A Qualitative Exploration of Barriers to Treatment Among HPV-Positive Women in a Cervical Cancer Screening Study in Western Kenya.

BACKGROUND: Cervical cancer screening through self-collected high-risk human papillomavirus (HPV) testing has increased screening uptake, particularly in low-resource settings. Improvement ultimately depends, however, on women with positive results accessing follow-up treatment. Identifying the barriers to timely treatment is needed to tailor service delivery for maximum impact. MATERIALS AND METHODS: This qualitative study was conducted within a self-collected HPV screening trial in Migori County, Kenya. HPV-positive women were referred for no-cost cryotherapy treatment at the county hospital. Women not attending within 60 days of receiving HPV-positive results were randomly selected for in-depth interviews (IDIs). IDIs were coded and analyzed to develop an analytical framework and identify treatment barriers. RESULTS: Eighty-one women were interviewed. IDIs showed a poor understanding of HPV and cervical cancer, impacting comprehension of screening results and treatment instructions. All 81 had not undergone treatment but reported intending to in the future. Eight reported seeking treatment unsuccessfully or not qualifying, primarily due to pregnancy. Transportation costs and long distances to the hospital were the most reported barriers to treatment. Other obstacles included work, household obligations, and fear of treatment. Impacts of social influences were mixed; some women reported their husbands prevented seeking treatment, others reported their husbands provided financial or emotional support. Few women experienced peer support. CONCLUSIONS: Women faced many barriers to treatment following HPV screening in rural Kenya. Transportation barriers highlight a need for local treatment capacity or screen-and-treat approaches. Ensuring women understand their results and how to seek treatment is essential to improving cervical cancer screening in low-resource settings.

Developing a framework to describe stigma related to cervical cancer and HPV in western Kenya.

BACKGROUND: Despite a high prevalence of human papillomavirus (HPV) and cervical cancer in low and middle-income countries, stigma remains an issue. Addressing HPV and cervical cancer stigma could significantly improve health outcomes for these conditions. The objective of this study was to identify the manifestations of stigma and their potential impacts on health-seeking behavior. METHODS: Twenty-six in-depth interviews were conducted with women living with HIV, HIV-negative women, community health volunteers, and health care providers in Kisumu, Kenya in 2019. The interviews were designed to draw out existing attitudes or experiences related to stigma within the community. We conducted a thematic analysis of the interviews to identify internalized, anticipated, and discriminatory attitudes. RESULTS: Within internalized attitudes, a prominent observed theme was a fear of death associated with a positive HPV test. This stemmed from a lack of understanding of differences between HPV and cervical cancer and posed a significant barrier for women deciding to seek screening or to continue with treatment. Discriminatory attitudes of community members, including assumptions of promiscuity, infidelity, or HIV status, were perceived to prevent women from accessing screening and treatment opportunities. The interviews also exhibited a limited awareness of HPV in this region, which may have contributed to a lack of enacted stigma towards people living with HPV or cervical cancer. CONCLUSION: Stigma has the potential to lead to decreased screening and treatment uptake through its drivers. This includes a decreased perception of personal risk due to a lack of knowledge, which results in increased HPV-risk behaviors. Future research must focus on creating and integrating stigma-reducing interventions, primarily to encourage women to seek out primary and secondary preventative measures.

Barriers and Facilitators to Cervical Cancer Screening in Western Kenya: a Qualitative Study.

About nine out of 10 cervical cancer deaths occur in low-resource countries, with a particularly high burden in sub-Saharan Africa. The objectives of this study were to assess barriers and facilitators to cervical cancer screening in western Kenya from the perspectives of community members and healthcare providers. We conducted two focus groups with female community members (n = 24) and one with providers (n = 12) in Migori County, Kenya. Discussion guides queried about knowledge and awareness of cervical cancer prevention; structural, social, and personal barriers; and facilitators towards cervical cancer screening uptake. Group discussions were recorded, transcribed, and analyzed for emerging themes. Participants in both groups reported low awareness of HPV and cervical cancer screening in the community, and identified that as a main barrier to screening. Community members reported fear of pain and embarrassment as significant barriers to a screening pelvic exam. They also reported that providers' lack of knowledge and discomfort with a sensitive subject were significant barriers. A personal connection to cervical cancer and/or screening was associated with willingness to screen and awareness. Providers reported workload and lack of supplies and trained staff as significant barriers to offering services. Based on these findings, we identified three intervention components to address these facilitators and barriers to screening. They include utilizing existing social networks to expand awareness of cervical cancer risk and screening, training non-physician health workers to meet the demand for screening, and employing female-driven screening techniques such as self-collection of specimens for HPV testing. Cervical cancer prevention programs must take into account the local realities in which they occur. In low-resource areas in particular, identifying low-cost, effective, and culturally appropriate strategies for addressing poor screening uptake is important given limited funding. This study took a formative approach to identify facilitators and barriers to cervical cancer screening based on focus groups and interviews with community members and healthcare providers.

A Qualitative Exploration of Women's Experiences with a Community Health Volunteer-Led Cervical Cancer Educational Module in Migori County, Kenya.

Detection and treatment of human papillomavirus (HPV) and cervical precancer through screening programs is an effective way to reduce cervical cancer deaths. However, high cervical cancer mortality persists in low- and middle-income countries. As screening programs become more widely available, it is essential to understand how knowledge about cervical cancer and perceived disease risk impacts screening uptake and acceptability. We evaluated women's experiences with a cervical cancer education strategy led by community health volunteers (CHVs) in Migori County, Kenya, as part of a cluster randomized controlled trial of cervical cancer screening implementation strategies. The educational modules employed simple language and images and sought to increase understanding of the relationship between HPV and cervical cancer, the mechanisms of self-collected HPV testing, and the importance of cervical cancer screening. Modules took place in three different contexts throughout the study: (1) during community mobilization; (2) prior to screening in either community health campaigns or health facilities; and (3) prior to treatment. Between January and September 2016, we conducted in-depth interviews with 525 participants to assess their experience with various aspects of the screening program. After the context-specific educational modules, women reported increased awareness of cervical cancer screening and willingness to screen, described HPV- and cervical cancer-related stigma and emphasized the use of educational modules to reduce stigma. Some misconceptions about cervical cancer were evident. With effective and context-specific training, lay health workers, such as CHVs, can help bridge the gap between cervical cancer screening uptake and acceptability.

Female perspectives on male involvement in a human-papillomavirus-based cervical cancer-screening program in western Kenya.

BACKGROUND: To be effective, population-based cervical cancer prevention programs must be tailored to meet the needs of the target population. One important factor in cervical cancer screening may include male involvement. To iteratively improve a screening program employing self-collected vaginal swabs for human-papillomavirus (HPV) testing in western Kenya, we examined the role of male partners and community leaders in decision-making and accessing screening services. METHODS: We carried out 604 semi-structured, in-depth interviews (IDIs) with women and community health volunteers who took part in a multiphase trial of implementation strategies for HPV-based cervical cancer screening. IDIs were coded and themes related to decision-making, screening and treatment barriers, and influence of male partners and community leaders were identified and analyzed. RESULTS: Women experienced both support and opposition from their male partners. Partner support took the form of financial support for transportation and emotional support and encouragement, while opposition ranged from anticipated negative reactions to lack of permission, isolation, and abandonment. Though most women described their own partners as supportive, many felt that other male partners would not be supportive. Most participants believed that increased HPV and cervical cancer knowledge would increase partner support. Women reported a general acceptance of involvement of community leaders in education and screening campaigns, in a setting where such leaders may hold influence over men in the community. CONCLUSION: There was a clear interest in involving male partners in the cervical cancer prevention process, specifically in increasing knowledge and awareness. Future research should explore the feasibility and effectiveness of engaging male partners in cervical cancer screening and prevention programs.

Perspectives of women participating in a cervical cancer screening campaign with community-based HPV self-sampling in rural western Kenya: a qualitative study.

BACKGROUND: Despite cervical cancer being preventable with effective screening programs, it is the most common cancer and the leading cause of cancer-related death among women in many countries in Africa. Screening involving pelvic examination may not be feasible or acceptable in limited-resource settings. We sought to evaluate women's perspectives on human papillomavirus (HPV) self-sampling as part of a larger trial on cervical cancer prevention implementation strategies in rural western Kenya. METHODS: We invited 120 women participating in a cluster randomized trial of cervical cancer screening implementation strategies in Migori County, Kenya for in-depth interviews. We explored reasons for testing, experience with and ability to complete HPV self-sampling, importance of clinician involvement during screening, factors and people contributing to screening decision-making, and ways to encourage other women to come for screening. We used validated theoretical frameworks to analyze the qualitative data. RESULTS: Women reported having positive experiences with the HPV self-sampling strategy. The factors facilitating uptake included knowledge and beliefs such as prior awareness of HPV, personal perception of cervical cancer risk, desire for improved health outcomes, and peer and partner encouragement. Logistical and screening facilitators included confidence in the ability to complete HPV self-sampling strategy, proximity to screening sites and feelings of privacy and comfort conducting the HPV self- sampling. The barriers to screening included fear of need for a pelvic exam, fear of disease and death associated with cervical cancer. We classified these findings as capabilities, opportunities and motivations for health behavior using the COM-B framework. CONCLUSIONS: Overall, HPV self-sampling was an acceptable cervical cancer screening strategy that seemed to meet the needs of the women in this community. These findings will further inform aspects of implementation, including outreach messaging, health education, screening sites and emphasis on availability and effectiveness of preventative treatment for women who screen positive.

Evaluating a community-based cervical cancer screening strategy in Western Kenya: a descriptive study.

BACKGROUND: The incidence of cervical cancer in Kenya is among the highest in the world. Few Kenyan women are able to access screening, thus fueling the high cervical cancer burden. Self-collected human papilloma Virus (HPV) tests, administered during community-health campaigns in rural areas may be a way to expand access to screening. METHODS: In December 2015, we carried out a four-day community health campaign (CHC) to educate participants about cervical cancer prevention and offer self-administered HPV screening. Community enumeration, outreach and mobilization preceded the CHC. Samples were sent to Migori County Hospital for HPV DNA testing using careHPV Test Kits. Women were notified of results through their choice of short message service (SMS), phone call, home visit or clinic visit. HPV positive women were referred for cryotherapy following a screen-and-treat strategy. RESULTS: Door-to-door enumeration identified approximately 870 eligible women in Ngodhe Community in Migori County. Among the 267 women attending the campaign, 255 women enrolled and collected samples: 243 tests were successfully resulted and 12 were indeterminate. Of the 243 resulted tests, 47 (19%) were positive for HPV, with young age being the only significant predictor of positivity. In multivariate analysis, each additional year of age conferred about a 4% decrease in the odds of testing positive (95% CI 0.1 to 7%, p = 0.046). Just over three-quarters of all women (195/255), were notified of their results. Those who were unable to be reached were more likely to prefer receiving results from clinic (54/60, 90%) and were less likely to have mobile phones (24/60, 73%). Although 76% of HPV positive women were notified of their results, just half (51%) of those testing positive presented for treatment. HPV positive women who successfully accessed the treatment facility did not differ from their non-presenting counterparts by demographics, health history, desired route of notification or access to a mobile phone. CONCLUSION: Nearly a third of eligible women in Ngodhe Community attended the CHC and were screened for cervical cancer. Nearly all women who attended the CHC underwent cervical cancer screening by self-collected HPV tests. Three-quarters of all participants received results, but just half of HPV positive participants presented for treatment in a timely fashion, suggesting that linkage to treatment remains a major challenge. TRIAL REGISTRATION: NCT02124252 , Registered 25 April 2014.

Gendered gaps to tuberculosis prevention and care in Kenya: a political economy analysis study.

BACKGROUND: Tuberculosis (TB) remains a public health concern in Kenya despite the massive global efforts towards ending TB. The impediments to TB prevention and care efforts include poor health systems, resource limitations and other sociopolitical contexts that inform policy and implementation. Notably, TB cases are much higher in men than women. Therefore, the political economy analysis (PEA) study provides in-depth contexts and understanding of the gender gaps to access and successful treatment for TB infection. DESIGN: PEA adopts a qualitative, in-depth approach through key informant interviews (KII) and documentary analysis. SETTING AND PARTICIPANTS: The KIIs were distributed among government entities, academia, non-state actors and community TB groups from Kenya. RESULTS: The themes identified were mapped onto the applied PEA analysis framework domains. The contextual and institutional issues included gender concerns related to the disconnect between TB policies and gender inclusion aspects, such as low prioritisation for TB programmes, limited use of evidence to inform decisions and poor health system structures. The broad barriers influencing the social contexts for TB programmes were social stigma and cultural norms such as traditional interventions that negatively impact health-seeking behaviours. The themes around the economic situation were poverty and unemployment, food insecurity and malnutrition. The political context centred around the systemic and governance gaps in the health system from the national and devolved health functions. CONCLUSION: Broad contextual factors identified from the PEA widen the disparity in targeted gender efforts toward men. Following the development of effective TB policies and strategies, it is essential to have well-planned gendered responsive interventions with a clear implementation plan and monitoring system to enhance access to TB prevention and care.

Communication strategies to improve human papillomavirus (HPV) immunisation uptake among adolescents in sub-Saharan Africa: a systematic review and meta-analysis.

OBJECTIVES: Developing countries face the greatest cervical cancer disease burden and mortality with suboptimal immunisation uptake. This review explores the communication strategies adopted, successes, challenges and lessons learnt in sub-Saharan countries to enhance human papillomavirus (HPV) immunisation. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed, Hinari, Cochrane Library, Trip database, CINAHL, Web of Science, Scopus and seven grey resources were searched through May 2022. ELIGIBILITY CRITERIA: We included observational studies addressing communication strategies for HPV immunisation uptake. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers used standardised methods to search, screen and code included studies. Data extraction and assessment of risk of bias were done in duplicate to enhance validity of the results. Meta-analysis was conducted using the random-effects model. Findings were summarised and synthesised qualitatively. RESULTS: Communication intervention to facilitate decision-making achieved uptake rate of 100% (95% CI 0.99% to 1.00%), followed by intervention to enable communication, which achieved 92% (95% CI 0.92% to 0.92%). Communication intervention to inform and educate achieved 90% (95% CI 0.90% to 0.90%).Targeting both healthcare workers and community leaders with the communication intervention achieved 95% (95% CI 0.91% to 0.98%), while teachers and school boards achieved 92% (95% CI 0.84% to 1.01%). Targeting policymakers achieved 86% (95% CI 0.78% to 0.93%).Based on the method of communication intervention delivery, use of training achieved an uptake rate of 85% (95% CI 0.84% to 0.87%); similarly, drama and dance achieved 85% (95% CI 0.84% to 0.86%). However, use of information, education and communication materials achieved 82% (95% CI 0.78% to 0.87%). CONCLUSION: HPV vaccine communication is critical in ensuring that the community understands the importance of vaccination. The most effective communication strategies included those which educate the population about the HPV vaccine, facilitate decision-making on vaccine uptake and community ownership of the vaccination process immunisation. PROSPERO REGISTRATION NUMBER: CRD42021243683.

Clinical readiness for essential maternal and child health services in Kenya: A cross-sectional survey.

High rates of maternal and neonatal morbidity and mortality in Kenya may be influenced by provider training and knowledge in emergency obstetric and neonatal care in addition to availability of supplies necessary for this care. While post-abortion care is a key aspect of life-saving maternal health care, no validated questionnaires have been published on provider clinical knowledge in this arena. Our aim was to determine provider knowledge of maternal-child health (MCH) emergencies (post-abortion care, pre-eclampsia, postpartum hemorrhage, neonatal resuscitation) and determine factors associated with clinical knowledge. Our secondary aim was to pilot a case-based questionnaire on post-abortion care. We conducted a cross-sectional survey of providers at health facilities in western Kenya providing maternity services. Providers estimated facility capacity through perceived availability of both general and specialized supplies. Providers reported training on the MCH topics and completed case-based questions to assess clinical knowledge. Knowledge was compared between topics using a linear mixed model. Multivariable models identified variables associated with scores by topic. 132 providers at 37 facilities were interviewed. All facilities had access to general supplies at least sometime while specialized supplies were available less frequently. While only 56.8% of providers reported training on post-abortion care, more than 80% reported training on pre-eclampsia, postpartum hemorrhage, and neonatal resuscitation. Providers' clinical knowledge across all topics was low (mean score of 63.3%), with significant differences in scores by topic area. Despite less formal training in the subject area, providers answered 71.6% (SD 16.7%) questions correctly on post-abortion care. Gaps in supply availability, training, and clinical knowledge on MCH emergencies exist. Increasing training on MCH topics may decrease pregnancy and postpartum complications. Further, validated tools to assess knowledge in post-abortion care should be created, particularly in sub-Saharan Africa where legal restrictions on abortion services exist and many abortions are performed in unsafe settings.

'I'm here to save my life': a qualitative study of experiences navigating a cryotherapy referral system for human papillomavirus-positive women in western Kenya.

BACKGROUND: We sought to understand the beliefs, social norms and logistical factors that affect human papillomavirus (HPV)-positive women's uptake of cryotherapy treatment as part of a two-part cervical cancer screening strategy in rural Kenya. METHODS: In-depth interviews within a parent cluster-randomised trial. SETTING: Government-run county hospital in western Kenya. PARTICIPANTS: 273 of 372 (73.4%) HPV-positive women who underwent cryotherapy RESULTS: Many women feared that an HPV infection meant they would develop cancer. Almost all women reported initial fear of the treatment procedure, followed by a more positive experience than anticipated. Lacking funds for transportation to the treatment site was the most common barrier. Women felt that decentralised treatment would be the most important facilitator of greater access. Spousal encouragement and financial support were key facilitators of treatment access, however many women felt that other husbands in the community would not be supportive. Women described successfully acquiring treatment as empowering, and almost all would recommend seeking cryotherapy to other women who test HPV-positive. Most felt eager to share their own experiences with others to encourage treatment. CONCLUSIONS: The main facilitators of treatment access were understanding of the health risks and sense of empowerment. A decentralised treatment model or transportation support may facilitate access, along with improved health messaging about HPV infection, cancer and the treatment process. Focusing on women's personal feelings of empowerment may further improve uptake and satisfaction. These data will be used to design a strategy to improve linkage to treatment. TRIAL REGISTRATION: NCT02124252.

How Providing Cervical Cancer Screening Results via Cell Phone Affects Patient Follow-Up Rates in Western Kenya.

PURPOSE: Human papillomavirus (HPV) testing is being more widely used in simplified cervical cancer screening protocols in low-resource settings. One challenge to successful implementation is the multiple visits necessary to provide results and follow-up. mHealth strategies may reduce visit burden by providing information through text message. METHODS: As part of a cluster-randomized trial to compare HPV testing in clinics and community health campaigns in western Kenya, we carried out a mixed-methods study to assess women's preferences and experiences with different strategies to receive their results. Women could opt to receive their HPV results via text message, cell phone call, home visit, or return clinic visit. We examined overall receipt of results, follow-up rates, and acceptability by notification method. RESULTS: Among the 4,947 women who underwent HPV-based cervical cancer screening, 1,596 (32%) received results via text message, 1,181 (24%) via cell phone call, 1,563 (32%) via clinic visit, and 605 (12%) via home visit. Women opting for texts or calls were younger and had higher rates of prior cervical cancer screening, HIV testing, and modern contraceptive use (P < .001 for all). Home visits were associated with a significantly higher rate of treatment acquisition (45%) than texts (38%), cell phone calls (38%), and clinic visits (23%; P < .001). In a model controlling for age, prior screening, HIV testing, and contraceptive use, clinic visits remained significantly associated with decreased odds of treatment (adjusted odds ratio, 0.45; 95% CI, 0.29 to 0.69) compared with texts. Among treated women, there was no difference in time to treatment by notification method. CONCLUSION: Cell phone-based results notification strategies were preferred by women with greater health-seeking behavior; however, HPV-positive women who received results via home visit were more likely to pursue for treatment.