Knowledge, attitudes and practices regarding the Pap test among women in Northeastern Brazil

Socio-Demographic Factors and Other Predictors of Pap Test Uptake Among Women: A Retrospective Study in Ghana

Introduction

The World Health Organization has reported a rise in cervical cancer in Ghana. Ghanaian women predominantly undergo opportunistic Pap smear screening for cervical cancer. Numerous studies have documented differences in the sociodemographic traits of participants undergoing Pap smear testing or screening, which correlates with their screening habits. This study aims to assess sociodemographic variables, including others that determine Pap test utilization at a single center in Ghana.

Methods

A single-center survey was conducted by extracting data from the records of women who walked in for Pap smear testing. A telephone survey was also conducted among these women to document their barriers to utilizing the center. For data analysis, descriptive statistics and chi-square were utilized.

Results

A total of 197 participants' records were retrieved for the study. Most participants were market women (69.4%) and uneducated (71.4%). Their Pap smear screening records indicate that the majority (86%) had no history of cervical cancer screening, and only 3% tested positive for Pap smear test. Educational level, occupation and family history of cancer significantly correlated with participants' Pap smear history (p<0.05). However, most sociodemographic factors were not significant with the Pap test results of the participants (p>0.05). The perceived barrier identified by most participants was the need for more information (67.40%) on the test.

Conclusion

This study revealed that sociodemographic and gynaecological factors do not correlate with Pap test results. However, education level, occupation, and family history of cancer were significantly associated with the history of Pap smear uptake. The most significant barrier hindering Pap smear services was the need for more information.

Women's critical experiences with the pap smear for the development of cervical cancer screening devices

Global cervical cancer incidence and mortality have remained a major public health problem. Depending on the quality and coverage of preventive programs, and the capacity of health care systems, different screening tests are used, with the Pap smear being the most widely implemented. Several difficulties have been reported in accessing timely detection, causing late cervical cancer diagnosis. Trying to close these gaps, new screening devices have been developed in recent years; however, there is a lack of knowledge about whether or not women perspective has been included in the design process and technological development of these devices. This scoping review aimed to describe and synthesize scientific literature on women's critical experiences with Pap smears to prospectively contribute to the design, development, and scale-up of cervical cancer screening devices. The electronic databases Web of Science, Scopus, PubMed, PsycINFO and SciELO were searched for relevant studies published between 2012 and 2021; finally, 18 qualitative studies were included. Experiences were classified into four categories: fear and embarrassment, speculum pain and discomfort, outcome distress and health service barriers. Critical experiences before, during, and after the test were analyzed in turn. In particular, during the test, women reported pain associated with the use of the speculum. The acceptability of new screening devices will largely depend on comfort during the test and timely delivery of results. This review provides a useful qualitative synthesis, not only to advance the design of novel devices but also for future implementation research in cervical screening services.

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.

[Control of cervical cancer in the primary care setting in South American countries: systematic reviewControl del cáncer cervicouterino en los servicios de atención primaria de salud en los países de América del Sur: revisión sistemática]

Objetivo.

Descrever as estratégias para prevenção e controle do câncer do colo do útero (CCU) na atenção primária à saúde (APS) na América do Sul.

Métodos.

Revisão de literatura em duas etapas: revisão documental em sites governamentais de Argentina, Bolívia, Brasil, Chile, Colômbia, Equador, Paraguai, Peru, Uruguai e Venezuela; e revisão sistemática da literatura nas bases LILACS, MEDLINE, Scopus, SciELO e Science Direct.

Resultados.

Foram incluídos 21 documentos institucionais (planos, guias de prática e diretrizes nacionais) e 25 artigos. Todos os países tinham taxas elevadas de morbimortalidade por CCU. Predominou o rastreamento oportunístico na APS, embora os documentos disponíveis sinalizassem intenções e estratégias para diagnóstico precoce e acompanhamento longitudinal dos casos suspeitos e confirmados, preferencialmente na rede pública. Todos os países adotavam uma concepção abrangente de APS, embora o processo de implementação estivesse em estágios heterogêneos e predominassem a focalização e a seletividade. Destaca-se pior acesso ao rastreamento para mulheres de regiões rurais ou remotas e para povos originários. A indisponibilidade de serviços de APS próximos às residências/comunidade foi uma importante barreira para o rastreamento do CCU.

Conclusões.

A fragmentação dos sistemas de saúde e a segmentação na oferta de serviços são obstáculos para a prevenção e o controle do CCU na América do Sul. São necessários programas organizados de rastreamento do CCU e a incorporação de busca ativa para realização do Papanicolaou via APS. A interculturalidade nas práticas e a formulação de políticas numa perspectiva interseccional são fundamentais para superar as iniquidades no controle do CCU nos países sul-americanos.

Characteristics of patients diagnosed with cervical cancer in Brazil: preliminary results of the prospective cohort EVITA study (EVA001/LACOG 0215)

OBJECTIVES

Cervical cancer is the fourth most common cancer in women worldwide. Epidemiological and quality of life (QoL) data in patients with cervical cancer from low- and middle-income countries are scarce. We aimed to describe sociodemographic and clinicopathological characteristics and quality of life of patients with cervical cancer at diagnosis in Brazil.

METHODS

EVITA is a prospective cohort study of newly diagnosed patients with cervical cancer from May 2016 to December 2017, stages I-IVB, from 16 Brazilian sites representing the five Brazilian regions. At baseline, medical evaluation was performed and European Organization for Research and Treatment of Cancer (EORTC) QLQ-CX24/C30 questionnaires were administered.

RESULTS

A total of 631 patients were included. Mean±SD age was 49.3±13.9 years; skin color was non-white in 65.3%, and 68.0% had ≤8 years of formal education. In total, 85.1% of patients had a Pap smear. The main reasons reported by patients for not having a Pap smear were: lack of interest (46.9%), shame or embarrassment (19.7%), lack of knowledge (19.7%), and difficulty with access (9.1%). Most patients were diagnosed with locally advanced or metastatic disease (FIGO clinical stage II-IV in 81.8%- stage II in 35.2%, stage III in 36.1%, and stage IV in 10.5%). Patients with clinical stage III-IV had worse physical functioning and role functioning.

CONCLUSIONS

Cervical cancer in Brazil is usually diagnosed at an advanced stage. Most patients have low formal education and are unemployed. Lack of interest was identified as a main reason for not having a screening test, and limited access was reported as a reason by <10% of the patients. Awareness campaigns must be a governmental priority, specially focused on the needy population, along with wide access to treatment.

Barriers and facilitators for cervical cancer screening among adolescents and young people: a systematic review

BACKGROUND

Though cervical cancer is one of the leading causes of cancer-related death globally, its incidence is nearly entirely preventable. Young people have been an international priority for screening as this population has historically been under-screened. However, in both high-income and low-income countries, young people have not been screened appropriately according to country-specific guidelines. The aim of this systematic review was to systematically characterize the existing literature on barriers and facilitators for cervical cancer screening (CCS) among adolescents and young people globally.

METHODS

We conducted a systematic review following PRISMA guidelines of three key databases: Medline-OVID, EMBASE, and CINAHL. Supplementary searches were done through ClinicialTrials.Gov and Scopus. Databases were examined from 1946 until the date of our literature searches on March 12th 2020. We only examined original, peer-reviewed literature. Articles were excluded if they did not specifically discuss CCS, were not specific to individuals under the age of 35, or did not report outcomes or evaluation. All screening, extraction, and synthesis was completed in duplicate with two independent reviewers. Outcomes were summarized descriptively. Risk of bias for individual studies was graded using an adapted rating scale based on the Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices.

RESULTS

Of the 2177 original database citations, we included 36 studies that met inclusion criteria. The 36 studies included a total of 14,362 participants, and around half (17/36, 47.2%) of studies specifically targeted students. The majority of studies (31/36, 86.1%) discussed barriers and facilitators to Pap testing specifically, while one study analyzed self-sampling (1/36, 2.8%), one study targeted HPV DNA testing (1/36, 2.8%), and the remainder (4/36, 11.1%) were not specified. Our systematic review found that there are three large categories of barriers for young people: lack of knowledge/awareness, negative perceptions of the test, and systemic barriers to testing. Facilitators included stronger relationships with healthcare providers, social norms, support from family, and self-efficacy.

CONCLUSION

There are unique barriers and facilitators that affect CCS rates in adolescents and young people. Health systems and healthcare providers worldwide should address the challenges for this unique population.

The Quality of Pap Smears from the Brazilian Cervical Cancer Screening Program According to the Human Development Index

Brazil is a country with strong socioeconomic disparities, which may explain the different rates of cervical cancer incidence and mortality and influence the quality of cervical cancer screening tests. The aim of this study was to perform a trend analysis of some quality indicators of Pap smears according to the Municipal Human Development Index (MHDI). Information about cytopathological exams (approximately 65,000,000) performed from 2006 to 2014 in women ages 25 to 64 years was obtained from the Cervical Cancer Information System (SISCOLO). The average annual percentage change (AAPC) for each indicator was calculated using the Joinpoint Regression Program, according to MHDI levels. Very low frequencies of unsatisfactory cases (<5%) were observed at different MHDI levels. Although the positivity index in the low- and medium-MHDI groups has increased, the values remained below international recommendations (3%-10%). The HSIL (high-grade squamous intraepithelial lesion) percentage remained stationary at all levels of the MHDI. In the low- and medium-MHDI groups, most quality indicators were below the recommendations by Brazilian National Cancer Institute INCA, with no improvement trend; in the high-MHDI group, the majority of the indicators also presented no improvement, although they show slightly better quality indicators. The MHDI should be considered in the definition of the policies of the screening program for cervical cancer in Brazil, and the current program may require adjustments to achieve improved efficiency.

Knowledge of human papillomavirus and Pap test among Brazilian university students

SUMMARY OBJECTIVE: Human papillomavirus (HPV) is the most prevalent sexually transmitted virus in the world and is associated with an increased risk of cervical cancer. The most effective approach to cervical cancer control continues to be screening through the preventive Papanicolaou test (Pap test). This study analyzes the knowledge of university students of health science programs as well as undergraduate courses in other areas of knowledge on important questions regarding HPV. METHOD: Four hundred and seventy-three university students completed a questionnaire assessing their overall knowledge regarding HPV infection, cervical cancer, and the Pap test. A descriptive analysis is presented, and multivariate analysis using logistic regression identified factors associated with HPV/cervical cancer information. RESULTS: Knowledge was higher for simple HPV-related and Pap test questions but was lower for HPV interrelations with genital warts and cervical cancer. Being from the health science fields and having high income were factors associated with greater knowledge. Only the minority of the participants recognized all the situations that increased the risk of virus infection presented in the questionnaire. CONCLUSIONS: These findings highlight the need for educational campaigns regarding HPV infection, its potential as a cervical cancer agent and the forms of prevention available.

Differential Impact of Education Level, Occupation and Marital Status on Performance of the Papanicolaou Test among Women from Various Regions in Brazil

Background: In Brazil, little is known regarding the underlying causes of differences among populations regarding socio-economic variables that affect women’s cervical cancer screening behavior. The present study focused on socio-economic variables that affect women’s performance of the Papanicolaou test, comparing two distinct Brazilian populations. Methods: We collected data regarding performance of the Papanicolaou test and socio-economic variables from 559 women in Mato Grosso do Sul (MS), in the Central East region, and 338 women in Paraíba (PB), in the Northeast region of Brazil. Nominal logistic regression modeling was performed to identify independent variables for both groups of data. Results: Of the women interviewed from MS and PB, 116 out of 599 (19.37%) and 94 out of 338 (27.81%), respectively, had not performed the Papanicolaou test within the last three years (p = 0.025). Low educational level characterized 570 (95.16%) and 203 (60.06%) of women from MS and PB, respectively (p = 0.000). Women in PB who had a low educational level and were unemployed had a 2.96-fold (OR = 0.338; 95% CI: 0.121 - 0.939) and 2.40-fold (OR = 0.416; 95% CI: 0.199 - 0.869) lower chance, respectively, to have performed the Papanicolaou test ≥ three times, or once within the last three years (p = 0.029; p = 0.014). The chance of women in MS who did not live in a stable relationship to have performed the test ≥ three times was 1.79-fold (OR = 0.560; 95% CI: 0.348 – 0.901) lower compared to women who reported a stable relationship (p = 0.039). Conclusions: High educational level, employment, and having a stable interpersonal relationship positively associated with performance of the Papanicolaou test among women in PB and MS. Despite having predominantly a low educational level, women in MS performed the Papanicolaou test more frequently than those in PB.

Participation in Cervical Screening by Self-collection, Pap, or a Choice of Either in Brazil

Most cervical cancers occur in women who do not participate in cervical-cancer screening. We therefore evaluated adherence to screening for clinic-based Pap testing, self-collected sampling for HPV testing, and choice of the 2 among 483 unscreened/underscreened women in Brazil. Three public Basic Health Units (BHU) were each randomly assigned to three arms: (i) Pap testing at the BHU (N = 160), (ii) "Self&HPV" (self-collection for HPV testing) (N = 161), and (iii) "Choice" between self-collection and HPV testing and Pap test at the local BHU (N = 162). The theory-based (PEN-3 and Health Belief Model) intervention in all three arms was implemented by trained Community Health Workers (CHW) at participants' home. With the first invitation, 60.0% in the Pap arm, 95.1% [154 of 161 (95.7%) who selected Self&HPV and 0 of 1 (0.0%) who selected Pap] in the Choice arm, and 100% in the Self&HPV arm completed screening. By the second invitation to choose a method of screening in the Choice arm, 100% completed screening. After three invitations, 75.0% of women in the Pap arm completed screening. Adherence to screening differed by study arm (P < 0.001). In conclusion, Self&HPV testing is a promising strategy for unscreened/underscreened women who are recalcitrant or unable to undergo clinic-based cervical screening to complement the screening modality used in the general population. In Brazil, where Pap testing is recommended for routine cervical screening, training CHWs in behavior change strategies and offering Self&HPV or Choice could greatly improve screening population coverage by reaching the unscreened/underscreened populations.

Social and Cultural Barriers to Women's Participation in Pap Smear Screening Programs in Low- and Middle-Income Latin American and Caribbean Countries: An Integrative Review

PURPOSE

Pap smear screening programs have been ineffective in reducing cervical cancer mortality in most Latin American and Caribbean countries, in part due to low screening rates. The purpose of this review was to analyze recent studies to identify demographic, social, and cultural factors influencing women's participation in Pap screening programs in Latin America and the Caribbean.

DESIGN/METHOD

For this integrative review, cervical cancer screening in Latin America and the Caribbean was searched using PubMed, CINAHL, EMBASE, and PsycINFO databases. Findings/Results: Demographic barriers to screening were socioeconomic status, education, race/ethnicity, and geography. Social barriers included lack of uniformity in screening guidelines, lack of knowledge regarding cervical cancer, and lack of preventive culture. Cultural barriers were fear/embarrassment and gender roles.

CONCLUSIONS

There are multilevel barriers to Pap smear utilization among women in Latin America and the Caribbean.

IMPLICATIONS FOR PRACTICE

Findings highlight a need for health system engagement, promotion of preventive care, and community-generated educational programs and solutions.

Cervical cancer screening coverage in a high-incidence region

OBJECTIVE

To analyze the coverage of a cervical cancer screening program in a city with a high incidence of the disease in addition to the factors associated with non-adherence to the current preventive program.

METHODS

A cross-sectional study based on household surveys was conducted. The sample was composed of women between 25 and 59 years of age of the city of Boa Vista, RR, Northern Brazil who were covered by the cervical cancer screening program. The cluster sampling method was used. The dependent variable was participation in a women’s health program, defined as undergoing at least one Pap smear in the 36 months prior to the interview; the explanatory variables were extracted from individual data. A generalized linear model was used.

RESULTS

603 women were analyzed, with an mean age of 38.2 years (SD = 10.2). Five hundred and seventeen women underwent the screening test, and the prevalence of adherence in the last three years was up to 85.7% (95%CI 82.5;88.5). A high per capita household income and recent medical consultation were associated with the lower rate of not being tested in multivariate analysis. Disease ignorance, causes, and prevention methods were correlated with chances of non-adherence to the screening system; 20.0% of the women were reported to have undergone opportunistic and non-routine screening.

CONCLUSIONS

The informed level of coverage is high, exceeding the level recommended for the control of cervical cancer. The preventive program appears to be opportunistic in nature, particularly for the most vulnerable women (with low income and little information on the disease). Studies on the diagnostic quality of cervicovaginal cytology and therapeutic schedules for positive cases are necessary for understanding the barriers to the control of cervical cancer.

Acceptability of self-collected human papillomavirus specimens in cervical cancer screening: A review

Cervical cancer morbidity and mortality is an important public health problem around the world. Some of the barriers to cervical cancer screening include the embarrassment, discomfort, lack of privacy and time and cost associated with clinician-collected, clinic-based screening with cytology or human papillomavirus tests. Self-collection of a human papillomavirus (HPV) test has been found to be generally more acceptable, less embarrassing, more comfortable, more private and easy to do and preferred to pelvic examination for cervical cytology by many women worldwide. The most commonly reported limitation to self-collection is a woman’s lack of confidence in her ability to perform it correctly. Self-collected human papillomavirus tests have been shown to be as or more sensitive than cytology or clinician-collected HPV tests. With confidence-building education about self-collection, it is likely a viable method to extend the reach of screening in high and low-resource areas around the world.