Cervical cancer screening at a tertiary care center in Rwanda

Understanding HPV Vaccination Policymaking in Rwanda: A Case of Health Prioritization and Public-Private-Partnership in a Low-Resource Setting

Rwanda is the first African country to implement a national HPV vaccination program in 2011. This study sought to clarify the HPV vaccination policymaking process in Rwanda through the lens of Kingdon's multiple stream framework and Foucault's concept of governmentality. Perspectives of policymakers engaged in HPV vaccination policy were gathered from published sources, along with key informant interviews. Rwanda's track record of successful vaccination programs enabled by a culture of local accountability created public and private sector incentives. Effective stakeholder engagement, health priority setting, and resource mobilization garnered locally and through international development aid, reflect indicators of policy success. The national HPV policymaking process in Rwanda unfolded in a relatively cohesive and stable policy network. Although peripheral stakeholder resistance and a constrained national budget can present a threat to policy survival, the study shows that such factors as the engagement of policy entrepreneurs within a policy network, private sector incentives, and international aid were effective in ensuring policy resolution.

Cervical cancer survival times in Africa

Objective

Accessibility to quality healthcare, histopathology of tumor, tumor stage and geographical location influence survival rates. Comprehending the bases of these differences in cervical cancer survival rate, as well as the variables linked to poor prognosis, is critical to improving survival. We aimed to perform the first thorough meta-analysis and systematic review of cervical cancer survival times in Africa based on race, histopathology, geographical location and age.

Methods and materials

Major electronic databases were searched for articles published about cervical cancer survival rate in Africa. The eligible studies involved studies which reported 1-year, 3-year or 5-year overall survival (OS), disease-free survival (DFS) and/or locoregional recurrence (LRR) rate of cervical cancer patients living in Africa. Two reviewers independently chose the studies and evaluated the quality of the selected publications, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA-P). We used random effects analysis to pooled the survival rate across studies and heterogeneity was explored via sub-group and meta-regression analyses. A leave-one-out sensitivity analysis was undertaken, as well as the reporting bias assessment. Our findings were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA-P).

Results

A total of 16,122 women with cervical cancer were covered in the 45 articles (59 studies), with research sample sizes ranging from 22 to 1,059 (median = 187.5). The five-year overall survival (OS) rate was 40.9% (95% CI: 35.5-46.5%). The five-year OS rate ranged from 3.9% (95% CI: 1.9-8.0%) in Malawi to as high as 76.1% (95% CI: 66.3-83.7%) in Ghana. The five-year disease-free survival rate was 66.2% (95% CI: 44.2-82.8%) while the five-year locoregional rate survival was 57.0% (95% CI: 41.4-88.7%).

Conclusion

To enhance cervical cancer survival, geographical and racial group health promotion measures, as well as prospective genetic investigations, are critically required.

Knowledge, Barriers and Motivators to Cervical Cancer Screening in Rwanda: A Qualitative Study

Background

Cervical cancer is a global public health problem with marked geographical disparity. High morbidity and mortality rates in developing countries are associated with low screening rates. In 2020, in Rwanda, 3.7 million women aged 15–59 years were at risk of developing cervical cancer, the most commonly diagnosed female cancer in Rwanda. Despite Rwanda being the first African country to vaccinate against human papilloma virus with a three-dose regimen vaccination coverage of nearly 93% in the target population of girls aged <15 years, and having established cervical cancer screening program, recent studies have found low screening rates. Our study sought to determine knowledge, motivators and barriers of cervical cancer screening.

Methods

We conducted a qualitative descriptive study; using focus group interview in an urban health facility (Muhima district hospital) and a rural health center (Nyagasambu health center) offering cervical screening services in Rwanda. Participants were women seeking these services and other women attending the health facility for any reason, and female staff working in these facilities. Interviews were recorded and transcribed, and data were analyzed using content analysis.

Results

Thirty women participated in focus group interview, with an average age of 39 years. Many of women showed knowledge about cervical cancer existence and prevention methods. However, fear for pain, lack of knowledge about screening, how and where the screening was done, and concern for privacy were recurring subthemes. Some participants also mentioned lack of health insurance as a barrier for cervical cancer screening.

Conclusion

Barriers to uptake cervical cancer screening services in Rwanda are related to poor information about cervical cancer and the importance of screening as well as non-adherence to medical insurance. Population sensitization through campaign and community outreach activities could have a positive impact on increasing the usage of cervical cancer screening in Rwanda.

Connaissances, utilisation et obstacles liés au dépistage du cancer du col utérin dans des hôpitaux de district de Kigali, au Rwanda

Contexte

Dans le monde, le cancer du col utérin arrive au troisième rang des cancers les plus fréquents chez les femmes, mais il passe au deuxième rang en Afrique orientale, où se trouve le Rwanda. Le dépistage périodique est un moyen de prévention efficace. Malgré cela, en Afrique, on estime que le taux de dépistage de ce cancer se situe entre 10 et 70 %. Plusieurs facteurs entravent le dépistage, surtout en Afrique subsaharienne. Au Rwanda, on recense peu d'écrits sur l'utilisation des services de dépistage et les facteurs nuisant au dépistage du cancer du col utérin.

Objectif

Évaluer les connaissances sur le dépistage du cancer du col utérin qu'ont les femmes fréquentant les hôpitaux de district de Kigali (au Rwanda), recenser l'utilisation de ce service et déterminer les obstacles qui empêchent d'y recourir.

Méthodologie

Une étude transversale descriptive a été menée, et les données ont été collectées au moyen d'un questionnaire structuré. Des questions nominales de type « oui ou non » ont mis en lumière les connaissances des femmes sur le cancer du col utérin et l'utilisation des services de dépistage. Pour cerner les obstacles au dépistage, nous avons utilisé des questions de type « échelle de Likert ». Ces données ont ensuite fait l'objet d'une analyse statistique descriptive et déductive. La sélection des répondantes s'est faite par échantillonnage aléatoire systématique depuis la base de données des patientes fréquentant les services gynécologiques de trois hôpitaux de district de Kigali (Rwanda).

Résultats

Au total, 329 femmes ont répondu au sondage. La moitié d'entre elles (n = 165) connaissaient bien le dépistage du cancer du col utérin. Le pourcentage de dépistage se situe à 28,3 %. Nous avons décelé un lien entre l'utilisation du dépistage et une bonne connaissance du sujet (P = 0,000, r = -0,392) ainsi que certains facteurs démographiques (P = 0,000). Parmi les obstacles qui concourent à restreindre l'accès au dépistage, nous avons relevé des obstacles individuels (méconnaissance de l'existence des services de dépistage), géographiques (milieu rural) et liés au système de santé et aux prestataires de soins (campagnes de sensibilisation déficientes, attitudes négatives des prestataires de soins envers les patientes et longs délais d'attente).

Conclusion

Dans les hôpitaux de district étudiés de Kigali (Rwanda), on constate un faible pourcentage de dépistage du cancer du col utérin causé par plusieurs obstacles. Il est donc fortement recommandé d'engager une campagne d'information permanente sur ce cancer et son dépistage. Enfin, il est crucial que les prestataires de soins qualifiés encouragent les femmes à se soumettre au dépistage, et qu'ils s'efforcent de réduire les obstacles qui s'y rattachent.

Knowledge, utilization and barriers of cervical cancer screening among women attending selected district hospitals in Kigali - Rwanda

Background

Cervical cancer is the third most common cancer attacking women globally, and the second in Eastern Africa where Rwanda is located. Regular screening is an effective prevention approach for cervical cancer. Despite that, the screening rate for cervical cancer in Africa is estimated between 10% and 70%, with a number of barriers. This is especially the case in sub-Saharan Africa. In Rwanda, there is limited literature on the rate of use of screening services or the barriers to cervical screening.

Objective

To assess knowledge, utilization, and barriers of cervical cancer screening among women attending selected district hospitals in Kigali, Rwanda.

Methods

A descriptive cross-sectional study with a structured questionnaire was used to collect data. Nominal 'yes' or 'no' questions were used to gather data on knowledge and utilisation of cervical cancer and its screening. Likert-type scale questions were used to identify different barriers to screening services. Data were analysed using descriptive and inferential statistics. Respondents were selected by systematic random sampling from the database of women attending gynaecology services at three district hospitals in Kigali, Rwanda.

Results

Three hundred and twenty-nine women responded to the survey. Half of the respondents (n = 165) had high knowledge level scores on cervical cancer screening. The cervical cancer screening rate was 28.3%. Utilization of screening was associated with knowledge (P = 0.000, r = -0.392) and selected demographic factors (P = 0.000). Individual barriers included poor knowledge on availability of screening services, community barriers included living in a rural area, and health provider and systems barriers included lack of awareness campaigns, negative attitudes of healthcare providers toward clients, and long waiting times; all barriers limit the access to screening services.

Conclusion

A low rate of cervical cancer screening was identified for women attending selected district hospitals in Kigali-Rwanda due to various barriers. On-going education on cervical cancer and its screening is highly recommended. It is important that trained health providers encourage their clients to have cervical cancer screening and work to reduce related barriers.

Healthcare provider challenges to early detection of cervical cancer at primary healthcare level in Rwanda

Our objective was to assess the health facility related factors that cause delays in cervical cancer diagnosis at a primary healthcare level in Rwanda. Healthcare providers in outpatient clinics at 10 health centers in Kigali city and the Eastern province of Rwanda were surveyed. Eighty-five healthcare providers participated; 83.5% were nurses and the remainder were midwives. Only 15 (17.6%) reported prior training on visual inspection with acetic acid (VIA) cervical cancer screening, and they were distributed among 6 of the 10 health centers surveyed. However, 76.5% of respondents reported that at least one person was trained in VIA at their health center. The basic equipment necessary for cervical cancer evaluation was reported to be generally available. Overall, only 31.8% of participants had good basic knowledge level on cervical cancer screening. No association was found between respondents' knowledge about cervical cancer screening and profession, education level, work experience or reported prior training on VIA. There is a gap in the number of primary healthcare providers with the skills to perform pelvic exam and VIA cervical cancer screening at health centers in Rwanda. As health centers are the first point of contact for patients with the healthcare system, there is a need to improve their knowledge and skills in performing cervical cancer screening and detection.

Determinants factors to Pap smear screening among married women in a city of South Iran: applying the BASNEF model

Background

Cervical cancer is known to be preventable because of the long pre-invasion period and the availability of appropriate screening methods. Pap smear is a selective screening approach, which is not taken seriously enough by many women.

Methods

This cross-sectional, descriptive, analytical study was performed using electronic health records of 202 women visiting the health centers chosen through the systematic sampling method. The data collection tool contained items on demographic information, awareness regarding cervical cancer, and the beliefs, attitudes, subjective norms, and enabling factors (BASNEF) model constructs. Data were analyzed using the linear regression analysis, logistic regression, and multivariate regression analysis with backward selection in SPSS, version 18.

Results

Based on the results, more than half of the women had never had a Pap smear test. Of the 202 women, only 14.8% had repeated the Pap smear test at the standard interval. Attitudes and subjective norms predicted the intention to have a Pap smear test among the eligible women. Overall, 10% of the changes in behavioral intention were explained by attitudes and subjective norms. In the BASNEF model, the behavioral intention was one of the most important factors that affected compliance with the Pap smear test among the eligible women.

Conclusion

Based on the results of this study, it is possible to improve screening behaviors among women through proper planning to increase awareness and improve attitudes, subjective norms, enabling factors, and behavioral intention. Pap smear plays an important role in controlling cervical cancer.

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.