Female perspectives on male involvement in a human-papillomavirus-based cervical cancer-screening program in western Kenya

Men's perceptions and perceived acceptability of their female partner's use of self-administered intravaginal therapies for treatment of cervical precancer in Kenya

Background

Cervical cancer continues to be a major health issue in low- and middle-income countries (LMICs). Despite increasing access to screening, access to precancer treatment remains a significant challenge in LMICs, highlighting a need for innovative, accessible and resource-appropriate treatment approaches, including self-administered therapies.

Methods

A cross-sectional mixed-methods study was conducted among men aged 25-65 with a current female partner in Kisumu County, Kenya. Participants were sequentially recruited and surveyed to evaluate their understanding of human papillomavirus and cervical cancer, their views on screening and treatment and their attitudes toward self-administered therapies. Focus group discussions (FGDs) with a subset of the survey participants further explored their treatment preferences and perceptions.

Results

Two hundred fourteen men participated in the survey, and 39 men participated in FGDs. The median age was 39 years, and 51% had a primary school education or less. Most (96%) were in a committed relationship, and 74% earned $10 or less daily. There was strong support for self-administered topical therapies, with 98% willing to support their partners using such treatments if available. Additionally, most participants were open to supporting necessary abstinence or condom use, though 76% believed their partners might hesitate to request condom use. When given an option, most preferred their partner to self-administer such therapies at home compared to provider administration at a health facility, citing convenience, cost-effectiveness and privacy. Preferences varied between two potential therapies, 5-Fluorouracil and Artesunate, based on their administration frequency, duration and abstinence requirements. Qualitative findings largely supported the quantitative analysis.

Conclusion

The study demonstrates strong support for self-administered topical therapies for cervical precancer among Kenyan men. Additional research on acceptability, feasibility and efficacy in different LMICs could pave the way for these therapies to help bridge current cervical precancer treatment gaps in these settings.

"There is nothing that can prevent me from supporting her:" men's perspectives on their involvement and support of women's use of topical therapy for cervical precancer treatment in Kenya

Purpose

Cervical cancer disproportionately impacts women in low- and middle-income countries (LMICs). The World Health Organization's (WHO) 90/70/90 strategy aims to eliminate cervical cancer by 2030 by increasing HPV vaccination coverage to 90%, screening 70% of eligible women, and effectively treating 90% of those with abnormal results by 2030, potentially preventing 62 million deaths in LMICs. LMICs, however, struggle with limited access to cervical precancer treatment, in part due to a lack of trained professionals and weak health systems. Effective non-surgical, self-administered, which have demonstrated efficacy in high-income countries, could bridge the treatment gap in LMICs and may be more scalable and cost-effective than provider-administered therapies. To inform feasibility studies in LMICs, data are needed on the role of male partners in influencing the acceptability and uptake of self-administered topical therapies, including their support of recommended abstinence and contraception guidelines associated with these therapies.

Methods

Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with men aged 25 to 65 years in Kenya to explore their perspective and perceived support regarding their female partners using topical self-administered therapies for cervical precancer treatment. The FGDs were moderated by local qualitative research assistants and conducted in local languages, transcribed, coded, and analyzed using qualitative description.

Results

Thirty-nine male participants meeting the eligibility criteria participated in five FGDs. The mean age of participants was 42.5 years. Most participants, 79.5%, had a female partner with a history of cervical precancer treatment, 5.1% did not, and 15.4% were unsure of their female partner's prior precancer treatment history. The study aimed to assess men's support of their female partners' use of topical therapies for treating cervical precancer. We find that male participants strongly express acceptance and willingness to support their wives or partners in using such therapies, if available. Reported supportive behavior included permitting the use of the therapies and support of maintaining abstinence during the recommended times. Additionally, participants desired male involvement in clinic and community-based education about topical therapies to facilitate widespread support.

Conclusion

The use of self-administered topical therapies for cervical precancer treatment, if supported by efficacy studies in LMICs, may support achieving the WHO's 2030 goal of 90% treatment access. We find that with adequate education, men express overwhelming support of their female partner's use of topical therapies, including adherence to abstinence and contraception guidelines.

Perceived acceptability of self-administered topical therapy for cervical precancer treatment among women undergoing cervical cancer screening in Kenya

Purpose

Innovative strategies are urgently needed to meet the World Health Organization's 2030 target of treating 90% of women with precancerous cervical lesions, especially in countries most affected by cervical cancer. We assessed the acceptability of self-administered intravaginal therapies for treating cervical precancer in women undergoing cervical cancer screening and precancer treatment in Kenya.

Methods

We conducted a cross-sectional study among women aged 18 to 65 years undergoing cervical cancer screening or precancer treatment between January and October 2023 in Kisumu County, Kenya. Participants completed a questionnaire about their perceptions and perceived acceptability of self- or provider-administered topical therapies for cervical precancer treatment. Quantitative data were summarized using descriptive statistics.

Results

A total of 379 questionnaires were completed. The median age of participants was 35 years (IQR 25-62), 62% had a primary education or less, and 71% earned $5 or less daily. All participants had been screened for cervical cancer, and 191 (51%) had received precancer treatment, primarily thermal ablation. Ninety-eight percent of participants were willing to use a self-administered intravaginal therapy for cervical precancer, if available. The majority, 91%, believed their male partner would support their use. Given a choice, 63% preferred self-admiration at home compared to provider-administration of a topical therapy in the clinic, citing time and cost savings. In multivariate analysis, married women were more likely to expect partner support for self-administration than single women. Participants preferred a therapy used less frequently but for a longer duration, compared to daily use therapy with a shorter duration of use.

Conclusions

Self-administered intravaginal therapies for cervical precancer treatment are highly acceptable among women undergoing screening and precancer treatment in Kenya.

Men's perceptions and perceived acceptability of their female partner's use of self-administered intravaginal therapies for treatment of cervical precancer in Kenya

Background

Cervical cancer continues to be a major health issue in low- and middle-income countries (LMICs). Despite increasing access to screening, access to precancer treatment remains a significant challenge in LMICs, highlighting a need for innovative, accessible, and resource-appropriate treatment approaches, including self-administered therapies.

Methods

A cross-sectional mixed-methods study was conducted among men aged 25-65 with a current female partner in Kisumu County, Kenya. Participants were sequentially recruited and surveyed to evaluate their understanding of HPV and cervical cancer, their views on screening and treatment, and their attitudes toward self-administered therapies. Focus group discussions with a subset of the survey participants further explored their treatment preferences and perceptions.

Results

Two hundred fourteen men participated in the survey, and 39 men participated in focus group discussions. The median age was 39 years, and 51% had a primary school education or less. Most (96%) were in a committed relationship, and 74% earned $10 or less daily. There was strong support for self-administered topical therapies, with 98% willing to support their partners using such treatments if available. Additionally, most participants were open to supporting necessary abstinence or condom use, though 76% believed their partners might hesitate to request condom use. When given an option, most preferred their partner to self-administer such therapies at home compared to provider administration at a health facility, citing convenience, cost-effectiveness, and privacy. Preferences varied between two potential therapies, 5-Fluorouracil (5FU) and Artesunate, based on their administration frequency, duration, and abstinence requirements. Qualitative findings largely supported the quantitative analysis.

Conclusions

The study demonstrates strong support for self-administered topical therapies for cervical precancer among Kenyan men. Additional research on acceptability, feasibility, and efficacy in different LMICs could pave the way for these therapies to help bridge current cervical precancer treatment gaps in these settings.

Women and health providers' perspectives on male support for cervical cancer screening in Gwanda district, Zimbabwe

Several studies have shown that male involvement increases the uptake of sexual and reproductive health programmes for improved family health outcomes. The role of men in reducing the burden of cervical cancer has however not been researched in Zimbabwe. It is for this reason that this study explores male support for cervical cancer screening programmes from the perspective of women and health providers in the Gwanda district of Zimbabwe. A qualitative approach that engaged thirty-six women aged 25-50 years in focus group discussions, and twenty-five health providers with different roles in the cervical cancer screening programme in in-depth interviews was used to determine their perspectives on male support for cervical cancer screening. Data were analysed thematically using ATLAS.ti Computer Assisted Qualitative data analysis software. Key findings reflected that men lacked knowledge on cervical cancer and its risk factors and prevention. Subsequently, they engaged in sexual behaviours that increased their partners' risk of acquiring Human Papillomavirus infection, the virtually necessary cause of cervical cancer. Furthermore, men did not provide the necessary emotional and financial support for their women to access screening and treatment. Participants were optimistic that innovative awareness creation strategies and intense, sustained cervical cancer education efforts targeting men could increase male partner support. Involvement of community leaders was seen as crucial in the facilitation of male involvement for programme acceptance and improved uptake of cervical cancer screening. Male involvement is seen as an integral component of the cervical cancer prevention and control programme that has to be implemented in Gwanda district to minimise male partner-related barriers to cervical cancer screening. Further research focusing on men is required to identify specific knowledge gaps that would enable development of appropriate strategies that best involve men in cervical cancer prevention and control interventions.

Understanding the cervical cancer self-collection preferences of women living in urban and rural Rwanda

Cervical cancer is a leading cause of cancer among women in low- and middle-income countries. Women in Rwanda have high rates of cervical cancer due to limited access to effective screening methods. Research in other low-resource settings similar to Rwanda has shown that HPV-based self-collection is an effective cervical cancer screening method. This study aims to compare the preferences of Rwandan women in urban and rural settings toward self-collection and to report on factors related to self-collection amenability. A cross-sectional survey was conducted from June 1-9, 2022. Women were recruited from one urban and one rural clinic in Rwanda. Women were eligible for the study if they were ≥ 18 years and spoke Kinyarwanda or English. The survey consisted of 51 questions investigating demographics and attitudes towards self-collection for cervical cancer screening. We reported descriptive statistics stratified by urban and rural sites. In total, 169 urban and 205 rural women completed the survey. The majority of respondents at both sites had a primary school or lower education and were in a relationship. Both urban and rural respondents were open to self-collection; however, rates were higher in the rural site (79.9% urban and 95.6% rural; p-value<0.001). Similarly, women in rural areas were more likely to report feeling unembarrassed about self-collection (65.3% of urban, 76.8% of rural; p-value<0.001). Notably, almost all urban and rural respondents (97.6% urban and 98.5% rural) stated they would go for a cervical cancer pelvic examination to a nearby health center if their self-collected results indicated any concern (p-value = 0.731). Rwandan women in both urban and rural areas largely support self-collection for cervical cancer screening. Further research is needed to better understand how to implement self-collection screening services in Rwanda.

Lipids in the reproduction of sires

The main class of nutritional interest for lipids are fatty acids (FA), which correspond to 90% of triglycerides, the main form of lipid storage in both plants and animals. FAs serve as a source of energy in the diet of cattle; however, they also have an important non-caloric effect on animal organisms as they are important components of the physical and functional structures of cells and participate in the composition of steroid hormones. As such, research has studied the improvement of semen quality through the provision of polyunsaturated FAs in bull diets, as well as the use of FAs in semen extenders in order to reduce damage to sperm cells, which can alter lipid composition and the quality of frozen sperm. Therefore, the objective of this work was to review the effectiveness of lipids on reproductive efficiency, based on their effects on semen quality and hormonal production. Supplementation with polyunsaturated FAs positively alters semen composition and in vitro fertility; however, results vary according to the type of FA used, the method of administration, and its quality. Fish oil and linseed oil showed better results in qualitative parameters in fresh and thawed semen. The use of cyclodextrins to incorporate or extract cholesterol from plasma membranes can also improve the viability of cryopreserved semen.

Effectiveness of family-centred sexual health education and HPV self-sampling in promoting cervical cancer screening among hard-to-reach indian women in rural and tribal areas: a community-based pilot study

BACKGROUND

While cervical cancer deaths have declined steeply in high-income countries due to the widespread use of the Papanicolaou test (Pap test), the same trend has not emerged in low or middle-income countries (LMICs). Access to screening in LMICs like India is limited due to barriers such as limited healthcare infrastructures, lack of sexual health education, and stigma demarcating sexually transmitted infections (STIs). HPV self-sampling (HPV-SS), a woman-centered and at-home method for screening, can be utilized as a unique screening tool to overcome some of these barriers. Our study examined the effectiveness of HPV-SS, supported by family-centred arts-based sexual health literacy on the uptake of cervical cancer screening among hard-to-reach women in rural and remote areas in India.

METHODS

Our community-based mixed methods pilot study recruited 240 participants (120 women and 120 male partners or family members) through female Accredited Social Health Activists (ASHA) across 3 Indian villages of Shirgoan, Khodala, and Jamsar in Palghar district. Inclusion criteria included women ages 30-69 who were under or never screened (UNS) and their male partners/family members aged 18 or over. Knowledge and attitudes about cervical cancer and screening and their perceived stigma surrounding STI were assessed using validated scales prior to and after attending a 2-hour arts-based sexual health education (SHE). In addition, participants' uptake of cervical cancer screening was assessed after attendance in SHE.

FINDINGS

Results revealed significant improvement in knowledge and attitudes about cervical cancer and screening, and a reduction in the STI stigma after participation in SHE sessions (overall mean difference in Knowledge: z = 6.1 ± 2.4, P < 0.001; attitudes about Pap-test and VIA: z = 2.2 ± 8.4, P < 0.001 and z = 2.9 ± 8.2, P < 0.001; STI stigma: z = 2.8 ± 12.4, P < 0.001). 118 out of 120 female participants chose to be screened and 115 opted for HPV-SS.

CONCLUSIONS

The implementation of HPV-SS coupled with family-centered arts-based and culturally appropriate SHE is highly promising in promoting cervical cancer screening among hard-to-reach women. Evidence from our study can be used to advance public health policies and inform the scale-up of similar initiatives in other villages and states across rural India and other LMICs.

"We Shall Tell them with Love, Inform them what we have Learnt and then Allow them to go" - Men's Perspectives of Self-Collected Cervical Cancer Screening in Rural Uganda: A Qualitative Inquiry

Uganda has high incidence rates of cervical cancer (47.5/100,000/year) due to limited screening access. In settings where men hold most of the decision-making power, they play an important role in women's uptake of cervical cancer screening. We aimed to capture men's knowledge, beliefs and perspectives about cervical cancer, community-based screening and health system barriers. Focus group discussions were conducted with men in rural Uganda. Data were verbatim translated and transcribed into English. Transcripts were analysed in ATLAS.ti using a deductive approach of thematic content analysis and applied to an implementation research framework. Twenty-three men participated in focus groups. Men held poor knowledge of cervical cancer, its causes and treatment. Men felt screening would be acceptable by women if men and women were educated. Men highlighted health system barriers to accessing screening including: 1) poor-quality health services, 2) large distances to facilities/lack of affordable transportation and 3) lack of health workers/mistreatment by health workers. Men described supporting women through assisting with transportation, psychosocial support and sharing information. They requested services for men to be decentralized alongside community outreaches for cervical cancer screening. Engaging men in the implementation, education and planning of community-based cervical cancer screening programs is critical. Not engaging men is a missed opportunity to provide them with services and education. Concerted efforts must be made in educating men and reducing health system barriers to ensure rural women receive cervical cancer screening and follow-up care in low-income settings. Clinicaltrials.gov, NCT04000503; Registered 27 June 2019.

Preferences for Breast and Cervical Cancer Screening Among Women and Men in Kenya: Key Considerations for Designing Implementation Strategies to Increase Screening Uptake

Breast and cervical cancer incidence rates and mortality rates in Kenya are high. Screening is globally accepted as a strategy for early detection and downstaging of these cancers for better outcomes, but despite the efforts established by the Kenyan government to provide these services to eligible populations, uptake has remained disproportionately low. Using data from a larger study aimed at understanding the implementation and scale-up of cervical cancer screening services, we analyzed data to compare the preferences for breast and cervical cancer screening services between men and women (25-49 years) in rural and urban communities in Kenya. Participants were recruited in concentric circles starting at the center of six subcounties. One woman and one man per household were enrolled for data collection on a continuous basis. More than 90% of both men and women had a monthly income of less than US $500. The top three preferred sources of information on screening for cancers affecting women were health care providers; community health volunteers; and media such as television, radio, newspapers, and magazines. More women (43.6%) than men (28.0%) trusted community health volunteers to provide health information on cancer screening. Printed materials and mobile phone messages were preferred by approximately 30% of both genders. Over 75% of both men and women preferred an integrated model of service delivery. These findings show that there are many similarities that can be leveraged when designing implementation strategies for population-wide breast and cervical cancer screening hence reducing the challenge of addressing diverse preferences of men and women which may not be easy to reconcile.

Reach and effectiveness of an HPV self-sampling intervention for cervical screening amongst under- or never-screened women in Toronto, Ontario Canada

BACKGROUND

Cervical cancer is almost entirely preventable with appropriate and timely screening. In Ontario, Canada, South Asian, Middle Eastern and North African women have some of the lowest rates of screening and a suggested higher burden of cervical cancer. With increasing international evidence and adoption of HPV testing, many screening programs are making the move away from Pap tests and towards HPV testing with the option of HPV self-sampling seeming promising for under- or never-screened (UNS) women. Our study aimed to understand the uptake and acceptability of an HPV self-sampling intervention amongst these disproportionately UNS women in Peel region and surrounding areas in Ontario.

METHODS

A community -based mixed methods approach guided by the RE-AIM framework was used to recruit approximately 100 UNS racialized immigrant women aged 30-69, during the period of June 2018 to December 2019. The main recruitment strategy included community champions (i.e. trusted female members of communities) to engage people in our selected areas in Peel Region. Participants completed a study questionnaire about their knowledge, attitudes and practices around cervical cancer screening, self-selected whether to use the HPV self-sampling device and completed follow-up questions either about their experience with self-sampling or going to get a Pap test.

RESULTS

In total, 108 women participated in the study, with 69 opting to do self-sampling and 39 not. The majority of women followed through and used the device (n = 61) and found it 'user friendly.' The experience of some participants suggests that clearer instructions and/or more support once at home is needed. Survey and follow-up data suggest that privacy and comfort are common barriers for UNS women, and that self-sampling begins to address these concerns. Across both groups addressing misinformation and misconceptions is needed to convince some UNS women to be screened. Family, friends and peers also seemed to play a role in the decision-making process.

CONCLUSIONS

HPV self-sampling is viewed as an acceptable alternative to a Pap test for cervical screening, by some but not all UNS women. This method begins to address some of the barriers that often prevent women from being screened and is already being offered in some jurisdictions as an alternative to clinical cervical cancer screening.

Involving men in cervical cancer prevention; a qualitative enquiry into male perspectives on screening and HPV vaccination in Mid-Western Uganda

INTRODUCTION

Evidence-based preventive strategies for cervical cancer in low-resource setting have been developed, but implementation is challenged, and uptake remains low. Women and girls experience social and economic barriers to attend screening and human papillomavirus (HPV) vaccination programs. Male support has been proven successful in uptake of other reproductive healthcare services. This qualitative study with focus groups aimed to understand the perspectives of males on cervical cancer screening and HPV vaccination in Western-Uganda This knowledge could be integrated into awareness activities to increase the attendance of cervical cancer screening and HPV vaccination programs.

MATERIALS AND METHODS

Focus group discussions were conducted with men aged 25 to 60 years, who were married and/or had daughters, in Kagadi district, Mid-Western Uganda. All interviews were transcribed verbatim and thematically analyzed using an inductive approach.

RESULTS

Eleven focus group discussions were conducted with 67 men. Men were willing to support their wives for screening and their daughters for HPV vaccination. Misperceptions such as family planning and poor personal hygiene leading to cervical cancer, and misperception of the preventative aspect of screening and vaccination were common. Women with cervical cancer suffer from stigmatization and family problems due to loss of fertility, less marital sexual activity, domestic violence and decreased economic productivity.

CONCLUSIONS

Ugandan men were willing to support cervical cancer prevention for their wives and daughters after being informed about cervical cancer. Limited knowledge among men about the risk factors and causes of cervical cancer, and about the preventative aspect of HPV vaccination and screening and their respective target groups, can limit uptake of both services. Screening and vaccination programs should actively involve men in creating awareness to increase uptake and acceptance of prevention.

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

RESULTS

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

CONCLUSION

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

Individual and intimate-partner factors associated with cervical cancer screening in Central Uganda

Intimate-partner factors have a significant effect on the uptake of services that affect maternal reproductive health outcomes. There is limited research on intimate-partner factors associated with cervical cancer screening. Therefore, this article examines the intimate-partner correlates of cervical cancer screening among married women in Central Uganda. We conducted a cross-sectional survey in Wakiso and Nakasongola districts in Central Uganda. A total of 656 married women aged 25–49 participated in the study. Frequency distributions for descriptive statistics and Pearson chi-squared tests were done to identify the association of selected individual explanatory variables and intimate-partner factors with cervical cancer screening. Finally, multivariable complementary log-log regressions were used to estimate intimate-partner factors associated with women’s cervical cancer screening uptake in Central Uganda. About 2 in 10 (20%) of the participants had been screened for cervical cancer. The following characteristics when examined separately in relation to the uptake of cervical cancer screening service and were significant: woman’s age, education attainment, occupation, wealth index, parity, male partner’s age, and male partner’s emotional support. After adjusting for independent factors, cervical cancer screening was significantly associated with women who had; attained secondary (AOR = 2.19; CI 1.18–4.06) compared to none/ primary education, and received partner’s emotional support (AOR = 30.06; CI 13.44–67.20) compared to those who did not receive partner’s emotional support. In Central Uganda, cervical cancer screening among married women was significantly associated with women’s education, and partner’s emotional support. These factors point to the importance of intimate-partner factors. Therefore, more effort should be directed at encouraging men’s participation. This should be supplemented with empowering women through education to increase uptake of screening services.

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

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

A comparison of behavioural models explaining cervical cancer screening uptake

BACKGROUND

Cervical cancer represents a very high burden of disease, especially in Low- and Middle-income economies. Screening is a recommended prevention method in resource-poor settings. Cervical cancer screening (CCS) uptake is influenced by various psycho-social factors, most of which are included in behavioural models. Unlike demographic characteristics, these factors are modifiable. While few studies have compared these models in terms of their capacity to predict health behaviour, this study considers three health behaviour theories to assess and compare the predictors of CCS behaviour and intention.

METHODS

A survey was conducted among 607 sexually active women in the South Indian state of Karnataka. Data was collected regarding socio-demographic factors, health literacy, knowledge on CCS, and the socio-cognitive factors related to CCS that are represented in the Health Belief Model (HBM), Theory of Planned Behaviour (TPB) and Theory of Care-Seeking Behaviour (TCSB). Logistic regression analyses tested to what extent each of the theoretical models explained cervical cancer screening (CCS) intention and regular screening behaviour, comparing the variance explained by each of the models.

RESULTS

CCS intention was best explained by the TPB, followed by the HBM. Of the constructs included in these models, positive attitude towards the screening procedure and perceived benefits contributed most significantly to screening intention, followed by fear, anxiety or embarrassment related to the disease or screening procedure, and context specific barriers.

CONCLUSION

Health behavioural models such as the TPB and HBM can help to identify the main socio-cognitive factors explaining the intention of women to participate in CCS. As such, they can inform interventions to target specific determinants of screening intention and behaviour, and enhance their effectiveness by addressing women's screening attitude, perceived benefits, and emotions as well as reducing context specific barriers to screening.

Cervical cancer screening in a population of black South African women with high HIV prevalence: A cross-sectional study

Cervical cancer is largely preventable through early detection, but screening uptake remains low among black women in South Africa. The purpose of this study was to determine the prevalence and factors associated with cervical cancer screening in the past 10 years among black African women in primary health care (PHC) clinics, in Gauteng Province, South Africa. This was a cross-sectional study involving 672 consecutively recruited black women at cervical cancer screening programs in PHC clinics between 2017 and 2020. An interviewer-administered questionnaire covered socio-demographics, HIV status, sexual history, cervical cancer risk factors knowledge, and screening behaviours in the past 10 years. The mean age of participants was 38 years. More than half (63%) were aged 30-49 years. Most completed high school education (75%), were unemployed (61%), single (60%), and HIV positive (48%). Only 285 (42.4%) of participants reported screening for cervical cancer in the past 10 years. Of participants that reported receiving information on screening, 27.6% (n = 176) and 13.97% (n = 89) did so from healthcare facilities and community platforms respectively. Participants aged 30 years or more were more likely to report for cervical cancer screening as compared to other categories in the past 10 years. The study found low cervical cancer screening prevalence. This calls for health education campaigns and prevention strategies that would target individual patients' contexts and stages of behavioral change. Such strategies must also consider socio-demographic and clinical correlates of cervical cancer screening and promote better integration into PHC services in South Africa.

Family-Centered Sexual Health Intervention to Promote Cervical Cancer Screening Uptake Among Low-income Rural Women in India: A Community-Based Mixed-Method Pilot study (Preprint)

Background

Objective

Methods

Results

Conclusions

International Registered Report Identifier (IRRID)

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.

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.

Women's experiences in a community-based screen-and-treat cervical cancer prevention program in rural Malawi: a qualitative study

BACKGROUND

Malawi has the world's highest cervical cancer incidence and mortality due to high rate of HIV coupled with inadequate screening and treatment services. The country's cervical cancer control program uses visual inspection with acetic acid (VIA) and cryotherapy, but screening is largely limited by poor access to facilities, high cost of cryotherapy gas, and high loss-to-follow-up. To overcome these limitations, we implemented a community-based screen-and-treat pilot program with VIA and thermocoagulation. Through a qualitative study, we explore the experiences of women who underwent this community-based pilot screening program.

METHODS

We implemented our pilot program in rural Malawi and conducted an exploratory qualitative sub-study. We conducted in-depth interviews with women who were treated with thermocoagulation during the program. We used semi-structured interviews to explore screen-and-treat experience, acceptability of the program and attitudes towards self-sampling for HPV testing as an alternative screening method. Content analysis was conducted using NVIVO v12.

RESULTS

Between July - August 2017, 408 participants eligible for screening underwent VIA screening. Thirty participants had VIA positive results, of whom 28 underwent same day thermocoagulation. We interviewed 17 of the 28 women who received thermocoagulation. Thematic saturation was reached at 17 interviews. All participants reported an overall positive experience with the community-based screen-and-treat program. Common themes were appreciation for bringing screening directly to their villages, surprise at the lack of discomfort, and the benefits of access to same day treatment immediately following abnormal screening. Negative experiences were rare and included discomfort during speculum exam, long duration of screening and challenges with complying with postprocedural abstinence. Most participants felt that utilizing self-collected HPV testing could be acceptable for screening in their community.

CONCLUSIONS

Our exploratory qualitative sub-study demonstrated that the community-based screen-and-treat with VIA and thermocoagulation was widely accepted. Participants valued the accessible, timely, and painless thermocoagulation treatment and reported minimal side effects. Future considerations for reaching rural women can include community-based follow-up, cervical cancer education for male partners and self-sampling for HPV testing.

Lactoferrin: A Glycoprotein Involved in Immunomodulation, Anticancer, and Antimicrobial Processes

Lactoferrin is an iron binding glycoprotein with multiple roles in the body. Its participation in apoptotic processes in cancer cells, its ability to modulate various reactions of the immune system, and its activity against a broad spectrum of pathogenic microorganisms, including respiratory viruses, have made it a protein of broad interest in pharmaceutical and food research and industry. In this review, we have focused on describing the most important functions of lactoferrin and the possible mechanisms of action that lead to its function.

"A loving man has a very huge responsibility": A mixed methods study of Malawian men's knowledge and beliefs about cervical cancer

BACKGROUND

In Malawi, numerous barriers may prevent women from accessing cervical cancer screening services - including social factors such as male partner involvement. We conducted surveys that included open- and closed-ended questions with married Malawian men to evaluate their knowledge and beliefs about cervical cancer.

METHODS

HIV-positive adult (≥18 years) men (married or in a stable relationship) were recruited from an antiretroviral therapy clinic in Lilongwe, Malawi. Men were asked a series of survey questions to assess their knowledge about cervical cancer, experience with cervical cancer, their female partner's screening history, and their beliefs about gender norms and household decision-making. Following the survey, participants responded to a set of open-ended interview questions about cervical cancer screening, and men's role in prevention.

RESULTS

One hundred-twenty men were enrolled with average age 44 years and 55% having completed secondary school or higher education. Despite only moderate knowledge about cervical cancer and screening (average assessment score of 62% correct), all men expressed support of cervical cancer screening, and most (86%) believed they should be involved in their female partner's decision to be screened. Over half (61%) of men said their female partner had previously been screened for cervical cancer, and this was positively correlated with the male respondent having more progressive gender norms around sexual practices. Some men expressed concerns about the screening process, namely the propriety of vaginal exams when performed by male clinicians, and whether the procedure was painful.

CONCLUSIONS

Male partners in Malawi want to be involved in decisions about cervical cancer screening, but have limited knowledge about screening, and hold rigid beliefs about gender norms that may affect their support for screening. Messaging campaigns addressing men's concerns may be instrumental in improving women's adoption of cervical cancer screening services in Malawi and similar settings.

Qualitative assessment of knowledge and attitudes towards cervical cancer screening among male Latino immigrants in Houston, Texas

Background

Male spouses and partners play an important role in determining a woman’s willingness to participate in cervical cancer screening. However, the attitudes and behaviors by which they influence a woman’s decision to undergo Pap testing remain poorly understood.

Methods

A series of semi-structured, qualitative interviews were conducted in Spanish with 19 recent Latino immigrants in Houston, Texas. The interview format was designed to establish each individual’s pattern of engagement with the United States healthcare system, assess baseline knowledge of cervical cancer screening and evaluate attitudes and patterns of communication with their female partners regarding health care. Interview questions were constructed using principles of the Theory of Reasoned Action. All interviews were conducted in Spanish. After translation, responses were coded and scored with the goal of identifying themes and key observations.

Results

Most subjects reported few, if any, interactions with the healthcare system since their arrival in the United States. Although most participants reported being aware that women should be seen by their doctors regularly, fewer than half could clearly indicate the purpose of a Pap test or could state with certainty the last time their female partner had undergone screening. Multiple subjects expressed a general distrust of the health care system and concern for its costs. Approximately half of subjects reported that they accompanied their female partner to the health care provider’s office and none of the participants reported that they were present in examination rooms at the time their partner underwent screening. Multiple participants endorsed that there may be some concerns within their community regarding women receiving frequent gynecologic care and distrust of the healthcare system. Almost all interviewed subjects stated that while they would allow their female partners to see male physicians, they also expressed the opinion that other men might be uncomfortable with this and that women would likely be more comfortable with female physicians.

Conclusions

Strategies to enhance knowledge of HPV and cancer screening and improve trust in the health care system among male spouses or partners should be explored with the goal of promoting cervical cancer screening among immigrant Latinx populations.

"It is big because it's ruining the lives of many people in Malawi": Women's attitudes and beliefs about cervical cancer

Adoption of routine cervical cancer screening in Malawi is very low, even though it has the highest cervical cancer burden in the world. We performed a multi-level assessment of Malawian women's knowledge and perceptions of cervical cancer risk and screening. Using the Multi-Level Health Outcomes Framework, we conducted interviews with 60 adult Malawian women aged 18-62 at facilities with cervical cancer screening. Eligible participants were recruited regardless of HIV status or history of screening, and asked about their experiences with cervical cancer disease and screening. Interviews were audio recorded and a theory-informed codebook was developed. Analysis focused on thematic differences across groups by age, HIV status, and screening history. Half of the sample (n = 30) had either never been screened for cervical cancer or were at the facility for their first-ever screen. Most women said that cervical cancer is dangerous, and many knew someone affected. Many women spoke about the importance of screening for prevention of cancer. Risk factors were generally well-understood, including increased risk with HIV, although this was misunderstood by some HIV-negative women to mean they were not at risk. Social networks were identified as a key determinant of screening, and gender issues were likewise highly salient. Despite high knowledge levels about cervical cancer, there remain significant challenges to improving screening, including interpersonal and system-level barriers. Future work should strengthen service delivery, target social networks and intimate partners, and develop targeted communication strategies for HIV-positive and -negative groups, especially in high-burden settings.