Provision of cervical cancer prevention services in Northern Uganda: a survey of health workers from rural health centres

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Increased Knowledge Mediates the Effect of Game Changers for Cervical Cancer Prevention on Diffusion of Cervical Cancer Screening Advocacy Among Social Network Members in a Pilot Trial

BACKGROUND

Game Changers for Cervical Cancer Prevention (GC-CCP), a peer-led, group advocacy training intervention, increased cervical cancer (CC) prevention advocacy not only among intervention recipients, but also their social network members (referred to as "alters") who were targeted with advocacy in a pilot randomized controlled trial. We examined mediators and moderators of this effect on alter advocacy, to understand how and for whom the intervention had such an effect.

METHOD

Forty women (index participants) who had recently screened for CC enrolled and were randomly assigned to receive the GC-CCP intervention (n = 20) or the wait-list control (n = 20). Up to three alters from each participant (n = 103) were surveyed at baseline and month 6. Measures of CC-related cognitive constructs (knowledge, enacted stigma, and risk management self-efficacy), as well as extent of advocacy received from index participants, were assessed as mediators of the intervention effect on alter advocacy using multivariate regression analyses. Alter characteristics were examined as moderators.

RESULTS

Increased CC-related knowledge partially mediated the intervention effect on increased alter engagement in CC prevention advocacy; those with greater gains in knowledge reported greater engagement in advocacy. No moderators of the intervention effect were identified.

CONCLUSION

The effect of GC-CCP on alter CC prevention advocacy is enhanced by increased alter knowledge pertaining to CC prevention, causes, and treatment and suggests this may be key for diffusion of intervention effects on increased CC prevention advocacy throughout a social network.

TRIAL REGISTRATION

NCT04960748 (registered on clinicaltrials.gov , 7/14/2021).

Knowledge and practice of cervical cancer screening and its associated factors among women attending maternal health services at public health institutions in Assosa Zone, Benishangul-Gumuz, Northwest Ethiopia, 2022: a cross-sectional study

BACKGROUND

Cervical cancer ranks as the second most frequent cancer among all women in Ethiopia and the second most frequent cancer among women between 15 and 44 years of age, resulting in over 4884 moralities annually. Although there is a focus on health promotion through teaching and screening in Ethiopia's intended transition toward universal healthcare, there is little information available on baseline levels of knowledge and screening uptake related to cervical cancer.

OBJECTIVES

This study explored the levels of knowledge and screening rates of cervical cancer along with its associated factors among women of reproductive age in Assosa Zone, Benishangul-Gumuz, Ethiopia in 2022.

METHODOLOGY

A facility-based cross-sectional study was conducted. A systematic sampling technique was used to select 213 reproductive-age women from selected health institutions, from 20 April 2022 to 20 July 2022. A validated and pretested questionnaire was used for data collection. Multi-logistic regression analyses were done to identify factors independently associated with cervical cancer screening. Adjusted OR with 95% CI was estimated to measure the strength of association. The level of statistical significance was declared at a p value of <0.05. The results were presented in tables and figures.

RESULT

Knowledge of cervical cancer screening in this study was 53.5%, and 36% of respondents had practised cervical cancer screening. Family history of cervical cancer (AOR)=2.5, 95% CI (1.04 to 6.44)), place of residence (AOR=3.68, 95% CI (2.23, 6.54)) and availability of health services at nearby (AOR=2.03, 95% CI (1.134, 3.643)) were significantly associated with knowledge of cervical cancer screening, while educational status (AOR=2.811, 95% CI (1.038 to 7.610)), knowing someone diagnosed with cervical cancer (AOR=8.3, 95% CI (2.4, 28.69)), Knowledge of cervical cancer(AOR=2.17, 95%CI(1.077, 4.384) and feeling feeling at risk (AOR=3.26 95% CI (1.52, 5.04)) were associated with the practice of cervical cancer screening.

CONCLUSION AND RECOMMENDATION

Knowledge and practice of cervical cancer screening in this study were low. Therefore, the reproductive women must be encouraged to have early cervical cancer screening at precancerous stage by informing their susceptibility to cervical cancer.

Health facility assessments of cervical cancer prevention, early diagnosis, and treatment services in Gulu, Uganda

BACKGROUND

Cervical cancer is ranked globally in the top three cancers for women younger than 45 years, with the average age of death at 59 years of age. The highest burden of disease is in low-to-middle income countries (LMICs), responsible for 90% of the 311,000 cervical cancer deaths in 2018. This growing health disparity is due to the lack of quality screening and treatment programs, low human papillomavirus (HPV) vaccination rates, and high human immunodeficiency virus (HIV) co-infection rates. To address these gaps in care, we need to develop a clear understanding of the resources and capabilities of LMICs' health care facilities to provide prevention, early diagnosis through screening, and treatment for cervical cancer.

OBJECTIVES

This project aimed to assess baseline available cervical cancer prevention, early diagnosis, and treatment resources, at facilities designated as Health Center III or above, in Gulu, Uganda.

METHODS

We adapted the World Health Organization's Harmonized Health Facility Assessment for our own HFA and grading scale, deploying it in October 2021 for a cross-sectional analysis of 21 health facilities in Gulu.

RESULTS

Grading of Health Center IIIs (n = 16) concluded that 37% had "excellent" or "good" resources available, and 63% of facilities had "poor" or "fair" resources available. Grading of Health Center IVs and above (n = 5) concluded that 60% of facilities had "excellent" or "good" resources, and 40% had "fair" resources available.

DISCUSSION

The analysis of health facilities in Gulu demonstrated subpar resources available for cervical cancer prevention, early diagnosis, and treatment. Focused efforts are needed to expand health centers' resources and capability to address rising cervical cancer rates and related health disparities in LMICs. The development process for this project's HFA can be applied to global cervical cancer programming to determine gaps in resources and indicate areas to target improved health equity.