Sociodemographic inequities in cervical cancer screening, treatment and care amongst women aged at least 25 years: evidence from surveys in Harare, Zimbabwe

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.

Access to palliative care in patients with advanced cancer of the uterine cervix in the low- and middle-income countries: a systematic review

BACKGROUND

Women with advanced uterine cervical cancer suffer from a combination of moderate to severe physical, psychological, social, and spiritual distress due to their disease and are in need of palliative care to improve their quality of life. Approximately 85% of the women live in the low- and middle-income countries. Whether these women and their families access palliative care is not known.

OBJECTIVES

To understand the geographic accessibility, availability, financial accessibility, and acceptability of palliative care by patients with advanced cervical cancer and their families.

METHODS

We conducted a Systematic review following PRISMA guidelines in CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE, PsychINFO, PubMed and Scopus for the core concepts: palliative care, access, advanced uterine cervical cancer. Eligible articles were published in English, contained original data on experiences of patients and/or caregivers including symptoms management, and discussed available resources, communication, satisfaction, and healthcare utilization.

RESULTS

Overall there was limited access to palliative care with the few available facilities located in cities, far from the rural areas where most women lived. Pervasive poverty was common with poor affordability of healthcare, travelling, accommodation, and subsistence expenses. Misconceptions and poor knowledge of the disease, cultural beliefs and attitudes, and other health system insufficiencies also presented challenges for access.

CONCLUSION

Concerted effort should be made to improve availability of palliative care facilities. Health education to address misconceptions and other cognitive barriers that limit access among cervical cancer patients and their families should be urgently undertaken in the LMICs.

Patterns in the prevalence and wealth-based inequality of cervical cancer screening in India

BACKGROUND

Cervical cancer is the second leading cause of deaths due to cancer among women in India. This study assesses the prevalence of cervical cancer screening among women in the 30 to 49 years age-group and its relation to demographic, social and economic factors. The equity in the prevalence of screening is studied with respect to the women's household wealth.

METHODS

Data from the fifth National Family Health Survey are analyzed. The adjusted odds ratio is used to assess the prevalence of screening. The Concentration Index (CIX) and the Slope Index of Inequality (SII) are analyzed to assess the inequality.

RESULTS

The average national prevalence of cervical cancer screening is found to be 1.97% (95% C.I, 1.8-2.1), ranging from 0.2% in West Bengal and Assam to 10.1% in Tamil Nadu. Screening is significantly more prevalent among the following demographics: educated, higher age group, Christian, scheduled caste, Government health insurance coverage, and high household wealth. Significantly lower prevalence is found among Muslim women, women from scheduled tribes, general category castes, non-Government health insurance coverage, high parity, and those who use oral contraceptive pills and tobacco. Marital status, place of residence, age at first sexual activity, and IUD usage are not significant influencers. At the national level, CIX (0.22 (95% C.I, 0.20-0.24)) and SII (0.018 (95% C.I, 0.015-0.020)) indicate significantly higher prevalence of screening among women from the wealthier quintiles. Significantly higher screening prevalence among wealthier quintiles in the North-East (0.1), West (0.21) and Southern (0.05) regions and among the poor quintiles in the Central (-0.05) region. Equiplot analysis shows a "top inequality pattern" in the North, North-East and Eastern regions, with overall low performance where the rich alone manage to avail screening. The Southern region exhibits an overall progress in screening prevalence with the exception of the poorest quintile, which is left behind. Pro-poor inequality exists in the Central region, with significantly higher prevalence of screening among poor.

CONCLUSION

The prevalence of cervical cancer screening is very low (2%) in India. Cervical cancer screening is substantially higher among women with education and Government Health insurance coverage. Wealth-based inequality exists in the prevalence of cervical cancer screening and the prevalence is concentrated among the women from wealthier quintiles.

Access to Radiation Therapy and Related Clinical Outcomes in Patients With Cervical and Breast Cancer Across Sub-Saharan Africa: A Systematic Review

PURPOSE

To better understand the barriers to accessing standard-of-care radiation therapy (RT) for breast and cervical cancer in sub-Saharan Africa and their impact on outcomes.

METHODS

A comprehensive literature search was completed with a medical librarian. Articles were screened by title, abstract, and full text. Included publications were analyzed for data describing barriers to RT access, available technology, and disease-related outcomes, and further grouped into subcategories and graded according to predefined criteria.

RESULTS

A total of 96 articles were included: 37 discussed breast cancer, 51 discussed cervical cancer, and eight discussed both. Financial access was affected by health care system payment models and combined burdens of treatment-related costs and lost wages. Staffing and technology shortages limit the ability to expand service locations and/or increase capacity within existing centers. Patient factors including use of traditional healers, fear of stigma, and low health literacy decrease the likelihood of early presentation and completion of therapies. Survival outcomes are worse than most high- and middle-income countries and are affected by many factors. Side effects are similar to other regions, but these findings are limited by poor documentation capabilities. Access to palliative RT is more expeditious than definitive management. RT was noted to lead to feelings of burden, lower self-esteem, and worsened quality of life.

CONCLUSION

Sub-Saharan Africa represents a diverse region with barriers to RT that differ on the basis of funding, available technology and staff, and community populations. Although long-term solutions must focus on building capacity by increasing the number of treatment machines and providers, short-term improvements should be implemented, such as interim housing for traveling patients, increased community education to reduce late-stage diagnoses, and use of virtual visits to avoid travel.

Role of Occupation in Shaping Cancer Disparities

Simple Summary

The investigation of cancer disparities is of major importance. In this paper, we address this issue through the occupational point of view, trying to capture how work and its related factors impact on cancer inequalities. The data we provide may increase awareness relevant to cancer control, and stimulate further studies aimed at the identification of the occupational determinants of cancer disparities and the quantification of their role.

Abstract

Cancer occurrence is characterized globally by profound socioeconomic differences. Occupation is a fundamental component of socioeconomic status. In this review, we discuss the role of occupation as a determinant of cancer disparities. First, we address the issue of participation in cancer screening programs based on income, health insurance, occupational status and job title. Second, we review the role of occupation in contributing to disparities by acting as a mediator between cancer and (i) education and (ii) race/ethnicity. Lastly, we analyze data from a multicenter case−control study of lung cancer to calculate the mediating role of occupational exposure to diesel exhaust, silica and welding fumes in the association between education and lung cancer. By addressing the complex paths from occupation to cancer inequalities from multiple points of view, we provide evidence that occupational-related characteristics, such as income, health insurance, unemployment and hazardous exposures impinge on cancer control and outcomes. The increasing awareness of these aspects is fundamental and should lead to public health interventions to avoid inequalities rising from occupational factors.

Mapping Evidence on Management of Cervical Cancer in Sub-Saharan Africa: Scoping Review

Cervical cancer (CC) is the most common viral infection of the reproductive tract and in Sub-Saharan Africa (SSA), its morbidity and mortality rates are high. The aim of this review was to map evidence on CC management in SSA. The scoping review was conducted in accordance with Arksey and O’Malley’s scoping review framework. The review included studies on different aspects of CC management. The review was also done following the steps and guidelines outlined in the PRISMA-Extension for Scoping Reviews (PRISMA-ScR) checklist. The following databases were searched: PubMed, EBSCOhost, Scopus and Cochrane Database of Systematic Review. A total of 1121 studies were retrieved and 49 which were eligible for data extraction were included in the review. The studies were classifiable in 5 groups: 14 (28.57%) were on barriers to CC screening, 10 (20.41%) on factors associated with late-stage presentation at diagnosis, 11 (22.45%) on status of radiotherapy, 4 (8.20%) on status of chemotherapy and 10 (20.41%) on factors associated with high HPV coverage. High HPV vaccine coverage can be achieved using the class school-based strategy with opt-out consent form process. Barriers to CC screening uptake included lack of knowledge and awareness and unavailability of screening services. The reasons for late-stage presentation at diagnosis were unavailability of screening services, delaying whilst using complementary and alternative medicines and poor referral systems. The challenges in chemotherapy included unavailability and affordability, low survival rates, treatment interruption due to stock-outs as well as late presentation. Major challenges on radiotherapy were unavailability of radiotherapy, treatment interruption due to financial constraints, and machine breakdown and low quality of life. A gap in understanding the status of CC management in SSA has been revealed by the study implying that, without full knowledge of the extent of CC management, the challenges and opportunities, it will be difficult to reduce infection, improve treatment and palliative care. Research projects assessing knowledge, attitude and practice of those in immediate care of girls at vaccination age, situational analysis with health professionals and views of patients themselves is important to guide CC management practice.

Religious Denomination, Religiosity, Religious Attendance, and Cancer Prevention. A Systematic Review

Recent research highlighted the influence of religion among health outcomes. To the best of our knowledge, there is no systematic review that summarizes the evidence on the relationship between religious factors and the utilization of cancer screenings. Therefore, this article aims to list the findings about the influence of religious denominations, the importance of religion in one’s life, and religious practices, such as church attendance on the utilization of cancer screenings. PubMed, PsycInfo and CINAHL were searched using a predefined algorithm in June 2020. We included observational studies that examined the association between religion and cancer screening use and employed appropriate items to quantify these key variables. Study selection, data extraction and quality assessment were performed independently by two reviewers. We detected n=27 studies that fulfilled the inclusion criteria. Hereby, n=16 used data from the United States. Most of the studies that were included in our review found a positive association between religious attendance and cancer screening utilization. There was mixed evidence concerning religious denomination as well as religiosity and use of cancer screenings. The studies suggest that religious factors are related to the utilization of cancer screenings. The findings of this systematic review may be helpful to resolve the underuse of cancer screenings by revealing at-risk-groups.

Effect of crisis intervention nursing on perioperative psychological state and self-efficacy of patients undergoing laparoscopic radical hysterectomy

OBJECTIVE

To evaluate the effect of crisis intervention nursing on perioperative psychological state and self-efficacy of patients with laparoscopic radical hysterectomy.

METHOD

A total of 151 cervical cancer patients that underwent laparoscopic radical surgery during January 2018 to March 2020 in our hospital were selected as the research objects. The patients were divided into control group (n=73) and observation group (n=78) according to treatment regimen. The control group received conventional nursing measures, and the observation group was treated with crisis intervention nursing in addition to the traditional measures. The changes of psychological state, self-efficacy, psychological crisis, hope degree before and after intervention, and the satisfaction of the two groups with nursing care were compared.

RESULTS

The scores of HAMA, HAMD, self-efficacy, psychological crisis and hope degree in the two groups were remarkably improved after intervention compared with before intervention (all P<0.05), and the improvement of each index in observation group was obviously superior to that in control group (P<0.05). After intervention, the satisfaction to nursing care in observation group was dramatically higher than that in control group (P<0.05).

CONCLUSION

The application of crisis intervention nursing on patients with laparoscopic radical hysterectomy is conductive to alleviating the adverse emotions such as anxiety and depression, reducing their sense of psychological crisis, improving the self-efficacy and hope degree of curing disease, as well as the satisfaction rate with the nursing care, which is worthy of clinical application.

Cervical Cancer Screening Postpandemic: Self-Sampling Opportunities to Accelerate the Elimination of Cervical Cancer

The persisting burden of cervical cancer in underserved populations and low-resource regions worldwide, worsened by the onset of the COVID-19 pandemic, requires proactive strategies and expanded screening options to maintain and improve screening coverage and its effects on incidence and mortality from cervical cancer. Self-sampling as a screening strategy has unique advantages from both a public health and individual patient perspective. Some of the barriers to screening can be mitigated by self-sampling, and resources can be better allocated to patients at the highest risk of developing cervical cancer. This review summarizes the implementation options for self-sampling and associated challenges, evidence in support of self-sampling, the available devices, and opportunities for expansion beyond human papillomavirus testing.

Gaps and opportunities for cervical cancer prevention, diagnosis, treatment and care: evidence from midterm review of the Zimbabwe cervical Cancer prevention and control strategy (2016-2020)

BACKGROUND

Cervical cancer is the fourth most common cancer amongst women globally and it accounts for the majority of cancer deaths among females in Zimbabwe. The objective of this midterm review analysis was to identify the gaps and opportunities for cervical cancer prevention, diagnosis, treatment, and care to inform the next cervical cancer strategy in Zimbabwe.

METHODS

A mixed methods approach was used for the midterm review. Secondary data was collected from programme documents, published and grey literature. Primary data was collected in six provinces through key informant interviews with officials and focus group discussions with beneficiaries. After data analysis, a draft report was presented to a technical working group to validate the findings and to fill in any gaps.

RESULTS

This midterm review revealed a myriad of gaps of the strategy particularly in diagnosis, treatment and care of cervical cancer and the primary focus was on secondary prevention. There was no data to quantify the level of awareness and advocacy for cervical cancer prevention. Our results revealed that there was no data on the proportion of women who ever tested for cervical cancer which existed nationally. Our findings suggest that some health facilities were screening women above 50 years old using VIAC, which is an inappropriate approach for those women. Quality control of VIAC and treatment of precancers were not part of the strategy. Pathological services were not efficient and effective due to lack of resources and additionally data on investigations were not routinely collected and available at the national level. Other gaps identified were limited funding, human resources, equipment, and commodities as well as lack of leadership at the national level to coordinate the various components of the cervical cancer programme. There are also numerous opportunities identified to build upon some successes realized to date.

CONCLUSIONS

Our findings emphasized the importance of effective and holistic planning in cervical cancer screening programmes in low-resource settings. In addition, huge investments are required in cervical cancer programmes and governments need to take centre role in mobilizing the requisite resources.

Reasons for never receiving a pap test among Brazilian women: National health survey

OBJECTIVE

To identify reasons among Brazilian women for never having a Pap test.

DESIGN

We designed a cross-sectional study that used data from the National Health Survey.

SAMPLE

Two thousand four hundred and two women 25-64 years old who never had a pap test.

MEASURES

Variables were age, race, education, marital status, housing condition, primary health care access, health insurance, self-perceived health, and social support network. We calculated the prevalence of different reasons and odds ratios for each.

RESULTS

The most frequent reason for never having a test were linked to women thinking the test was unnecessary (42.3%) which had a significant association with marital status (OR = 1.52; 95% CI = 1.07-1.91), age (OR = 1.56; 95% CI = 1.21-1.99), area of residence (OR = 1.15; 95% CI = 1.02-1.39), having a health insurance (OR = 1.18; 95% CI = 1.01-1.36), and self-perceived health (OR = 1.42; 95% CI = 1.28-1.56). The second most frequent reason was not knowing they needed a test (22.9%) which was associated with age (OR = 1.95; 95% CI = 1.74-2.16) and self-perceived health (OR = 1.56; 95% CI = 1.33-1.80).

CONCLUSIONS

The findings suggest lack of knowledge about cervical cancer and its prevention among Brazilian women. We consider it essential that the health service can provide the test, as well as the necessary guidelines for raising the awareness of the target audience.

Multimodality screening and prevention of cervical cancer in sub-Saharan Africa: a collaborative model

PURPOSE OF REVIEW

Although cervical cancer continues to decrease in incidence throughout the developed world because of rigorous screening and vaccination campaigns, the disease remains a major cause of cancer-related morbidity and mortality in resource-limited regions including sub-Saharan Africa. This review summarizes current efforts to implement cost-effective and widespread cervical cancer education, screening, and community-based interventions in Africa and the challenges faced by local healthcare workers.

RECENT FINDINGS

Effective screening with cytology (with or without high-risk human papillomavirus [HPV] DNA testing) as well as HPV self-sampling remains problematic in African countries because of a paucity of cytopathologists and resources. Accordingly, visual inspection of the cervix with acetic acid (VIA) with cryotherapy triage has gained traction in mass-screening campaigns because of low-cost supplies.

SUMMARY

Public education to facilitate screening is essential. VIA remains a strong community-based approach. The involvement of technology in teaching local providers, advertising screenings to the community, and helping improve follow-up may also improve screening efforts. Ultimately, the best form of prevention is through HPV vaccination, which also requires implementation of ongoing public education programs.

Wealth-related inequalities of women's knowledge of cervical cancer screening and service utilisation in 18 resource-constrained countries: evidence from a pooled decomposition analysis

INTRODUCTION

Resource-constrained countries (RCCs) have the highest burden of cervical cancer (CC) in the world. Nonetheless, although CC can be prevented through screening for precancerous lesions, only a small proportion of women utilise screening services in RCCs. The objective of this study was to examine the magnitude of inequalities of women's knowledge and utilisation of cervical cancer screening (CCS) services in RCCs.

METHODS

A total of 1,802,413 sample observations from 18 RCC's latest national-level Demographic and Health Surveys (2008 to 2017-18) were analysed to assess wealth-related inequalities in terms of women's knowledge and utilisation of CCS services. Regression-based decomposition analyses were applied in order to compute the contribution to the inequality disparities of the explanatory variables for women's knowledge and utilisation of CCS services.

RESULTS

Overall, approximately 37% of women had knowledge regarding CCS services, of which, 25% belonged to the poorest quintile and approximately 49% from the richest. Twenty-nine percent of women utilised CCS services, ranging from 11% in Tajikistan, 15% in Cote d'Ivoire, 17% in Tanzania, 19% in Zimbabwe and 20% in Kenya to 96% in Colombia. Decomposition analyses determined that factors that reduced inequalities in women's knowledge of CCS services were male-headed households (- 2.24%; 95% CI: - 3.10%, - 1.59%; P < 0.01), currently experiencing amenorrhea (- 1.37%; 95% CI: - 2.37%, - 1.05%; P < 0.05), having no problems accessing medical assistance (- 10.00%; 95% CI: - 12.65%, - 4.89%; P < 0.05), being insured (- 6.94%; 95% CI: - 9.58%, - 4.29%; P < 0.01) and having an urban place of residence (- 9.76%; 95% CI: - 12.59%, - 5.69%; P < 0.01). Similarly, factors that diminished inequality in the utilisation of CCS services were being married (- 8.23%;95% CI: - 12.46%, - 5.80%; P < 0.01), being unemployed (- 14.16%; 95% CI: - 19.23%, - 8.47%; P < 0.01) and living in urban communities (- 9.76%; 95% CI: - 15.62%, - 5.80%; P < 0.01).

CONCLUSIONS

Women's knowledge and utilisation of CCS services in RCCs are unequally distributed. Significant inequalities were identified among socioeconomically deprived women in the majority of countries. There is an urgent need for culturally appropriate community-based awareness and access programs to improve the uptake of CCS services in RCCs.