Uptake of Cervical Cancer Screening in Ethiopia by Self-Sampling HPV DNA Compared to Visual Inspection with Acetic Acid: A Cluster Randomized Trial

Working towards health: A model of cervical cancer screening and treatment for factory employees in Haiti

OBJECTIVE

In Haiti, cervical cancer continues to cause high levels of mortality and morbidity due to lack of resources and political unrest. Haitian women employed in factories are especially vulnerable because they are unable to take time away from work to access health resources. We aimed to describe a low-cost intervention which successfully addressed this need.

METHODS

We present a retrospective review of data gathered through a public-private partnership, in which women working in garment factories near Port-au-Prince, Haiti, were offered health education, clinical breast exam, and free human papillomavirus (HPV) self-swab testing at their place of employment. Women testing positive for HPV were subsequently tested using visual inspection with acetic acid (VIA) to inform treatment referrals, and treated with mobile thermocoagulation in factory infirmaries. Factory-employed healthcare workers were trained on cancer screening, including VIA and clinical breast exam.

RESULTS

A total of 6843 out of 6983 (98%) female factory employees attended free reproductive health education sessions, and 4005 out of 4153 eligible women (97%) were screened using HPV self-swab testing; 5176 women received a clinical breast exam. Of the women screened for HPV, 1001 (25%) tested positive and 905 (90%) of HPV-positive women received VIA testing and thermocoagulation. The intervention had a total cost of US$76 000, over half of which was spent on an HPV testing machine.

CONCLUSIONS

Innovative approaches to the prevention of cervical cancer are especially necessary in very low-resource, politically unstable environments like Haiti. Self-swab and screen-and-treat programs in the workplace were acceptable to employees and factory owners. This low-cost model was reached vulnerable women through a public-private partnership, and tracked them through screening and treatment. It could be implemented elsewhere or extended to include other health services.

Human papillomavirus self-sampling versus provider-sampling in low- and middle-income countries: a scoping review of accuracy, acceptability, cost, uptake, and equity

Introduction

HPV self-sampling is a relatively new, cost-effective and widely accepted method, however, uptake in LMICs remains limited. We aimed to map out the evidence and identify gaps in accuracy, acceptability, cost, equity and uptake of self-sampling vs. provider-sampling in LMICs.

Methods

We searched: MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, and Global Index Medicus, from 1946 to July 2023. Inclusion criteria entailed studies focusing on self-sampling alone or compared to provider-sampling for HPV testing and reporting on at least one outcome of interest (accuracy, acceptability, cost, equity, or uptake). Two authors independently screened titles, abstracts, and full texts, resolving disagreements through discussion. Data was extracted by one reviewer independently, with quality checks by senior authors, and results were synthesised narratively.

Results

Our search yielded 3,739 records, with 124 studies conducted on 164,165 women aged 15-88 years between 2000 and 2023 included. Most studies were from the African region (n = 61, 49.2%). Designs included cross-sectional (n = 90, 81.1%), randomised (n = 5, 4.5%), modelling (n = 4, 3.6%), micro-costing (n = 2, 1.8%), and non-randomised crossover (n = 1, 0.9%) studies. Outcomes included; acceptability (n = 79, 63.7%), accuracy (n = 51, 41.1%), cost (n = 7, 5.6%), and uptake (n = 7, 5.6%). Most studies reported that participants preferred self-sampling, with only a few studies (n = 7, 8.9%) studies favouring provider-sampling. The sensitivity and specificity of self-sampling ranged from 37.5-96.8% and 41.6-100.0%, respectively. One study directly compared the sensitivity and specificity of dry self-collected vs. wet provider-collected sample transportation. Laboratory costs were similar, but overall costs were lower for self-sampling. Uptake was higher for self-sampling in five of the seven studies. Most studies (n = 106) mentioned equity factors like age (n = 69, 65.1%), education (n = 68, 64.2%) and place of residence (n = 59, 55.6%) but no analysis of their impact was provided.

Conclusion

HPV self-sampling is acceptable and cost-effective but, evidence of its accuracy shows varying sensitivity and specificity. Evidence on the accuracy of dry self-collected vs. wet provider-collected sample transportation is limited. Research evaluating HPV self-sampling's accuracy, including comparisons of transportation modes, uptake, the impact of equity factors in LMICs and comparisons with high-income countries is essential to inform cervical cancer screening uptake.

Systematic review registration

https://doi.org/10.17605/OSF.IO/34TUY.

Service-Delivery Models to Increase the Uptake of Non-Communicable Disease Screening in South-Central Ethiopia: A Difference-In-Differences Analysis

BACKGROUND

Screening for non-communicable diseases (NCDs) is a critical step for early detection and the prevention of consequent morbidity and mortality. To facilitate NCD screening, the Ethiopian Ministry of Health has developed screening guidelines. However, like other low- and middle-income countries, interventions to increase the uptake of NCD-screening services in Ethiopia remain ineffective. Thus, this study aimed to determine the effectiveness of service delivery models to increase NCD-screening service uptake in south-central Ethiopia.

METHOD

A health-facility-based quasi-experimental study design was employed to determine the effectiveness of providing a multiple-NCD-screening service in addition to social- and behavioral-change communication (SBCC) intervention to increase the uptake of NCD-screening services. The interviewer-administered structured questionnaire was adapted from previously published research and used to collect data during the baseline and end-line survey periods. A difference-in-differences analysis was used to determine the effectiveness of the intervention.

RESULTS

Compared with routine care, the availability of a multiple-NCD-screening service, together with SBCC intervention, was found to significantly increase the uptake of cervical cancer screening, clinical breast examination, blood pressure measurement, and blood glucose-measurement services, by 18, 9, 44 and 23 percent points, respectively. However, the availability of a multiple-NCD-screening service without SBCC intervention increased clinical breast-examination service uptake by 9% point and blood glucose-measurement service uptake by 18% point without increasing the uptake of cervical cancer-screening or blood pressure-measurement services.

CONCLUSION

The integration of multiple-NCD-screening services accompanied by SBCC intervention that promotes them is an important approach for improving the uptake of NCD-screening services.

Invitation strategy of vaginal HPV self-sampling to improve participation in cervical cancer screening: a systematic review and meta-analysis of randomized trials

BACKGROUND

Human papillomavirus (HPV) self-sampling is recognized as a feasible option for enhancing screening for cervical cancer, particularly among hard-to-reach women. The magnitude of the effectiveness of screening participation under different invitation strategies was reported. This review seeks to compare the effectiveness of invitation strategies in increasing screening participation of HPV self-sampling across diverse study settings.

METHODS

A systematic literature search was conducted in Embase, MEDLINE, and PubMed in April 2023. Articles were included if (1) their target participants were aged between 25 and 70 years; (2) participants in the intervention arm were randomized to receive HPV self-sampling devices through various invitation strategies; (3) participants in the control arm who either received invitations for cervical cancer screening other than HPV self-sampling or opportunistic screening as usual care; (4) studies that provided sufficient data on screening participation in HPV self-sampling as outcome measured. The study design of the included articles was limited to randomized controlled trials.

RESULTS

A total of 15 articles were included in this review. Invitation strategies of disseminating HPV self-sampling devices included opt-out and opt-in. Meta-analysis revealed screening participation in the self-sampling group was significantly greater than control arm (OR 3.43, 95% CI 1.59-7.38), irrespective of the invitation strategy employed. Among invitation strategies, opt-out appeared to be more effective on increasing screening participation, compared to control and opt-in strategy (opt-out vs. control OR 3.91, 95% CI 1.82-8.42; opt-in vs. control OR 1.34, 95% CI 0.28-6.39).

CONCLUSIONS

Opt-out strategy is more successful at improving screening participation compared to opt-in and routine invitation to cervical screening. It is therefore a promising way to improve participation in cervical cancer screening. The findings of this review provide important inputs to optimize strategies for inviting women to participate in vaginal HPV self-sampling across the study setting, thus improving participation in cervical cancer screening.

Prevalence of human papillomaviruses in self-collected samples among women attending antenatal care in Ethiopia: a cross-sectional study

Cervical cancer is the second most commonly diagnosed cancer in women in Ethiopia. However, data are limited on the prevalence of human papillomavirus (HPV) genotypes. Self-sampled vaginal lavages were obtained consecutively from 783 women attending 7 health facilities across Ethiopia. Genotype prevalence was assessed by Multiplex-Papillomavirus-Genotyping which detects and individually identifies 51 genotypes and 3 subtypes. Genotype-specific prevalence was described and associations with known risk factors were analysed. The overall HPV prevalence (age range 18-45) was 33.1% (95% confidence interval (CI) 29.8-36.4). The prevalence of HPV was different in the rural and urban population with 17.6% (95%CI 11.6-23.7) and 36.8% (95%CI 33.1-40.6) (p < 0.001 chi-square test), respectively. The most common high-risk types were HPV 16 (6.6%), followed by HPV 52 (4.3%), 51 and 39 (both 2.9%). Urban women compared to rural women had a higher risk of being HPV positive (odds ratio 2.36 (95% CI 1.47-3.79; p < 0.001). Age at sexual debut ≤15 years and polygamous husband (in urban women) also increased the risk of being HPV positive nearly two-fold. The high prevalence of hr-HPV in Ethiopian women in the reproductive age group shows the need for screening programs. The nonavalent HPV vaccine covers the most prevalent hr-HPV genotypes as found in this study and can therefore be used effectively. Since antenatal care is the best-utilised health service, implementing self-sampled vaginal lavage could be an opportunity for screening in this age group. Screening algorithms and triage still need to be defined to avoid over-treatment in these women.

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.

Capacity assessment and spatial analysis of cervical cancer services in The Gambia

BACKGROUND

Cervical cancer is the most common cancer and the leading cause of cancer-related death in Gambian women. The Gambian Ministry of Health is striving to improve access to screening, diagnostic, and treatment services for cervical cancer, but comprehensive data on currently available services is limited making it challenging to appropriately prioritize the ideal next steps for expanding care. This study aims to describe the current services available for the prevention, screening, and treatment of cervical cancer in The Gambia and provide suggestions for expanding geographic access to care.

METHODS

A survey aimed at assessing the availability of key cervical cancer-related services was developed and then administered in person by research assistants to all secondary and tertiary health facilities (HFs) in The Gambia. ArcGIS Pro Software and 2020 LandScan population density raster were used to visualize and quantify geographic access to care. Survey results were compared with published targets outlined by the Gambian Ministry of Health in the "Strategic Plan for the Prevention and Control of Cervical Cancer in The Gambia: 2016-2020."

RESULTS

One hundred and two HFs were surveyed including 12 hospitals, 3 major health centers, 56 minor health centers, and 31 medical centers/clinics. Seventy-eight of these HFs provided some form of cervical cancer-related service. HPV vaccination was available in all health regions. Two-thirds of the population lived within 10 km of a HF that offered screening for cervical cancer and half lived within 10 km of a HF that offered treatment for precancerous lesions. Ten HFs offered hysterectomy, but nine were located in the same region. Two HFs offered limited chemotherapy. Radiotherapy was not available. If all major health centers and hospitals started offering visual inspection with acetic acid and cryotherapy, 86.1% of the population would live within 25 km of a HF with both services.

CONCLUSIONS

Geographic access to cervical cancer screening, and precancer treatment is relatively widespread across The Gambia, but targeted expansion in line with the country's "Strategic Plan" would improve access for central and eastern Gambia. The availability of treatment services for invasive cancer is limited, and establishing radiotherapy in the country should continue to be prioritized.

Co-creation of human papillomavirus self-sampling delivery strategies for cervical cancer screening in rural Zimbabwe: nominal group technique

Background

Human papillomavirus (HPV) self-sampling is recommended for cervical cancer screening, particularly among women who do not participate in or have access to current screening methods offered in Zimbabwe. Key stakeholder involvement is critical in co-creating acceptable delivery strategies for implementing HPV self-sampling to ensure demand and facilitate uptake by the target population. The main objective of this study was to engage key stakeholders in co-creating acceptable HPV self-sampling delivery strategies for cervical cancer screening in rural Zimbabwe.

Methods

We invited key stakeholders and employed a nominal group technique (NGT) for data collection. We employed the NGT to (1) identify barriers to access and utilisation of available cervical cancer screening services and (2) co-create delivery strategies for HPV self-sampling. The workshop included 8 participants (women n = 4, health workers n = 2 and policymakers n = 2). Quantitative data was gathered by ranking ideas and qualitative data were collected from participant group discussions and analysed thematically. The results of the ranking exercise were fed back to the participants for comments.

Results

The most significant barriers to accessing and utilising current cervical cancer screening services by women were: Inadequate information and education on cervical cancer, lack of resources and funding for cervical cancer programmes, long distances to nearest health facilities, and low perceived personal risk of cervical cancer. Key stakeholders recommended enhanced education and awareness, results notification, linkage to care, community-based self-sampling, and the choice of sampling devices as potential HPV self-sampling delivery strategies.

Conclusion

Our study demonstrated the utility of the NGT for reaching a consensus. Using the NGT, we established priority delivery strategies for HPV self-sampling cervical cancer screening. Adequate education and awareness, early results notification, choice of sampling device and community-based self-sampling were crucial to HPV self-sampling screening in rural Zimbabwe. The proposed delivery strategies can guide the development of guidelines for designing and implementing an HPV self-sampling intervention. We recommend a study to determine women's most preferred HPV self-sampling delivery strategies before implementing the intervention.

Characteristics of Women Seeking Cervical Cancer Cytology Screening in a Private Health Facility

Background and Objectives: Over 80% of cervical cancer cases in sub-Saharan Africa are detected at late stages, predominantly due to the lack or inaccessibility of prevention services. Public health facilities in Ethiopia offer free cervical cancer screening for eligible women. Besides the public health facilities, private providers also offer a variety of screening services at the patients' expense. As the overall cervical cancer screening uptake in Ethiopia is still far below the 90% WHO target, coordination between all actors of the health system is key. This includes a close cooperation between the public and private sectors to combine the advantages of both to the benefit of all patients as well as media campaigns and community involvement to promote the self-initiation of screening. Materials and Methods: To gain insights into the utilization of cervical cancer screening in the private health sector, we conducted an institution-based cross-sectional study at Arsho medical laboratories in Addis Ababa. Every woman who came there for cervical cancer screening between 1 May and 30 June 2020 was asked to participate in a questionnaire-based, face-to-face interview about their socio-demographic background, cervical cancer screening experience and self-initiation of screening. A total of 274 women participated in the interviews. We further assessed the reproductive status of the patients, their risk factors for cervical cancer, source of information about the screening and barriers to cervical cancer screening. Results: The ages of the participants ranged between 20-49 years. The majority (over 70%) were married. A total of 37.6% reported self-initiating the screening. More than three-quarters of all interviewed women reported mostly using the private health care sector for all kinds of health services. Conclusions: While the Ethiopian government efforts on scaling up cervical cancer screening focus mainly on public health facilities, the private sector often does not get as much attention from policy makers. Efforts should be made to extend the government's interest in cervical cancer screening and implementation research to the private healthcare sector.

HPV self-sampling versus healthcare provider collection on the effect of cervical cancer screening uptake and costs in LMIC: a systematic review and meta-analysis

BACKGROUND

Cervical cancer is a major global health issue, with 89% of cases occurring in low- and middle-income countries (LMICs). Human papillomavirus (HPV) self-sampling tests have been suggested as an innovative way to improve cervical cancer screening uptake and reduce the burden of disease. The objective of this review was to examine the effect of HPV self-sampling on screening uptake compared to any healthcare provider sampling in LMICs. The secondary objective was to estimate the associated costs of the various screening methods.

METHOD

Studies were retrieved from PubMed, Embase, CINAHL, CENTRAL (by Cochrane), Web of Science, and ClinicalTrials.gov up until April 14, 2022, and a total of six trials were included in the review. Meta-analyses were performed mainly using the inverse variance method, by pooling effect estimates of the proportion of women who accepted the screening method offered. Subgroup analyses were done comparing low- and middle-income countries, as well as low- and high-risk bias studies. Heterogeneity of the data was assessed using I2. Cost data was collected for analysis from articles and correspondence with authors.

RESULTS

We found a small but significant difference in screening uptake in our primary analysis: RR 1.11 (95% CI: 1.10-1.11; I2 = 97%; 6 trials; 29,018 participants). Our sensitivity analysis, which excluded one trial that measured screening uptake differently than the other trials, resulted in a clearer effect in screening uptake: RR: 1.82 (95% CI: 1.67-1.99; I2 = 42%; 5 trials; 9590 participants). Two trials reported costs; thus, it was not possible to make a direct comparison of costs. One found self-sampling more cost-effective than the provider-required visual inspection with acetic acid method, despite the test and running costs being higher for HPV self-sampling.

CONCLUSION

Our review indicates that self-sampling improves screening uptake, particularly in low-income countries; however, to this date, there remain few trials and associated cost data. We recommend further studies with proper cost data be conducted to guide the incorporation of HPV self-sampling into national cervical cancer screening guidelines in low- and middle-income countries.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020218504.

Challenges in the Diagnosis and Individualized Treatment of Cervical Cancer

Cervical cancer is still the fourth most common cancer in women throughout the world; an estimated 604,000 new cases were observed in 2020. Better knowledge of its pathogenesis, gained in recent years, has introduced new preventive and diagnostic approaches. Knowledge of its pathogenesis has made it possible to provide individualized surgical and drug treatment. In industrialized countries, cervical cancer has become a less frequent tumor entity due to the accessibility of the human papilloma virus vaccination, systematic preventive programs/early detection programs, health care infrastructure and the availability of effective therapy options. Nevertheless, globally, neither mortality nor morbidity has been significantly reduced over the past 10 years, and therapy approaches differ widely. The aim of this review is to address recent advances in the prevention, diagnostic investigation and treatment of cervical cancer globally, focusing on advances in Germany, with a view toward providing an updated overview for clinicians. The following aspects are addressed in detail: (a) the prevalence and causes of cervical cancer, (b) diagnostic tools using imaging techniques, cytology and pathology, (c) pathomechanisms and clinical symptoms of cervical cancer and (d) different treatment approaches (pharmacological, surgical and others) and their impact on outcomes.

Mapping evidence on the acceptability of human papillomavirus self-sampling for cervical cancer screening among women in sub-Saharan Africa: a scoping review

OBJECTIVES

The objective of this scoping review was to map evidence on the acceptability of self-sampling for human papillomavirus testing (HPVSS) for cervical cancer screening among women in the sub-Saharan Africa region.

DESIGN

Scoping review.

METHODS

Using Arksey and O'Malley's framework, we searched Scopus, PubMed, Medline Ovid, Cochrane and Web of Science databases for evidence on the acceptability of HPVSS among women aged 25 years and older published between January 2011 and July 2021. We included studies that reported evidence on the acceptability of HPVSS for cervical cancer screening. Review articles and protocols were excluded. We also searched for evidence from grey literature sources such as dissertations/theses, conference proceedings, websites of international organisations such as WHO and relevant government reports. Two reviewers independently performed the extraction using a pre-designed Excel spreadsheet and emerging themes were narratively summarised.

RESULTS

The initial search retrieved 1018 articles. Of these, 19 articles were eligible and included in the review. The following themes emerged from the included articles: acceptability of HPVSS; lack of self-efficacy to perform HPVSS, complications when performing HPVSS, preferences for provider sampling or assistance; setting of HPVSS; HPVSS by vulnerable populations.

CONCLUSION

Evidence shows that HPVSS is highly acceptable for cervical cancer screening in sub-Saharan Africa. Further research exploring the acceptability of HPVSS among women residing in rural areas is required, as well as studies to determine women's preferences for HPVSS intervention including the preferred type of sampling devices. Knowledge on the acceptability and preferences for HPVSS is important in designing women-centred interventions that have the potential to increase screening coverage and participation in cervical cancer screening programmes.

Offering HPV self-sampling kits: an updated meta-analysis of the effectiveness of strategies to increase participation in cervical cancer screening

BACKGROUND

Human papillomavirus (HPV) testing on self-samples represents a great opportunity to increase cervical cancer screening uptake among under-screened women.

METHODS

A systematic review and meta-analysis on randomised controlled trials (RCTs) were performed to update the evidence on the efficacy of strategies for offering self-sampling kits for HPV testing compared to conventional invitations and to compare different self-sampling invitation scenarios. Four experimental invitational scenarios were considered. Women in the control group were invited for screening according to existing practice: collection of a cervical specimen by a healthcare professional. Random-effects models were used to pool proportions, relative participation rates and absolute participation differences.

RESULTS

Thirty-three trials were included. In the intention-to-treat analysis, all self-sampling invitation scenarios were more effective in reaching under-screened women compared to controls. Pooled participation difference (PD) and 95% confidence interval (CI) for experimental vs. control was 13.2% (95% CI = 11.0-15.3%) for mail-to-all, 4.4% (95% CI = 1.2-7.6%) for opt-in, 39.1% (95% CI = 8.4-69.9%) for community mobilisation & outreach and 28.1% (23.5-32.7%) for offer at healthcare service. PD for the comparison opt-in vs. mail-to-all, assessed in nine trials, was -8.2% (95% CI = -10.8 to -5.7%).

DISCUSSION

Overall, screening participation was higher among women invited for self-sampling compared to control, regardless of the invitation strategy used. Opt-in strategies were less effective than send-to-all strategies.

Does self-sampling for human papilloma virus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials

Objectives

A meta-analysis was conducted to examine the effectiveness of HPV self-sampling proposal on cervical cancer screening (CCS) uptake when compared with an invitation to have a clinician to collect the sample. Secondary outcomes were acceptability and preference of self-sampling compared to clinician-collected samples.

Methods

The present systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies examining the CCS uptake comparing self-sampling over invitation to be sampled by an healthcare professional and examining the proportion of women accepting or preferring self-sampling vs. clinician-collected sampling were included. The CCS uptake was also explored according to strategy of self-samplers' distribution, collection device type and screening status. Peters' test and Funnel Plot inspection were used to assess the publication bias. Quality of the studies was assessed through Cochrane Risk of Bias and NIH Quality Assessment tools.

Results

One hundred fifty-four studies were globally identified, and 482,271 women were involved. Self-sampling procedures nearly doubled the probability (RR: 1.8; 95% CI: 1.7-2.0) of CCS uptake when compared with clinician-collected samples. The opt-out (RR: 2.1; 95% CI: 1.9-2.4) and the door-to-door (RR: 1.8; 95% CI: 1.6-2.0) did not statistically significant differ (p = 1.177) in improving the CCS uptake. A higher relative uptake was shown for brushes (RR: 1.6; 95% CI: 1.5-1.7) and swabs (RR: 2.5; 95% CI: 1.9-3.1) over clinician-collected samples. A high between-studies variability in characteristics of sampled women was shown. In all meta-analyses the level of heterogeneity was consistently high (I 2 > 95%). Publication bias was unlikely.

Conclusions

Self-sampling has the potential to increase participation of under-screened women in the CCS, in addition to the standard invitation to have a clinician to collect the sample. For small communities door-to-door distribution could be preferred to distribute the self-sampler while; for large communities opt-out strategies should be preferred over opt-in. Since no significant difference in acceptability and preference of device type was demonstrated among women, and swabs and brushes exhibited a potential stronger effect in improving CCS, these devices could be adopted.

Histopathological profile of cervical punch biopsies and risk factors associated with high-grade cervical precancerous lesions and cancer in northwest Ethiopia

Introduction

Cervical cancer is an important public health problem in Ethiopia. However, the disease is not well characterized and studied in various parts of the country. This study was designed to describe the histopathological profile of cervical biopsies and to identify risk factors associated with high-grade cervical lesions and cancer (CIN2+C).

Methods

A cross-sectional study was conducted at Felege Hiwot Compressive Specialized Hospital (FHCSH) between 1 March 2019 and 30 October 2021. A structured questionnaire was used to collect data on the participants’ demographic, reproductive and gynecologic history. From women presented with different degrees of cervical lesions, a senior gynecologist collected cervical swabs using (Digene HC2 DNA collection device: Qiagen, Hilden, Germany) for detection of high-risk Human papillomaviruses (HR-HPV) and punch biopsy for histopathological examinations. HR-HPVs were detected using the Abbott Alinity m system following the manufacturer protocol at the Institute of Virology, Leipzig University Hospital, Germany. Collected data entered and analyzed using SPSS version 25. A logistic regression model was used for both bivariable & multivariable analysis in order to determine the association between independent variables and CIN2+C. Statistical significance was set at a p-value <0.05.

Results

In this study, 335 women were included; the mean age was at 46.5±11.4 years. Most were living in rural settings, 221(66%) and had no formal education, 259 (77.3%). More than half of the participants, 193(57.6%) were unaware of cervical cancer. The prevalence of HIV infection and previous history of cervical screening were 44(13.1%) and 93(27.8%), respectively. HR-HPVs were detected in 178(54.3%) of the participants. The majority of biopsies, 140(41.8%; 95%CI: 36.6–47.1%), were diagnosed as cervical carcinoma. Normal histology, cervicitis, cervical intraepithelial neoplasia (CIN)-1, CIN-2, and CIN-3 accounted for 74(22.1%), 30(9.0%), 40(11.9%), 12(3.6%), and 12(3.6%), respectively. High-grade lesions and cancer (CIN2+C) together accounted 164(49.0%; 95%CI: 43.6–54.2). Cervical cancer increased steadily with the age of the participants (p<0.001) in which women above the age of fifty were approximately four times more likely to develop CIN2+C than the younger ones (AOR: 3.73; 95%CI: 1.80–7.82; p<0.001). Likewise, no screening history in the last five years (AOR: 2.03; 95%CI: 1.05–3.92; p = 0.035) and being infected with HR-HPVs (AOR: 14.23; 95%CI: 7.9–25.64; p<0.001) were found significantly associated with CIN2+C.

Conclusions

The findings of this study revealed that cervical cancer continues to be an important women’s health challenge in northwest Ethiopia. Postmenopausal women, who had no screening history within a five-year period and those women who tested positive for HR-HPV need special attention. It is important to increase the awareness of women about cervical cancer and actions for early detection of precancerous lesions should be expanded.

A Technical Comparison of Human Papillomavirus Genotyping Assays from a Population-Based Cervical Cancer Screening in South Central Ethiopia

Purpose

High-risk Human Papillomavirus (HPV) is the most important cause of cervical cancer. The highest burden of disease is seen in Low- and Low-Middle-Income Countries (LMIC). Several new HPV screening assays have been developed for high-risk HPV (hr-HPV) testing. We compared the performance and adequacy of three HPV genotyping assays on samples from a population of rural women in south-central Ethiopia.

Patients and Methods

One hundred and ten cervical swabs from rural women screened for HPV were assayed. HPV DNA was tested using MPG-Luminex Assay, Anyplex II HPV HR Detection, and EUROArray HPV. MPG-Luminex Assay was used as a reference method to compute the sensitivity and specificity of the two commercial assays in detecting hr-HPV infections.

Results

Of the 110 samples, MPG-Luminex Assay found 18.2% positive for the 14 hr-HPV and 7.3% for the probable hr-HPV genotypes. Anyplex™ II HPV HR Detection assay and EUROArray HPV Assay identified 21.82% and 12.7% samples, respectively, for the 14 hr-HPVs and both 7.3% for the probable hr-HPV genotypes (κ=0.734). Among the 14 hr-HPV genotypes, the genotype-specific agreement of the three HPV genotyping assays was moderate or better for HPV16, 31, 35, 39, 52, 56, 66 and 68. The aggregated sensitivity in detecting the 14 hr-HPV infections of Anyplex™ II HPV HR Detection and EUROArray HPV assays was high, 100% and 70%, respectively. The specificities of Anyplex™ II HPV HR Detection and EUROArray HPV were 95.6% and 100%, respectively.

Conclusion

The three evaluated assays showed similar analytical performance in the detection of hr-HPV infections and moderate or better concordance in HPV genotyping. This study is part of the ongoing cluster-randomized trial that has been registered in clinicaltrials.gov (NCT03281135) on September 13, 2017.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Law, human rights and gender in practice: an analysis of lessons from implementation of self-care interventions for sexual and reproductive health

Self-care interventions for health are becoming increasingly available, and among the preferred options, including during the COVID-19 pandemic. This research assessed the extent of attention to laws and policies, human rights and gender in the implementation of self-care interventions for sexual and reproductive health (SRH), to identify where additional efforts to ensure an enabling environment for their use and uptake will be useful. A literature review of relevant studies published between 2010 and 2020 was conducted using PubMed, Scopus and Web of Science. Relevant data were systematically abstracted from 61 articles. In March–April 2021, semi-structured interviews were conducted with 10 key informants, selected for their experience implementing self-care interventions for SRH, and thematically analysed. Laws and policies, rights and gender are not being systematically addressed in the implementation of self-care interventions for SRH. Within countries, there is varied attention to the enabling environment including the acceptability of interventions, privacy, informed consent and gender concerns as they impact both access and use of specific self-care interventions, while other legal considerations appear to have been under-prioritised. Operational guidance is needed to develop and implement supportive laws and policies, as well as to ensure the incorporation of rights and gender concerns in implementing self-care interventions for SRH.

A systematic review of randomized control trials of HPV self-collection studies among women in sub-Saharan Africa using the RE-AIM framework

Introduction

Self-collection of samples for HPV testing may increase women’s access to cervical cancer screening in low- and middle-income settings. However, implementation remains poor in many regions. The purpose of this systematic review was to examine implementation data from randomized controlled trials evaluating human papillomavirus (HPV) self-collection testing among women in sub-Saharan Africa using the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) framework.

Methods

We searched four electronic databases (PubMed, CINAHL, Web of Science, and Global Health) for pragmatic randomized controlled trials that promote HPV self-collection among women in sub-Saharan Africa. Study selection and data extraction were conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) checklist. Two researchers independently extracted information from each article using a RE-AIM data extraction tool. The reporting of RE-AIM dimensions was summarized and synthesized across included interventions.

Results

We identified 2008 citations, and eight studies were included. These reported on five unique interventions. The five interventions were conducted in five countries: Cameroon, Ethiopia, Kenya, Nigeria, and Uganda. Intervention reach (80%) was the most commonly reported RE-AIM dimension, followed by adoption (56%), efficacy/effectiveness (52%), implementation (47%), and maintenance (0%). All the interventions described increased uptake of HPV testing among study participants (effectiveness). However, the majority of the studies focused on reporting internal validity indicators such as inclusion criteria (100%) and exclusion criteria (100%), and few reported on external validity indicators such as participation rate (40%), intervention cost (40%), staff selection (20%), and cost of maintenance (0%).

Conclusions

Our review highlights the under-reporting of external validity indicators such as participation rate, intervention, and maintenance costs in studies of self-collection for HPV testing among women in SSA. Future research should focus on including factors that highlight internal validity factors and external validity factors to develop a greater understanding of ways to increase not only reach but also implementation and long-term maintenance of these interventions. Such data may advance the translation of HPV interventions into practice and reduce health disparities in SSA. Findings highlight the need for innovative tools such as participatory learning approaches or open challenges to expand knowledge and assessment of external validity indicators to ultimately increase the uptake of HPV testing among women in SSA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00243-5.

Cervical cancer prevention: Human papillomavirus testing as primary screening

Low- and middle-income countries carry a high burden of preventable cervical cancer cases and deaths. Because human papillomavirus DNA-based testing is increasingly becoming the preferred method of screening for cervical cancer prevention, this commentary discusses next steps and key considerations for its expansion.

Cervical cancer screening "see and treat approach": real-life uptake after invitation and associated factors at health facilities in Gondar, Northwest Ethiopia

BACKGROUND

Although cervical cancer is a preventable disease, screening coverage in Ethiopia is far below the target. There is limited evidence on uptake among the general population in Ethiopia. Thus, this study was conducted to assess uptake and associated factors with the cervical cancer screening "see and treat approach" among eligible women in public health facilities in Gondar town, Northwest Ethiopia.

METHOD

A facility-based, cross-sectional study was conducted. The total sample size was 493. A consecutive sampling method was applied. Participants were informed about and invited to cervical cancer screening using visual inspection with acetic acid. Crude and adjusted odds ratios were calculated to determine statistical association with socio-demographic variables. Multivariable logistic regression was used to determine factors of cervical cancer screening uptake.

RESULT

Out of 464 women advised for screening, 76 (16.4, 95% CI [13, 19.8%]) attended the screening. Primary education and above (AOR = 5.3, 95% CI [2.20, 13.0]), knowledge about the disease (AOR = 8.4, 95% CI [3.33, 21.21]), perceived susceptibility (AOR = 6.5, 95% CI [2.72, 15.51]), fewer perceived barriers (AOR = 6.4, 95% CI [2.30, 17.80]), cues to action (AOR = 4.6, 95% CI [1.86, 11.32]), perceived self-efficacy (AOR = 5, 95% CI [2.14, 11.73]), and previous recommendation for screening (AOR = 2.7, 95% CI [1.15, 6.51]) were significantly associated with screening uptake.

CONCLUSION

The actual uptake of screening offered in this study was high relative to only 3% national screening coverage. There is a need to implement active invitation for screening with special focus on less-educated women. Repeated invitation may facilitate future screening uptake.

Human papillomavirus self-sampling versus standard clinician-sampling for cervical cancer screening in sub-Saharan Africa: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Human papillomavirus (HPV) infection remains a major health threat in sub-Saharan Africa (SSA). HPV self-sampling could help find and treat cervical cancer at an early stage. We aimed to evaluate the effectiveness of HPV self-sampling over the standard health facility-based clinician-sampling for cervical cancer screening through a systematic review and meta-analysis of available randomized controlled trials.

METHOD

We searched PubMed, Cochrane Central Register of Controlled Trials, ClinicalTrial.gov, and the WHO Global Health Library for articles in SSA published as of 31 May 2020. We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 guidelines for the design and reporting of the results. We included randomized control trials that compared HPV self-sampling with the standard of care. The primary endpoint was uptake of cervical cancer screening service. The secondary endpoints were linkage to care, acceptability, screening frequency, and adverse events. We used RevMan V.5.3 software for statistical analysis. We computed random-effect model to provide pooled estimates of available data and I-squared (I2) test to assess heterogeneity.

RESULT

Of 77 citations, we included four trials from Nigeria, Ethiopia, Kenya, and Uganda, encompassing 8200 participants with age ranging from 25 to 65 years. The pooled analysis showed significantly higher uptake of cervical cancer screening in women who used HPV self-sampling (risk ratio [RR] 1.72, 95% CI 1.58-1.87; p = 0.01), while this had a considerable heterogeneity as explained by subgroup analysis. Uptake was higher in women who were offered sampling kit at home or work (RR 2.05, 95% CI 1.80-2.33) and those who's kit was mailed to or invited to a nearby health center (RR 1.65, 95% CI 1.58-1.72, I2 = 0%) than those screened with the standard of care. There was no difference between the two groups in the rate of linkage to care of positive cases (RR 1.30, 95% CI 0.90-2.74, I2 = 91%). HPV self-sampling was acceptable and easy to use. None of the trials compared the frequency of screening or adverse events.

CONCLUSION

HPV self-sampling is an effective and feasible alternative to the standard health facility-based clinician-sampling for cervical cancer screening in SSA. It could improve the uptake of cervical cancer screening and harness the global strategy towards elimination of cervical cancer by 2030.

Health workers' perspectives on barriers and facilitators to implementing a new national cervical cancer screening program in Ethiopia

BACKGROUND

Cervical cancer disproportionately affects women in sub-Saharan Africa, compared with other world regions. In Ethiopia, a National Cancer Control Plan published in 2015, outlines an ambitious strategy to reduce the incidence and mortality of cervical cancer. This strategy includes widespread screening using visual inspection with acetic acid (VIA). As the national screening program has rolled out, there has been limited inquiry of provider experiences. This study aims to describe cancer control experts' perspectives regarding the cancer control strategy and implementation of VIA.

METHODS

Semi-structured interviews with 18 participants elicited provider perspectives on cervical cancer prevention and screening. Open-ended interview questions queried barriers and facilitators to implementation of a new national screening program. Responses were analyzed using thematic analysis and mapped to the Integrated Behavioral Model. Participants were health providers and administrators with positionality as cancer control experts including screening program professionals, oncologists, and cancer focal persons at town, zone, and federal health offices at eleven government facilities in the Arsi, Bale, and Shoa zones of the Oromia region, and in the capital Addis Ababa.

RESULTS

The cancer control plan and screening method, VIA, were described by participants as contextually appropriate and responsive to the unique service delivery challenges in Ethiopia. Screening implementation barriers included low community- and provider-awareness of cervical cancer and screening, lack of space and infrastructure to establish the screening center, lack of materials including cryotherapy machines for the "screen-and-treat" approach, and human resource issues such as high-turnover of staff and administration. Participant-generated solutions included additional training for providers, demand creation to increase patient flow through mass media campaigns, decentralization of screening from large regional hospitals to local health centers, improved monitoring and evaluation, and incentivization of screening services to motivate health providers.

CONCLUSIONS

As the Ethiopian government refines its Cancer Control Plan and scales up screening service implementation throughout the country, the findings from this study can inform the policies and practices of cervical cancer screening. Provider perspectives of barriers and facilitators to effective cancer control and screening implementation reveal areas for continued improvement such as provider training and coordination and collaboration in the health system.

Human Papilloma Virus self-sampling performance in low- and middle-income countries

Background

Screening for HPV has led to significant reductions in cervical cancer deaths in high-income countries. However, the same results have not been achieved in low- and middle-income countries (LMICs). HPV self-sampling is a novel approach that could improve screening rates.

Methods

This study’s objective is to summarize the recent literature on HPV self-sampling in LMICs, focusing on sensitivity/specificity, and feasibility/acceptability of self-sampling compared to traditional screening methods. We conducted a PubMed search for articles published in English within the last 10 years on self-sampling in LMICs.

Results

Fifty eligible articles from 26 countries were included, 19 of which came from sub-Saharan Africa and 18 from Latin America/Caribbean. Seven studies examined sensitivity, with five reporting rates higher than 91%. Six reported on specificity, which was also very high at 86–97.8%. Six studies examined self-sampling concordance with provider-collected sampling, with concordance rates ranging from 87 to 97.5%. A total of 38 studies examined the feasibility/acceptability of HPV self-sampling. Participation rates were very high in all studies, even when self-sampling was done at participants’ homes (over 89% participation). Overall, participants reported that HPV self-sampling was easy to perform (75–97%, 18 studies), painless (60–90%, nine studies), and preferred over provider-collected sampling (57–100%, 14 studies). Eight studies reported follow-up rates for participants who completed self-sampling; however, these rates varied widely-from 13.7 to 90%. The major benefits of self-sampling include convenience of screening from home, less embarrassment, and less travel. Improved education and awareness of self-sampling, combined with support from community health workers, could reduce perceptions of self-sampling being inferior to provider-collected sampling. Improving follow-up of abnormal results and improving linkages to treatment are also essential.

Conclusion

Our literature review highlights HPV self-sampling is a well-performing test that shows promise in terms of expanding screening efforts for the prevention of cervical cancer-related deaths in LMICs.

Community cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study

OBJECTIVE

To explore the barriers to successful home-based human papillomavirus (HPV) self-sampling in North Gondar, Ethiopia.

METHODS

The study participants were women who had previously participated in a community-wide home-based HPV self-sampling pilot study, community health workers, women's development army leaders, and the sample collectors of the home-based HPV self-sampling pilot study. A community based qualitative descriptive study was conducted. We applied purposive and convenience sampling. In total, 47 women participated in the study (in-depth interviews n = 22, four focus group discussions n = 25, 6-7 participants each). The study employed thematic analysis for clustering the emerged themes.

RESULTS

Husband disapproval was identified as the main barrier to the acceptance of home-based HPV self-sampling. Social influence, lack of knowledge about cervical cancer and screening, lack of health education on cervical cancer and HPV-based screening, feeling healthy, and religious influence were identified as additional barriers. Fear of using Evalyn brush® for self-sampling was found to be the main barrier to the provision of a quality sample. The inability of the sample collectors to check the proper utilization of Evalyn brush® and the difficulty in understanding the instructions did also contribute to the low-quality. Providing health education concerning cervical cancer and HPV self-sapling to women, male involvement in the screening program, and linking the screening service to existing local health facilities were suggested to guarantee the success of home-based HPV self-sampling.

CONCLUSIONS

Educating women regarding cervical cancer and HPV testing, providing clear instructions on how to collect self-sample, and male involvement in the screening program are prerequisites for a successful implementation of home-based HPV testing. Women empowerment should also be focused to overcome the identified sociocultural barriers. Furthermore, the screening program should guarantee the timely provision of the test results and offering women follow-up examinations and treatment for abnormal findings.

Population-based human papillomavirus infection and genotype distribution among women in rural areas of South Central Ethiopia

In Ethiopia, cervical cancer is the second leading cause of morbidity and mortality from all cancers in women. Persistent infection with human papillomaviruses (HPV) plays a key role in the development of cervical intraepithelial neoplasia and invasive cervical cancer. To establish baseline data on the population-based prevalence of HPV infection and genotype distribution, we investigated cervical HPV epidemiology among rural women. This population-based study was conducted among rural women aged 30-49 years in Butajira, south-central Ethiopia. A total of 893 samples were tested from 1020 screened women. A self-sampling device (Evalyn Brush, Rovers, Oss, The Netherlands) was used and HPV presence and genotype was determined using multiplexed genotyping (MPG) by BSGP5+/6+ PCR with Luminex read out. The HPV positivity rate was 23.2% (95% CI: 23.54-22.86%) and 20.5% (95% CI = 20.79-20.21) and 10.3% (95% CI = 10.52-10.08) women were high-risk (hr- and low-risk (lr-) HPV positive, respectively. Fifty five (7.2%) of the women showed multiple hr-HPV infections. Age-specific hr-HPV infection peaked in the age-group 30- to 34 years old (58.6%) and decreased in 35-39, 40-44 and 45-49 years to 20.4%, 4.5% and 3.8% respectively. The top five prevalent hr-HPV genotypes were HPV16 (57.1%), 35 (20.3%), 52 (15.8%), 31 (14.1%), and 45 (9.6%) in the Butajira district. As a first population-based study in the country, our results can serve as valuable reference to guide nationwide cervical cancer screening and HPV vaccination programs in Ethiopia.

Liquid-based cytology for the detection of cervical intraepithelial lesions in Jimma town, Ethiopia

Background

Cervical cancer is the second leading type of female cancer in Ethiopia. Screening for cervical cancer is primarily conducted using visual inspection with 5% acetic acid (VIA). Liquid-based cytology (LBC) is not yet widely used in Ethiopia.

Method

Women aged 21–65 years were tested using LBC and VIA to detect cervical dysplasia. Logistic regression analysis was conducted to identify associated factors. Cohen’s Kappa test was conducted to test agreement between LBC and VIA.

Results

Forty-two percent (n = 188) of 448 participants were 31 to 40 years of age and only two participants were above 60. Of the 448 participants, 419 (93.5%) were tested with LBC, 294 (65.6%) VIA and 272 (60.7%) with both LBC and VIA. Among women screened using LBC, 305 (72.8%) were negative for intraepithelial lesion or malignancy (NILM), 97 (23.2%) had low-grade squamous intraepithelial lesion (LSIL) and 17 (4.1%) had high-grade squamous intraepithelial lesion (HSIL). Presence of cervical lesions was generally lower in younger and older women. Majority, 39 (40%) of women with LSIL and 10 (59%) with HSIL were 41–50 years of age. Women aged 51–60 were more likely to have abnormal intraepithelial lesions compared to women aged 21–30 (AOR = 20.9, 95% CI = [7.2–60.9], p = 0.00). Out of 47 (10.8%) HIV-positive women, 14 (32.56%) had intraepithelial lesions of which 10 (23.3%) and 4 (9.3%) had LSIL and HSIL, respectively. Among women screened with VIA, 18 (6.1%) were positive; among the 272 (60.7%) women screened using both LBC and VIA, 6 (2.2%) were positive on both LBC and VIA tests. The level of agreement between the two tests was weak at a statistically significant level (kappa value = 0.155, p = 0.006).

Conclusion

LBC demonstrated high rates of cervical squamous intra-epithelial lesions in our study. VIA was a less reliable predictor of cervical squamous intra-epithelial lesions than LBC. Evaluating diagnostic accuracy of both LBC and VIA against a histological endpoint should be completed before adopting either or both screening modalities.

Cervical cancer screening in rural Ethiopia: a cross- sectional knowledge, attitude and practice study

Background

Cervical cancer is the fourth most common cancer among women worldwide. Sub- Saharan Africa has a high incidence, prevalence and mortality due to shortage and underutilization of screening facilities. This study aims to assess knowledge and attitude towards cervical cancer and its prevention, as well as practice of cervical cancer screening.

Methods

This cross-sectional community- based study was conducted in Butajira, Ethiopia in February 2018. Systematic cluster randomized sampling was used to select households from which women in the targeted age group of 30–49 years were invited to participate. Data was collected using a quantitative door to door approach. The questionnaire included socio-demographic data, obstetric history, general knowledge, risk factors, attitude and practice. Logistic regression was used to assess factors associated with knowledge, attitude and practice after dichotomizing the scores using the median as cut off point.

Results

Three hundred forty-two out of 354 women completed the interviewer administered questionnaire making the response rate 96.3%. 125 women (36%) were aware of cervical cancer and 14 (4.7%) knew symptoms. None of the women named HPV as a risk factor. 61% thought it was a deadly disease, 13.5% felt at risk of developing cervical cancer and 60.7% said cervical cancer is treatable. Eight women (2.3%) had previously been screened. 48.1% had a source of information concerning cervical cancer, of which 66.5% named nurses. Better knowledge was associated with 1–8 years of education (OR = 2.4; CI: 2.4–1.3), having a source of information (OR = 9.1, CI:4.0–20.6), use of contraceptives (OR = 2.3, CI: 1.3–4.0) and a higher income (OR = 1.009, CI: 1.00–1.01). Naming nurses (OR:5.0, CI:2.4–10.3), another source of information (OR = 3.3, CI:1.2–9.0), use of contraceptives (OR = 2.2, CI:1.2–3.8) and living in an urban area (OR = 3.3, CI:1.2–9.0) were associated with a positive attitude. Naming nurses (OR = 21,0, CI:10.4–42.3) and another source of information (OR = 5.8, CI:2.4–13.5) were associated with participating in cervical cancer screening.

Conclusion

Most women were unaware of cervical cancer, HPV-infection as a risk factor and did not feel susceptible to cervical cancer. As Health workers were the most commonly mentioned source of information, focus should be put on their further education.

Home-based HPV self-sampling assisted by a cloud-based electronic data system: Lessons learnt from a pilot community cervical cancer screening campaign in rural Ethiopia

Primary HPV testing and triage of HPV-positive women is an effective cervical cancer screening strategy. Such a multi-visit screening algorithm is also promising for community-based screening in resource-poor communities, provided a robust tracking system is in place.

A cervical cancer screening campaign was conducted in a rural community in Ethiopia. All women aged 25–65 years were offered genital self-sampling using the Evalyn Brush®. Samples were HPV-DNA-tested at a central laboratory. Key indicators were captured on tablet computers and linked by a cloud-based information system. HPV-positive women were examined at the local clinic using portable colposcopy, p16/Ki-67 dual stain cytology and biopsy examination. CIN2+ women were referred for LEEP to the referral hospital.

Of 749 enumerated age-eligible women 634 (85%, (95% CI 82–88)) consented to screening, 429 samples were adequate for HPV testing, giving a total testing coverage of 57% (95% CI 53–62). The hrHPV prevalence was 14% (95% CI 5–22), 72% (95% CI 60–84) attended the clinic for a triage examination. Home-based HPV-DNA self-sampling and clinic-based triage assisted by cloud-based information technology is feasible in rural Ethiopia. Key components of such strategy are broad community awareness, high competency of community workers, and establishment of an adequate self-sampling and HPV-DNA testing platform.

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.