social, psychological, economical and healthcare factors. Low- and middle-income countries must consider improving these aspects in order to adapt to the changing landscape.

Self-collection for HPV-based cervical screening: a qualitative evidence meta-synthesis

Background

Cervical cancer is the fourth most common cancer affecting women worldwide, with 85% of the burden estimated to occur among women in low and middle-income countries (LMICs). Recent developments in cervical cancer screening include a novel self-collection method for the detection of oncogenic HPV strains in the collected samples. The purpose of this review is to synthesise qualitative research on self-collection for HPV-based testing for cervical screening and identify strategies to increase acceptability and feasibility in different settings, to alleviate the burden of disease.

Methods

This review includes qualitative studies published between 1986 and 2020. A total of 10 databases were searched between August 2018 and May 2020 to identify qualitative studies focusing on the perspectives and experiences of self-collection for HPV-based cervical screening from the point of view of women, health care workers and other key stakeholders (i.e., policymakers). Two authors independently assessed studies for inclusion, quality, and framework thematic synthesis findings. The Socio-Ecological Model (SEM) was used to synthesize the primary studies.

Results

A total of 1889 publications were identified, of which 31 qualitative studies were included. Using an adapted version of SEM, 10 sub-themes were identified and classified under each of the adapted model’s constructs: (a) intrapersonal, (b) interpersonal, and (c) health systems/public policy. Some of the themes included under the intrapersonal (or individual) construct include the importance of self-efficacy, and values attributed to self-collection. Under the intrapersonal construct, the findings centre around the use of self-collection and its impact on social relationships. The last construct of health systems focuses on needs to ensure access to self-collection, the need for culturally sensitive programs to improve health literacy, and continuum of care.

Conclusion

This review presents the global qualitative evidence on self-collection for HPV-based testing and details potential strategies to address socio-cultural and structural barriers and facilitators to the use of self-collection. If addressed during the design of an HPV-based cervical cancer screening testing intervention program, these strategies could significantly increase the acceptability and feasibility of the intervention and lead to more effective and sustainable access to cervical screening services for women worldwide.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11554-6.

Genitalia-related nursing embarrassment and its associated factors among female nurses in mainland China: a nationwide cross-sectional study

Background

Genital-related care is a common nursing procedure and may cause embarrassment for nurses. However, nurses’ level of embarrassment and the factors associated with embarrassment have been scarcely studied. Therefore, a cross-sectional study was conducted to investigate genitalia-related care’s embarrassment and its associated factors among Chinese female nurses.

Methods

Online questionnaires regarding the frequency of genitalia-related care and the embarrassment level were distributed to female nurses from the gynecology and urology departments between October and December 2019. Participants also completed the Chinese version of the professional identity scale for nurses and the Jefferson scale of empathy. Mantel-Haenszel chi-square and ordinal logistic regression were used to explore factors associated with the level of embarrassment.

Results

In total, 648 female nurses from 54 hospitals in 31 cities in China were recruited. Among these respondents, approximately 67% provided genitalia-related care at least three days per week, and about 70% of nurses felt slightly embarrassed to extremely embarrassed when providing genitalia-related care. Compared to nurses from gynecology departments, nurses from urology departments felt more embarrassed during genitalia-related care (P<0.001). Ordinal regression analysis showed that the odds of nurses from gynecology and urology departments with total empathy scores greater than 100 experiencing higher levels of embarrassment than nurses with total empathy scores less than 100 were 0.47 and 0.45, respectively. Nurses from gynecology departments with higher professional identity scores, higher education levels, more frequent genital-related care experienced less embarrassment, while nurses from the urology department with prior sexual experience experienced less embarrassment.

Conclusions

Feeling embarrassed during genitalia-related nursing was common among Chinese female nurses, especially those from urology departments. Embarrassment during genitalia-related nursing was related to professional identity, empathy, educational level, genitalia-related care frequency, and sexual history. These findings highlight the importance of professional identity, empathy, and education among nurses.

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

To address gaps in access to cervical cancer screening and early diagnosis of breast cancer services in Sub-Saharan African (SSA), this scoping review was conducted to explore facilitators and barriers that exist on the patient-, provider-, and system-level. An extensive literature search was conducted in accordance with scoping review methodology and the Cochrane guidelines. Our search criteria were limited to original research studies conducted in community or clinical settings in SSA within the last 10 years (2010-2020). Themes found from this review included patient knowledge and provider education, access to screening services, trust, health-related behaviors, attitudes, values, and practices, community and social values, health infrastructure, resource allocation, and political will. Identified barriers included lack of knowledge about cervical and breast cancer among patients, gaps in education and training among providers, and lack of resources and health infrastructure at the facility level and within the overall health system. Facilitators included perceived risk of cancer, support and encouragement of the provider, and utilization of novel approaches in low-resource settings by health systems. To better address individual-, provider-, and health system and facility-based facilitators and barriers to care, there is a need for political and financial investment and further research on the health service delivery in specific national health systems, especially in the context of the global campaign to eliminate cervical cancer as a public health problem.

Perceptions on the collection of body fluids for research on persistence of Ebola virus: A qualitative study

Background

Against the background of the international public health emergency related to the Ebola outbreak in the Democratic Republic of Congo, in addition to other recent large Ebola epidemics, the issue of transmission due to viral persistence from survivors’ body fluids is becoming increasingly urgent. Clinical research in which body fluids play a role is critical and semen testing programs are part of the suggested response to the outbreak. Broad acceptance and understanding of testing programs and research, often in resource poor settings, is essential for the success and sustainability of clinical studies and an accurate epidemic response. Study participants’ perceptions on the collection of body fluids are therefore relevant for the programmatic planning and implementation of clinical studies.

Study aim and methods

In this qualitative study we aimed to explore the perceptions on bio-sampling in the Sierra Leone Ebola Virus Persistence Study (SLEVP study). We were interested to understand how norms on gender and sexuality related to perceptions and experiences of study participants and staff, specifically, in what way perceptions of the body, on intimacy and on body fluids related to the study process. We purposively sampled former study participants for in-depth interviews and focus-group discussions. We conducted 56 in-depth interviews and eight focus group discussions with 93 participants. In a participatory approach we included study participants in the analysis of data.

Results

Overall the SLEVP study was well perceived by study participants and study staff. Study participants conceived the testing of their body fluids positively and saw it as a useful means to know their status. However, some study participants were ambivalent and sometimes reluctant towards sampling of certain body fluids (especially semen, blood and vaginal fluid) due to religious or cultural reasons. Self-sampling was described by study participants as a highly unusual phenomenon. Several narratives were related to the loss of body fluids (especially semen) that would make men weak and powerless, or women dizzy and sick (especially blood). Some rumors indicated mistrust related to study aims that may have been expressions of broader societal challenges and historical circumstances. These reservations could eventually be overcome by guaranteeing confidentiality and privacy and by comprehensive professional counseling.

Conclusion

In the course of the sampling exercise, study participants were often obliged to transgress cultural and intimate boundaries. It is therefore important to understand the potential importance some of these perceptions have on the recruitment of study participants and the acceptability of studies, on a symbolic as well as a structural level. In order to capture any reservations it is necessary to provide plenty of possibilities of information sharing and follow-up of continuous consent.

Recent studies have shown that the Ebola Virus might persist in body fluids of survivors of the disease. Clinical research in which body fluids (semen, vaginal fluids, blood, sweat, tears, breast milk and rectal fluids) are sampled play an increasingly important role, specifically in light of growing EVD epidemics. The success of these studies, e.g. how many participants are recruited in a study and how many are staying until the end of a study, is highly dependent on the participants’ cooperation and understanding of testing programs. However, until now there has been only little research on how studies and testing programs in which body fluids are sampled are perceived and understood by study participants. In this study we were therefore interested to understand how study participants perceived the sampling and collection of body fluids and how their cultural or religious background may influence the willingness to participate and stay in a clinical study. We conducted one-to-one interviews and focus-group discussions with 93 former study participants of a viral persistence study. We found that overall study participants conceived the testing of their body fluids positively and saw it as a useful means to know their status. However, some study participants were ambivalent and sometimes reluctant towards sampling of certain body fluids (especially semen, blood and vaginal fluid) due to religious or cultural reasons. Self-sampling was described by study participants as a highly unusual phenomenon. Participants explained that the collection of certain body fluids would make men weak and powerless (especially the sampling of semen), or women dizzy and sick (especially blood). Rumors indicated that some participants mistrusted the study aims. In the course of the sampling exercise, study participants often felt that they had to transgress cultural and intimate boundaries. We conclude that it is important to understand the potential importance some of these perceptions have on the recruitment of study participants and the acceptability of studies. The understanding of the socio-cultural context of clinical research is relevant for the programmatic planning of such research.

Reasons for Not Attending Cervical Cancer Screening and Associated Factors in Rural Ethiopia

Social, economic, and cultural factors have been associated with the level of participation in cervical cancer screening programs. This study identified factors associated with nonparticipation in cervical cancer screening, as well as reasons for not attending, in the context of a population-based, cluster-randomized trial in Ethiopia. A total of 2,356 women aged 30 to 49 years in 22 clusters were invited to receive one of two screening approaches, namely human papillomavirus (HPV) self-sampling or visual inspection with acetic acid (VIA). Participants and nonparticipants were analyzed according to their sociodemographic and economic characteristics. Reasons were determined for the refusal of women to participate in either screening method. More women in the VIA arm compared to the HPV arm declined participation in the screening [adjusted OR (AOR) 3.5; 95% confidence interval (CI), 2.6-4.8]. Women who declined attending screening were more often living in rural areas (AOR = 2.0; 95% CI, 1.1-3.5) and were engaged in informal occupations (AOR = 1.6; 95% CI, 1.1-2.4). The majority of nonattendants perceived themselves to be at no risk of cervical cancer (83.1%). The main reasons given for not attending screening for both screening approaches were lack of time to attend screening, self-assertion of being healthy, and fear of screening. We found that perceived time constraints and the perception of being at no risk of getting the disease were the most important barriers to screening. Living in rural settings and informal occupation were also associated with lower participation. Offering a swift and convenient screening service could increase the participation of women in cervical cancer screening at the community level.

A cross-sectional study of barriers to cervical cancer screening uptake in Ghana: An application of the health belief model

Background

The high incidence (32.9, age-standardized per 100,000) and mortality (23.0, age-standardized per 100,000) of cervical cancer (CC) in Ghana have been largely attributed to low screening uptake (0.8%). Although the low cost (Visual inspection with acetic acid) screening services available at various local health facilities screening uptake is meager.

Objective

The purpose of the study is to determine the barriers influencing CC screening among women in the Ashanti Region of Ghana using the health belief model.

Methods

A analytical cross-sectional study design was conducted between January and March 2019 at Kenyase, the Ashanti Region of Ghana. The study employed self-administered questionnaires were used to collect data from 200 women. Descriptive statistics were used to examine the differences in interest and non-interest in participating in CC screening on barriers affecting CC screening. Multivariable logistic regression was used to determine factors affecting CC screening at a significance level of p<0.05.

Results

Unemployed women were less likely to have an interest in CC screening than those who were employed (adjustes odds ratio (aOR) = 0.005, 95%CI:0.001–0.041, p = 0.005). Women who were highly educated were 122 times very likely to be interested in CC screening than those with no or low formal education (aOR = 121.915 95%CI: 14.096–1054.469, p<0.001) and those who were unmarried were less likely to be interested in CC screening than those with those who were married (aOR = 0.124, 95%CI: 0.024–0.647, p = 0.013). Also, perceived threat, perceived benefits, perceived barriers and cues for action showed significant differences with interest in participating in screening with a P-values <0.003. The association was different for long waiting time, prioritizing early morning and late evening screening which showed no significant difference (P-value > 0.003).

Conclusions

Married women, unemployed and those with no formal education are less likely to participate in CC screening. The study details significant barriers to cervical cancer screening uptake in Ghana. It is recommended that the Ghana health services should develop appropriate, culturally tailored educational materials to inform individuals with no formal education through health campaigns in schools, churches and communities to enhance CC screening uptake.

Efficacy of strategies to increase participation in cervical cancer screening: GPs offering self-sampling kits for HPV testing versus recommendations to have a pap smear taken - A randomised controlled trial

Background

Cervical cancer is preventable by early detection and treatment of pre-cancerous lesions. The current screening policy in Belgium (3-yearly cytology on Pap smears) covers 60% of the target population. Offering self-samples by GPs can overcome barriers for women who are currently not screened.

Methods

Women aged 25–64 who did not have a Pap smear since three years and consulted a GP practice in a Flemish municipality between November 2014 and April 2015 were allocated in a 1:1 ratio to either the intervention arm where women were given a vaginal self-sampling kit or control arm where women were encouraged to make an appointment for having a Pap smear taken by a clinician.

Results

Eighty-eight consenting women were randomised. 35 (78%) out of 45 women in the self-sampling arm participated in screening compared to 22 (51%) out of 43 women in the control arm (p = 0.009). This difference remained significant after adjusting for covariates (age category, education level, time interval since last Pap smear, past Pap smear-taker).

Conclusion

GPs offering self-sampling kits resulted in a high participation. Larger trials should confirm this effect and evaluate feasibility of this approach.4. The authors would also like to include the following sentence in the acknowledgement “The laboratory AML (Antwerp, Belgium) is acknowledged for the free HPV testing on the self-samples."

A Qualitative Exploration of Women's Experiences with a Community Health Volunteer-Led Cervical Cancer Educational Module in Migori County, Kenya

Detection and treatment of human papillomavirus (HPV) and cervical precancer through screening programs is an effective way to reduce cervical cancer deaths. However, high cervical cancer mortality persists in low- and middle-income countries. As screening programs become more widely available, it is essential to understand how knowledge about cervical cancer and perceived disease risk impacts screening uptake and acceptability. We evaluated women's experiences with a cervical cancer education strategy led by community health volunteers (CHVs) in Migori County, Kenya, as part of a cluster randomized controlled trial of cervical cancer screening implementation strategies. The educational modules employed simple language and images and sought to increase understanding of the relationship between HPV and cervical cancer, the mechanisms of self-collected HPV testing, and the importance of cervical cancer screening. Modules took place in three different contexts throughout the study: (1) during community mobilization; (2) prior to screening in either community health campaigns or health facilities; and (3) prior to treatment. Between January and September 2016, we conducted in-depth interviews with 525 participants to assess their experience with various aspects of the screening program. After the context-specific educational modules, women reported increased awareness of cervical cancer screening and willingness to screen, described HPV- and cervical cancer-related stigma and emphasized the use of educational modules to reduce stigma. Some misconceptions about cervical cancer were evident. With effective and context-specific training, lay health workers, such as CHVs, can help bridge the gap between cervical cancer screening uptake and acceptability.

HPV self-sampling acceptability and preferences among women living with HIV in Botswana

OBJECTIVE

To assess the acceptability and preferences of HPV screening with self-sampling and mobile phone results delivery among women living with HIV (WLWH) in Botswana, as an alternative to traditional speculum screening.

METHODS

WLWH aged 25 years or older attending an infectious disease clinic in Gaborone were enrolled in a cross-sectional study between March and April 2017. Women self-sampled with a flocked swab, had a speculum exam, and completed an interviewer-administered questionnaire about screening acceptability, experiences, and preferences.

RESULTS

Of the 104 WLWH recruited, 98 (94%) had a history of traditional screening. Over 90% agreed self-sampling was easy and comfortable. Ninety-five percent were willing to self-sample again; however, only 19% preferred self-sampling over speculum exam for future screening. Preferences differed by education and residence with self-sampling being considered more convenient, easier, less embarrassing, and less painful. Speculum exams were preferred because of trust in providers' skills and women's low self-efficacy to sample correctly. Almost half (47%) preferred to receive results via mobile phone call. Knowledge of cervical cancer did not affect preferences.

CONCLUSION

HPV self-sampling is acceptable among WLWH in Botswana; however, preferences vary. Although self-sampling is an important alternative to traditional speculum screening, education and support will be critical to address women's low self-efficacy to self-sample correctly.

Barriers and facilitators to uptake of cervical cancer screening among women in Uganda: a systematic review

BACKGROUND

Uganda has one of the highest age-standardized incidence rates of cervical cancer in the world. The proportion of Ugandan women screened for cervical cancer is low. To evaluate barriers and facilitators to accessing cervical cancer screening, we performed a systematic review of reported views of Ugandan women and healthcare workers. The aim of this review is to inform development of cervical cancer screening promotional and educational programs to increase screening uptake and improve timely diagnosis for women with symptoms of cervical cancer.

METHODS

Fourteen studies that included the views of 4386 women and 350 healthcare workers published between 2006 and 2019 were included. Data were abstracted by two reviewers and findings collated by study characteristics, study quality, and barriers and facilitators.

RESULTS

Nineteen barriers and twenty-one facilitators were identified. Study settings included all districts of Uganda, and the quality of included studies was variable. The most frequently reported barriers were embarrassment, fear of the screening procedure or outcome, residing in a remote or rural area, and limited resources / health infrastructure. The most frequent facilitator was having a recommendation to attend screening.

CONCLUSION

Understanding the barriers and facilitators to cervical cancer screening encountered by Ugandan women can guide efforts to increase screening rates in this population. Additional studies with improved validity and reliability are needed to produce reliable data so that efforts to remove barriers and enhance facilitators are well informed.

Barriers and facilitators to uptake of cervical cancer screening among women in Uganda: a systematic review

BACKGROUND

Uganda has one of the highest age-standardized incidence rates of cervical cancer in the world. The proportion of Ugandan women screened for cervical cancer is low. To evaluate barriers and facilitators to accessing cervical cancer screening, we performed a systematic review of reported views of Ugandan women and healthcare workers. The aim of this review is to inform development of cervical cancer screening promotional and educational programs to increase screening uptake and improve timely diagnosis for women with symptoms of cervical cancer.

METHODS

Fourteen studies that included the views of 4386 women and 350 healthcare workers published between 2006 and 2019 were included. Data were abstracted by two reviewers and findings collated by study characteristics, study quality, and barriers and facilitators.

RESULTS

Nineteen barriers and twenty-one facilitators were identified. Study settings included all districts of Uganda, and the quality of included studies was variable. The most frequently reported barriers were embarrassment, fear of the screening procedure or outcome, residing in a remote or rural area, and limited resources / health infrastructure. The most frequent facilitator was having a recommendation to attend screening.

CONCLUSION

Understanding the barriers and facilitators to cervical cancer screening encountered by Ugandan women can guide efforts to increase screening rates in this population. Additional studies with improved validity and reliability are needed to produce reliable data so that efforts to remove barriers and enhance facilitators are well informed.

Genital self-sampling for HPV-based cervical cancer screening: a qualitative study of preferences and barriers in rural Ethiopia

Background

In the context of WHO’s “task shifting” project and growing global consensus on primary HPV-based cervical cancer screening, self-sampling is a promising new tool to expand screening access, uptake and coverage for women worldwide. We aimed to explore perceptions and acceptability of HPV self-sampling-based cervical cancer screening among community members and health professionals in rural northwest Ethiopia and to identify preferences and socio-cultural barriers regarding self-sampling in order to design a suitable high-coverage screening intervention for a rural African setting.

Methods

Four community-based focus group discussions (FGD) were conducted in the rural district of Dabat, Northwest Ethiopia, each comprising 8 to 14 female participants, counting a total of 41 participants. The groups were homogenously composed in terms of their socio-economic status in the community. They included health centre attendees, community members, nurses and health development army leaders (HDAL). Two qualitative data collection experts conducted the interviews in the local language, using a FGD guide with several thematic areas. All participants granted written informed consent prior to the conduct of the interviews. As a concrete example of an existing self-sampling approach for cervical cancer screening we used the Evalyn® Brush.

Results

Emerging themes included (i) misconceptions and low awareness about cervical cancer among community residents and primary health care providers in rural northwest Ethiopia, (ii) stigmatization and social exclusion of affected women, (iii) delay in seeking of health care due to poor access and availability of services, and lacking of a concept of early cancer prevention, (iv) need of spousal permission, (v) fear of financial burden and (vi) fear of social marginalization. The self-sampling device was regarded to be acceptable and was judged to be easy to use for most women. The existing Ethiopian health care structure could facilitate a community approach.

Conclusion

Home-based self-sampling for cervical cancer screening is a socially acceptable and feasible “task shifting” method that will increase cervical cancer screening access and coverage in the Ethiopian study community. Education, awareness creation, community mobilization and family inclusion are identified as key activities to promote, implement and facilitate “task shifting” approaches like self-sampling.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7354-4) contains supplementary material, which is available to authorized users.

Understanding Men's Perceptions of Human Papillomavirus and Cervical Cancer Screening in Kampala, Uganda

Purpose

This preliminary study explores Ugandan men’s knowledge and attitudes about human papillomavirus (HPV), cervical cancer, and screening.

Methods

A local physician led an education session about cervical cancer for 62 men in Kisenyi, Kampala in Uganda. Trained nurse midwives administered surveys to assess knowledge and attitudes before and after the education session.

Results

From the pre-education survey, only 24.6% of men had heard of HPV previously, and 59% of men had heard of cervical cancer. Posteducation, 54.5% of men believed only women could be infected with HPV and 32.7% of men believed antibiotics could cure HPV. Despite their limited knowledge, 98.2% of men stated they would support their partners to receive screening for cervical cancer, and 100% of men surveyed stated they would encourage their daughter to get the HPV vaccine if available.

Conclusions

Knowledge of HPV and cervical cancer among Ugandan men is low. Even after targeted education, confusion remained about disease transmission and treatment. Ongoing education programs geared toward men and interventions to encourage spousal communication about reproductive health and shared decision making may improve awareness of cervical cancer prevention strategies.

Community-based HPV self-collection versus visual inspection with acetic acid in Uganda: a cost-effectiveness analysis of the ASPIRE trial

BACKGROUND

Cervical cancer is the leading cause of cancer death for women in Uganda, despite the potential for prevention through organised screening. Community-based self-collected human papillomavirus (HPV) testing has been proposed to reduce barriers to screening.

OBJECTIVE

Our objective was to evaluate the cost-effectiveness of the Advances in Screening and Prevention of Reproductive Cancers (ASPIRE) trial, conducted in Kisenyi, Uganda in April 2014 (n=500). The trial compared screening uptake and compliance with follow-up in two arms: (1) community-based (ie, home or workplace) self-collected HPV testing (facilitated by community health workers) with clinic-based visual inspection with acetic acid (VIA) triage of HPV-positive women ('HPV-VIA') and (2) clinic-based VIA ('VIA'). In both arms, VIA was performed at the local health unit by midwives with VIA-positive women receiving immediate treatment with cryotherapy.

DESIGN

We informed a Monte Carlo simulation model of HPV infection and cervical cancer with screening uptake, compliance and retrospective cost data from the ASPIRE trial; additional cost, test performance and treatment effectiveness data were drawn from observational studies. The model was used to assess the cost-effectiveness of each arm of ASPIRE, as well as an HPV screen-and-treat strategy ('HPV-ST') involving community-based self-collected HPV testing followed by treatment for all HPV-positive women at the clinic.

OUTCOME MEASURES

The primary outcomes were reductions in cervical cancer risk and incremental cost-effectiveness ratios (ICERs), expressed in dollars per year of life saved (YLS).

RESULTS

HPV-ST was the most effective and cost-effective screening strategy, reducing the lifetime absolute risk of cervical cancer from 4.2% (range: 3.8%-4.7%) to 3.5% (range: 3.2%-4%), 2.8% (range: 2.4%-3.1%) and 2.4% (range: 2.1%-2.7%) with ICERs of US$130 (US$110-US$150) per YLS, US$240 (US$210-US$280) per YLS, and US$470 (US$410-US$550) per YLS when performed one, three and five times per lifetime, respectively. Findings were robust across sensitivity analyses, unless HPV costs were more than quadrupled.

CONCLUSIONS

Community-based self-collected HPV testing followed by treatment for HPV-positive women has the potential to be an effective and cost-effective screening strategy.

Lung Cancer Screening Participation: Developing a Conceptual Model to Guide Research

PURPOSE

To describe the development of a conceptual model to guide research focused on lung cancer screening participation from the perspective of the individual in the decision-making process.

METHODS

Based on a comprehensive review of empirical and theoretical literature, a conceptual model was developed linking key psychological variables (stigma, medical mistrust, fatalism, worry, and fear) to the health belief model and precaution adoption process model.

RESULTS

Proposed model concepts have been examined in prior research of either lung or other cancer screening behavior. To date, a few studies have explored a limited number of variables that influence screening behavior in lung cancer specifically. Therefore, relationships among concepts in the model have been proposed and future research directions presented.

CONCLUSION

This proposed model is an initial step to support theoretically based research. As lung cancer screening becomes more widely implemented, it is critical to theoretically guide research to understand variables that may be associated with lung cancer screening participation. Findings from future research guided by the proposed conceptual model can be used to refine the model and inform tailored intervention development.

Breast and gynecological cancer patients' risk factors associated with biopsychosocial problem-related distress

OBJECTIVES

Inequalities exist between breast and gynecological cancer patients' experiences, leading to high levels of distress throughout the cancer journey. The present study aims to identify differences in source of biopsychosocial problem-related distress between women diagnosed with breast or gynecological cancers.

METHODS

From 2009 to 2016, women with breast (n = 2111) and gynecological (n = 641) cancers were screened using the core items of the instrument You, Your Family, and City of Hope are a Team. This is a touch screen-based instrument that assess problem-related distress due to physical, practical, functional, emotional, and other problems and identifies types of assistance requested. Data were analyzed using the linear regression model.

RESULTS

A significant difference in overall biopsychosocial problems rated as high distress was found between breast (M = 5.0) and gynecological (M = 6.2) cancer patients (P < .001). Gynecological cancer patients endorsed a greater number of problems to talk with a member of the team (alone or with written information), while both cancer groups requested written information equally. Gynecological cancer was associated with higher physical, functional, emotional, and total distress. Younger patients, non-Asian, and those with lower education and lower household income also reported greater distress.

CONCLUSIONS

Gynecological cancer patients represent a high-risk group, reporting greater problem-related distress and higher levels of requested assistance. Age, education, race/ethnicity, and income were found to be potential risk factors. Findings highlight the importance of considering characteristics and special needs related to specific types of cancer to assist in the effective treatment of distress throughout the continuum of care.

Acceptability of cervical cancer screening using visual inspection among women attending a childhood immunization clinic in Uganda

Objective

To evaluate the acceptability and performance of cervical cancer (CC) screening using visual inspection with acetic acid (VIA) integrated into a rural immunization clinic in Uganda.

Methods/materials

We conducted a cross-sectional pilot study in rural Uganda. We explored associations between women's characteristics and acceptance of VIA testing. We collected samples for Papanicolaou (Pap) smear testing in a random subset of women and used results from this test as a comparator for assessing VIA performance.

Results

We enrolled 625 women of whom 571 (91.4%) accepted and 54 (8.6%) refused CC screening. In the univariate model, age (Odds Ratio (OR)=1.10; p-value<0.001) and employment status (OR 2.00; p-value=0.019) were significantly associated with acceptance of VIA screening. In the multivariate model, no characteristic was independently associated with acceptance of VIA screening after adjusting for other factors. Compared to reference Pap smear, CC screening with VIA had a sensitivity of 50% and a specificity of 97.7%.

Conclusions

CC screening with VIA is highly acceptable in the setting of rural immunization clinics in Uganda. Studies to assess which screening method would be the most effective and cost-effective are needed before stakeholders can consider adopting screening programs at scale.

Knowledge, facilitators and barriers to cervical cancer screening among women in Uganda: a qualitative study

OBJECTIVES

To explore community knowledge, facilitators and barriers to cervical cancer screening among women in rural Uganda so as to generate data to inform interventions.

DESIGN

A qualitative study using focus group discussions and key informant interviews.

SETTING

Discussions and interviews carried out in the community within two districts in Eastern Uganda.

PARTICIPANTS

Ten (10) focus group discussions with 119 screening-eligible women aged between 25 and 49 years and 11 key informant interviews with healthcare providers and administrators.

RESULTS

Study participants' knowledge about cervical cancer causes, signs and symptoms, testing methods and prevention was poor. Many participants attributed the cause of cervical cancer to use of contraception while key informants said that some believed it was due to witchcraft. Perceptions towards cervical cancer and screening were majorly positive with many participants stating that they were at risk of getting cervical cancer. The facilitators to accessing cervical cancer screening were: experiencing signs and symptoms of cervical cancer, family history of the disease and awareness of the disease/screening service. Lack of knowledge about cervical cancer and screening, health system challenges, fear of test outcome and consequences and financial constraints were barriers to cervical cancer screening.

CONCLUSION

Whereas perceptions towards cervical cancer and screening were positive, knowledge of study participants on cervical cancer was poor. To improve cervical cancer screening, effort should be focused on reducing identified barriers and enhancing facilitators.

Self-collection based HPV testing for cervical cancer screening among women living with HIV in Uganda: a descriptive analysis of knowledge, intentions to screen and factors associated with HPV positivity

Background

Women living with HIV (WHIV) are disproportionately impacted by cervical dysplasia and cancer. The burden is greatest in low-income countries where limited or no access to screening exists. The goal of this study was to describe knowledge and intentions of WHIV towards HPV self-collection for cervical cancer screening, and to report on factors related to HPV positivity among women who participated in testing.

Methods

A validated survey was administered to 87 HIV positive women attending the Kisenyi Health Unit aged 30–69 years old, and data was abstracted from chart review. At a later date, self-collection based HPV testing was offered to all women. Specimens were tested for high risk HPV genotypes, and women were contacted with results and referred for care. Descriptive statistics, Chi Square and Fischer-exact statistical tests were performed.

Results

The vast majority of WHIV (98.9%) women did not think it necessary to be screened for cervical cancer and the majority of women had never heard of HPV (96.4%). However, almost all WHIV found self-collection for cervical cancer screening to be acceptable. Of the 87 WHIV offered self-collection, 40 women agreed to provide a sample at the HIV clinic. Among women tested, 45% were oncogenic HPV positive, where HPV 16 or 18 positivity was 15% overall.

Conclusions

In this group of WHIV engaged in HIV care, there was a high prevalence of oncogenic HPV, a large proportion of which were HPV genotypes 16 or 18, in addition to low knowledge of HPV and cervical cancer screening. Improved education and cervical cancer screening for WHIV are sorely needed; self-collection based screening has the potential to be integrated with routine HIV care in this setting.

Strategies for Community Education Prior to Clinical Trial Recruitment for a Cervical Cancer Screening Intervention in Uganda

Introduction

Community engagement and education can improve acceptability and participation in clinical trials conducted in Kisenyi, Uganda. In preparation for a randomized controlled trial exploring different methods for cervical cancer screening, we explored optimal engagement strategies from the perspective of community members and health professionals.

Methods

We conducted key informant interviews followed by serial community forums with purposeful sampling and compared the perspectives of women in Kisenyi (N = 26) to health-care workers (HCW) at the local and tertiary care center levels (N = 61) in a participatory, iterative process.

Results

Key themes identified included format, content, language, message delivery, and target population. Women in Kisenyi see demonstration as a key part of an educational intervention and not solely a didactic session, whereas health professionals emphasized the biomedical content and natural history of cervical cancer. Using local language and lay leaders with locally accessible terminology was more of a priority for women in Kisenyi than clinicians. Simple language with a clear message was essential for both groups. Localization of language and reciprocal communication using demonstration between community members and HCW was a key theme.

Conclusion

Although perceptions of the format are similar between women and HCW, the content, language, and messaging that should be incorporated in a health education strategy differ markedly. The call for lay leaders to participate in health promotion is a clear step toward transforming this cervical cancer screening project to be a fully participatory process. This is important in scaling up cervical cancer screening programs in Kisenyi and will be central in developing health education interventions for this purpose.

Influence of Spirituality and Modesty on Acceptance of Self-Sampling for Cervical Cancer Screening

Introduction

Whereas systematic screening programs have reduced the incidence of cervical cancer in developed countries, the incidence remains high in developing countries. Among several barriers to uptake of cervical cancer screening, the roles of religious and cultural factors such as modesty have been poorly studied. Knowledge about these factors is important because of the potential to overcome them using strategies such as self-collection of cervico-vaginal samples. In this study we evaluate the influence of spirituality and modesty on the acceptance of self-sampling for cervical cancer screening.

Methodology

We enrolled 600 participants in Nigeria between August and October 2014 and collected information on spirituality and modesty using two scales. We used principal component analysis to extract scores for spirituality and modesty and logistic regression models to evaluate the association between spirituality, modesty and preference for self-sampling. All analyses were performed using STATA 12 (Stata Corporation, College Station, Texas, USA).

Results

Some 581 (97%) women had complete data for analysis. Most (69%) were married, 50% were Christian and 44% were from the south western part of Nigeria. Overall, 19% (110/581) of the women preferred self-sampling to being sampled by a health care provider. Adjusting for age and socioeconomic status, spirituality, religious affiliation and geographic location were significantly associated with preference for self-sampling, while modesty was not significantly associated. The multivariable OR (95% CI, p-value) for association with self-sampling were 0.88 (0.78–0.99, 0.03) for spirituality, 1.69 (1.09–2.64, 0.02) for religious affiliation and 0.96 (0.86–1.08, 0.51) for modesty.

Conclusion

Our results show the importance of taking cultural and religious beliefs and practices into consideration in planning health interventions like cervical cancer screening. To succeed, public health interventions and the education to promote it must be related to the target population and its preferences.

Factors associated with receiving Pap tests among married immigrant women of Vietnamese origin in southern Taiwan

The purpose of this study was to explore the factors associated with Pap testing among married immigrant women of Vietnamese origin residing in Taiwan, including demographics, knowledge of cervical cancer, knowledge of Pap tests, fatalism, attitudes toward cervical cancer, and barriers to receiving Pap tests. A cross-sectional correlational design was used. Data were collected from July 2012 to January 2013. Participants were recruited through snowball sampling in two communities in Southern Taiwan. A total of 451 married immigrant women of Vietnamese origin aged 30 years and over were invited to participate in the study and 427 participated. Data analysis included descriptive statistics and multivariate logistic regression. Participants with no children were significantly less likely to have received a Pap test (odds ratio = 0.278, 95% confidence interval [CI] = 0.135-0.569); each additional point of knowledge about Pap tests increased the likelihood of having a Pap test by 19% (odds ratio = 1.190, 95% CI = 1.093-1.297), and each additional point in barriers to receiving Pap tests decreased the chances of having received a Pap test (odds ratio = 0.714, 95% CI = 0.637-0.800). The results can provide governments with a reference for developing policies for cervical cancer prevention among married immigrant Vietnamese women.