Interventions to increase uptake of cervical screening in sub-Saharan Africa: a scoping review using the integrated behavioral model

Abstract

Background: Sub-Saharan Africa (SSA) experiences disproportionate burden of cervical cancer incidence and mortality due in part to low uptake of cervical screening, a strategy for prevention and down-staging of cervical cancer. This scoping review identifies studies of interventions to increase uptake of cervical screening among women in the region and uses the Integrated Behavioral Model (IBM) to describe how interventions might work. Methods: A systematic search of literature was conducted in PubMed, Web of Science, Embase, and CINAHL databases through May 2019. Screening and data charting were performed by two independent reviewers. Intervention studies measuring changes to uptake in screening among women in SSA were included, with no restriction to intervention type, study setting or date, or participant characteristics. Intervention type and implementation strategies were described using behavioral constructs from the IBM.Results: Of the 3704 citations the search produced, 19 studies were selected for inclusion. Most studies were published between 2014 and 2019 (78.9%) and were set in Nigeria (47.4%) and South Africa (26.3%). Studies most often assessed screening with Pap smears (31.6%) and measured uptake as ever screened (42.1%) or screened during the study period (36.8%). Education-based interventions were most common (57.9%) and the IBM construct of knowledge/skills to perform screening was targeted most frequently (68.4%). Willingness to screen was high, before and after intervention. Screening coverage ranged from 1.7 to 99.2% post-intervention, with six studies (31.6%) reporting a significant improvement in screening that achieved ≥60% coverage. (Continued on next page)Conclusions: Educational interventions were largely ineffective, except those that utilized peer or community health educators and mHealth implementation strategies. Two economic incentivization interventions were moderately effective, by acting on participants' instrumental attitudes, but resulted in screening coverage less than 20%. Innovative service delivery, including community-based self-sampling, acted on environmental constraints, striving to make services more available, accessible, and appropriate to women, and were the most effective. This review demonstrates that intent to perform screening may not be the major determinant of screening behavior, suggesting other theoretical frameworks may be needed to more fully understand uptake of cervical screening in sub-Saharan Africa, particularly for health systems change interventions.

Health workers’ perspectives on barriers and facilitators to implementing a new national cervical cancer screening program in Ethiopia

“…Similarly, Shiferaw et al characterized high staff turn-over as a threat, with 26% of workers trained to offer VIA (n = 20/77) no longer working at the screening site at the follow-up [3]. Many of these same challenges have been reported elsewhere in sub-Saharan Africa [40][41][42][43][44].…”

Cervical cancer knowledge and screening uptake by marginalized population of women in inner-city Durban, South Africa: Insights into the need for increased health literacy

“… 30 Pap smear uptake was found to be significantly higher in those who have higher knowledge of cervical cancer, with lack of knowledge forming the biggest barrier to screening. 33 However, a scoping review of screening uptake initiatives in sub-Saharan Africa by Lott et al 34 reported that strategies aimed at increasing screening uptake are more likely to succeed when they simultaneously address multiple constraining factors (such as addressing education while also considering environmental constraints and language barriers). 34 When seeking to increase women’s knowledge of cervical cancer and screening, it is also vitally important that they are empowered to use this knowledge by ensuring ease of access to testing.…”

“…33 However, a scoping review of screening uptake initiatives in sub-Saharan Africa by Lott et al 34 reported that strategies aimed at increasing screening uptake are more likely to succeed when they simultaneously address multiple constraining factors (such as addressing education while also considering environmental constraints and language barriers). 34 When seeking to increase women’s knowledge of cervical cancer and screening, it is also vitally important that they are empowered to use this knowledge by ensuring ease of access to testing. Studies have shown knowledge levels improved after an educational session 16 , 35 which ultimately has a positive effect on increased screening.…”

Acceptability and preferences for self‐collected screening for cervical cancer within health systems in rural Uganda: A mixed‐methods approach

“…Educational interventions alone have shown limited effects compared to interventions focusing on integrated community-based service delivery of SC-CCS. 23,24 Despite the dearth of evidence in rural sub-Saharan Africa Not sure 3 (5) No response 1 (2) Didn't ask 1 (2) Preferred method of receiving positive test results…”