"There is nothing that can prevent me from supporting her:" men's perspectives on their involvement and support of women's use of topical therapy for cervical precancer treatment in Kenya.

Purpose: Cervical cancer disproportionately impacts women in low- and middle-income countries (LMICs). The World Health Organization's (WHO) 90/70/90 strategy aims to eliminate cervical cancer by 2030 by increasing HPV vaccination coverage to 90%, screening 70% of eligible women, and effectively treating 90% of those with abnormal results by 2030, potentially preventing 62 million deaths in LMICs. LMICs, however, struggle with limited access to cervical precancer treatment, in part due to a lack of trained professionals and weak health systems. Effective non-surgical, self-administered, which have demonstrated efficacy in high-income countries, could bridge the treatment gap in LMICs and may be more scalable and cost-effective than provider-administered therapies. To inform feasibility studies in LMICs, data are needed on the role of male partners in influencing the acceptability and uptake of self-administered topical therapies, including their support of recommended abstinence and contraception guidelines associated with these therapies. Methods: Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with men aged 25 to 65 years in Kenya to explore their perspective and perceived support regarding their female partners using topical self-administered therapies for cervical precancer treatment. The FGDs were moderated by local qualitative research assistants and conducted in local languages, transcribed, coded, and analyzed using qualitative description. Results: Thirty-nine male participants meeting the eligibility criteria participated in five FGDs. The mean age of participants was 42.5 years. Most participants, 79.5%, had a female partner with a history of cervical precancer treatment, 5.1% did not, and 15.4% were unsure of their female partner's prior precancer treatment history. The study aimed to assess men's support of their female partners' use of topical therapies for treating cervical precancer. We find that male participants strongly express acceptance and willingness to support their wives or partners in using such therapies, if available. Reported supportive behavior included permitting the use of the therapies and support of maintaining abstinence during the recommended times. Additionally, participants desired male involvement in clinic and community-based education about topical therapies to facilitate widespread support. Conclusion: The use of self-administered topical therapies for cervical precancer treatment, if supported by efficacy studies in LMICs, may support achieving the WHO's 2030 goal of 90% treatment access. We find that with adequate education, men express overwhelming support of their female partner's use of topical therapies, including adherence to abstinence and contraception guidelines.

Men's perceptions and perceived acceptability of their female partner's use of self-administered intravaginal therapies for treatment of cervical precancer in Kenya.

Background: Cervical cancer continues to be a major health issue in low- and middle-income countries (LMICs). Despite increasing access to screening, access to precancer treatment remains a significant challenge in LMICs, highlighting a need for innovative, accessible, and resource-appropriate treatment approaches, including self-administered therapies. Methods: A cross-sectional mixed-methods study was conducted among men aged 25-65 with a current female partner in Kisumu County, Kenya. Participants were sequentially recruited and surveyed to evaluate their understanding of HPV and cervical cancer, their views on screening and treatment, and their attitudes toward self-administered therapies. Focus group discussions with a subset of the survey participants further explored their treatment preferences and perceptions. Results: Two hundred fourteen men participated in the survey, and 39 men participated in focus group discussions. The median age was 39 years, and 51% had a primary school education or less. Most (96%) were in a committed relationship, and 74% earned $10 or less daily. There was strong support for self-administered topical therapies, with 98% willing to support their partners using such treatments if available. Additionally, most participants were open to supporting necessary abstinence or condom use, though 76% believed their partners might hesitate to request condom use. When given an option, most preferred their partner to self-administer such therapies at home compared to provider administration at a health facility, citing convenience, cost-effectiveness, and privacy. Preferences varied between two potential therapies, 5-Fluorouracil (5FU) and Artesunate, based on their administration frequency, duration, and abstinence requirements. Qualitative findings largely supported the quantitative analysis. Conclusions: The study demonstrates strong support for self-administered topical therapies for cervical precancer among Kenyan men. Additional research on acceptability, feasibility, and efficacy in different LMICs could pave the way for these therapies to help bridge current cervical precancer treatment gaps in these settings.

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.

"There is nothing that can prevent me from supporting her:" Men's perspectives on their involvement and support of women's use of topical therapy for cervical precancer treatment in Kenya.

Purpose: Cervical cancer disproportionately impacts women in low- and middle-income countries (LMICs). The World Health Organization's (WHO) 90/70/90 strategy aims to eliminate cervical cancer by 2030 by increasing HPV vaccination coverage to 90%, screening 70% of eligible women, and effectively treating 90% of those with abnormal results by 2030, potentially preventing 62 million deaths in LMICs. LMICs, however, struggle with limited access to cervical precancer treatment, in part due to a lack of trained professionals and weak health systems. Effective non-surgical, self-administered, which have demonstrated efficacy in high-income countries, could bridge the treatment gap in LMICs and may be more scalable and cost-effective than provider-administered therapies. To inform feasibility studies in LMICs, data are needed on the role of male partners in influencing the acceptability and uptake of self-administered topical therapies, including their support of recommended abstinence and contraception guidelines associated with these therapies. Methods: Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with men aged 25 to 65 years in Kenya to explore their perspective and perceived support regarding their female partners using topical self-administered therapies for cervical precancer treatment. The FGDs were moderated by local qualitative research assistants and conducted in local languages, transcribed, coded, and analyzed using qualitative description. Results: Male participants in the FGDs strongly expressed acceptance and willingness to support their wives or partners in using topical therapies for cervical precancer treatment, if available. Reported supportive behavior included permitting the use of the therapies and support of maintaining abstinence during the recommended times. Additionally, participants desired male involvement in clinic and community-based education about topical therapies to facilitate widespread support. Conclusion: The use of self-administered topical therapies for cervical precancer treatment, if supported by efficacy studies in LMICs, may support achieving the WHO's 2030 goal of 90% treatment access. We find that with adequate education, men express overwhelming support of their female partner's use of topical therapies, including adherence to abstinence and contraception guidelines.

A Qualitative Study Documenting Black Birthing Individuals' Perspectives on the Disproportionate Rate of Preterm Birth in the Black Community.

Background: Compared with all other racial and ethnic groups, the rate of preterm birth (PTB) is 50% higher among non-Hispanic Blacks (NHB). There are limited published data focused on the etiology of the racial disparity in PTB from the perspective of Black birthing individuals who have had a lived experience with PTB. Methods: To gain insights into the etiology of the race disparity in PTB from the NHB patient's perspective, we conducted a qualitative descriptive study with NHBs who have a history of PTB. We conducted both focus group discussions (FGDs), in-depth interviews (IDIs), and used applied thematic analysis to analyze the data. Results: Seven individuals participated in 3 FGDs and 15 individuals participated in an IDI. The majority of participants named stress as a contributor to PTB among NHBs. Participants described that stress becomes an ongoing cycle with a cumulative effect on health. Three primary sources of stress were identified: (1) individual including stress from lack of personal wellness, (2) relational stress from intimate partner and familial relationships, and (3) community-level stress from occupations and societal expectations. Conclusion: Uncovering NHB patient's perspectives on the etiology of PTB is a critical step to develop interventions that mitigate the disparity impacting the Black community. Our findings suggest that multilevel interventions targeting individual-, relational-, and community-level stress may be necessary to reduce rates of PTB among NHB individuals.

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.

Pregnancy vs. paycheck: a qualitative study of patient's experience with employment during pregnancy at high risk for preterm birth.

BACKGROUND: Pregnant women with a history of preterm birth are at risk for recurrence, often requiring frequent prenatal visits for close monitoring and/or preventive therapies. Employment demands can limit uptake and adherence to recommended monitoring and preterm birth prevention therapies. METHOD: We conducted a qualitative descriptive study using in-depth interviews (IDIs) of pregnant women with a history of preterm birth. IDIs were conducted by trained qualitative interviewers following a semi-structured interview guide focused on uncovering barriers and facilitators to initiation of prenatal care, including relevant employment experiences, and soliciting potential interventions to improve prompt prenatal care initiation. The IDIs were analyzed via applied thematic analysis. RESULTS: We described the interview findings that address women's employment experiences. The current analysis includes 27 women who are majority self-described as non-Hispanic Black (74%) and publically insured (70%). Participants were employed in a range of professions; food services, childcare and retail were the most common occupations. Participants described multiple ways that being pregnant impacted their earning potential, ranging from voluntary work-hour reduction, involuntary duty hour reductions by employers, truncated promotions, and termination of employment. Participants also shared varying experiences with workplace accommodations to their work environment and job duties based on their pregnancy. Some of these accommodations were initiated by a collaborative employee/employer discussion, others were initiated by the employer's perception of safe working conditions in pregnancy, and some accommodations were based on medical recommendations. Participants described supportive and unsupportive employer reactions to requests for accommodations. CONCLUSIONS: Our findings provide novel insights into women's experiences balancing a pregnancy at increased risk for preterm birth with employment obligations. While many women reported positive experiences, the most striking insights came from women who described negative situations that ranged from challenging to potentially unlawful. Many of the findings suggest profound misunderstandings likely exist at the patient, employer and clinical provider level about the laws surrounding employment in pregnancy, safe employment responsibilities during pregnancy, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy.

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.

'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.

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.

The relationship between vaginal ring use and intimate partner violence and social harms: formative research outcomes from the CHARISMA study in Johannesburg, South Africa.

Despite being designed for autonomous use, research suggests partner approval is often in women's microbicide use. Microbicide study participants have described many ways product use affects relationships, from improving sexual pleasure to increasing harm, including exacerbating intimate partner violence (IPV). As the dapivirine ring proceeds closer to licensure, supporting women's agency to use microbicides safely is a priority. We conducted 42 in-depth interviews with former participants of the Microbicide Trials Network (MTN)-020 trial of the dapivirine vaginal ring and their male partners in Johannesburg, South Africa, to explore how ring use and partnership dynamics interacted. We sampled women who reported harms or partner non-support and women with supportive partners. Male and female narratives revealed high background levels of IPV. Women described how study participation/ring use exacerbated violence, and for a few couples served as a rationale for additional abuse. In response, women described feeling powerless and fearful of conflict, resulting in product nonuse. For one participant violence was reduced, and for several others, empowerment was sparked. These findings suggest future providers have the opportunity to shift more women from a place of fear/violence to one of safety/empowerment through the integration of IPV screening and relationship counselling.

Providing early detection and early intervention for autism spectrum disorder in South Africa: stakeholder perspectives from the Western Cape province.

We set out to examine key stakeholder perspectives on early detection and intervention for autism spectrum disorder (ASD) in South Africa. Early detection and intervention improves child and family outcomes and lessens long-term costs. We focused on stakeholders in the Western Cape province, one of the better-resourced in terms of healthcare. Eight senior management level stakeholders, two each from government's Health, Education, and Social Development, and the non-profit sector were identified using purposive sampling. In-depth interviews focused on key implementation- related themes. The National Integrated Early Childhood Development Policy was the most relevant to early detection and intervention. This policy, however, is not ASD specific. This lack of specificity is in keeping with an emerging theme: ASD was only seen within the context of other developmental disabilities, particularly by Health and Social Development. Specific ASD early detection and intervention may not currently align with Health and Social Development departmental goals. These departments are primarily responsible for identifying and providing services and financial support to young children with ASD. Increased ASD knowledge and local South African statistics on prevalence, burden and associated costs may alter this approach. At this time, ASD early intervention may be more closely aligned with Education department goals.