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Table 2 Description of interventions to increase uptake of cervical screening in sub-Saharan Africa and related outcomes

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

Study Population Intervention(s) and Comparison(s) Outcomes
Health Education Interventions
Abiodun 2014
[15]
Women, aged 25–64, in rural Nigeria a. Multi-component structured health education on cervical cancer and prevention featuring a culturally-relevant home video, didactic lectures, discussion session, and informational pamphlet delivered during one 4-h session.
b. Health education on breast cancer without a culturally-relevant video.
Follow-up: 13 weeks
Uptake: 4% difference in “ever screened” pre- to post-intervention (4.3 to 8.3%, p = 0.038) in intervention vs. 0.4% difference in control.
Awareness: 83.1% difference in “ever heard of cervical cancer” pre- to post-intervention (16.9 to 100%, p < 0.0001) in intervention vs. 1.3% difference in control. An 89.7% difference in “ever heard of screening” (10.3 to 100%) in intervention vs. 0.2% difference in control.
Knowledge: 68.5% difference in “very good” knowledge from pre- to post-intervention (2 to 70.5%, p < 0.0001); mean knowledge score increased 23.94 points (out of 40, 1.75 to 25.69) in intervention vs. 0.19 score increase in control.
Willingness to screen: Non-significant difference from pre- to post-intervention (89.7 to 92.3%, p = 0.283) in intervention vs. 2.0% difference in control.
Adamu 2012 [16] Female teachers in secondary schools, in Nigeria a. Health education on cervical cancer and prevention, with an emphasis on cervical cytology using Pap smear, delivered via lecture presented twice (1 month apart) and a Pap smear demonstration. Each participant received a coupon for a free Pap smear test.
b. No intervention (delayed intervention).
Follow-up: 3 months
Uptake: No significant increase in uptake from pre- to post-intervention in intervention group (1.1 to 3.4%, p = 0.45) or control.
Attitude: Mean attitude score improved by 17.4 points (35.4 to 52.8, p < 0.001) in intervention vs. 1.9 point decrease in control.
Knowledge: Mean knowledge of cervical cancer score increased by 31.7 points (25.5 to 57.2, p < 0.0001) in intervention vs. 11.5 points in control. Mean knowledge of Pap smear score increased by 10.9 points (17.1 to 28.0, p < 0.0001) in intervention vs. 1.3 point decrease in control.
Adonis 2017 [17] Health-insured females, aged 21–65, in South Africa a.i. A structured email using loss-framed messaging about cervical cancer and screening plus a request to attend screening, and one reminder email 3 months later. Messaging focused on risk with phrases like “too late” and “bad health outcomes”.
a.ii. A structured email using gain-framed messaging about cervical cancer and screening plus a request to attend screening, and one reminder email 3 months later. Messaging focused on improving health and well-being with phrases like “better health”.
b. A structured email using neutrally-framed messaging to provide only factual statements on recommendations for screening plus a request to attend screening, and one reminder email 3 months later.
Follow-up: 6 months after first message
Uptake: No statistically significant difference between the screening rates of the groups during the study period (8.81% in loss-framed intervention, 5.71% in in gain-framed intervention, 9.58% in control, p = 0.75). Measure of “ever screened” not reported.
Chigbu 2017 [18] Women, aged 30 and older, in rural Nigeria a. House-to-house cervical and breast cancer prevention education, delivered one-on-one using a structured information booklet, by a trained community health educator. Screening services were free, and HPV vaccination was offered for eligible children for a fee. Facilities were within walking distance in each community.
b. Before-and-after study design; each participant is their own control
Follow-up: 6 months
Uptake: 64.4% difference in “ever screened” from pre-to post-intervention (3.2 to 67.6%, p < 0.001).
Awareness: Of the women screened after the intervention, 94.3% were not aware of screening before the intervention.
Erwin 2019 [20] Women, aged 25–49, in urban and rural Tanzania a.i. An SMS behavior change communication intervention, with a series of 15 text messages about cervical cancer and context-specific barriers to screening, delivered over 21 days.
a.ii. The same SMS behavior change communication series + an eVoucher to cover transportation costs to the screening clinic, and a reminder message when the voucher was set to expire.
b. One SMS message (sent up to three times) with the location and hours of the closest screening clinic.
Follow-up: 2 months
Uptake: 8.6% difference in screening during the follow-up period in SMS only intervention group compared to control group (12.9% vs. 4.3%; AOR = 3.0, 95% CI: 1.5–6.2); 13.7% difference in SMS + eVoucher intervention group than control group (18% vs. 4.3%; AOR = 4.7, 95% CI: 2.93–7.44). Measure for “ever screened” not reported.
Gana 2017 [21] Women, registered as venders with local market association, in Nigeria a. Health education on cervical cancer delivered through two sessions held 4 weeks apart, with Information, Education, and Communication (IEC) materials distributed at the end of each session.
b. No intervention (delayed intervention).
Follow-up: 3 months after second session
Uptake: No significant change in “ever had Pap smear” from pre- to post-intervention (1.1 to 3.4%, p = 0.621).
Awareness: 28.4% difference in awareness of Pap smear test between intervention and control (34.1% vs. 5.7%, p < 0.0001).
Mbachu 2017 [25] Women, aged 21+, who worshipped in selected Anglican dioceses, in Nigeria a. Health education on cervical cancer and prevention, delivered by peer educators (clergy wives) in 3 to 6 group sessions, 1–1.5 h each, over a period of 3 months. Sessions included didactic teaching and discussion.
b. Before-and-after study design; each participant is their own control.
Follow-up: Unclear
Uptake: 6.8% difference in “ever screened” from pre- to post-intervention (10.5 to 17.3%, p = 0.02).
Willingness to screen: No significant increase from pre- to post-intervention (79.3 to 80.8%, p = 0.52).
Other outcomes reported: perceived severity of cervical cancer, individual risk perception, perceived benefit of screening
Ndikom 2017
[29]
Women utilizing maternal health services, in Nigeria a. Health education on cervical cancer and prevention, delivered by nurses through one group session, guided by standardized flex charts. Intervention sites were four health centers.
b. No intervention, women attending antenatal clinics at control hospitals.
Follow-up: 6 months
Uptake: No significant difference between intervention and control groups post-intervention (3.6% vs. 2.3%, p = 0.27).
Awareness: 58.6% difference in “ever heard about cervical cancer” from pre- to post-intervention in intervention group (12.9 to 71.5%) vs. 3.9% difference in control (p = 0.001). 40.1% increase in awareness of where to get screened (12.9 to 53.0%) in intervention vs. 2.3% decrease in control (p < 0.001).
Knowledge: 50.9% difference in proportion of participants with “poor” knowledge from pre- to post-intervention (94.2 to 43.3%) vs. 10% difference in “poor” knowledge in control (p < 0.001).
Willingness to screen: 15.2% difference from pre-to-post-intervention (75.8 to 91.0%) in intervention group vs. 13.8% difference (71.5 to 85.3%) in control (p = 0.01).
Risi 2004
[31]
Women, aged 35–65, in peri-urban South Africa a.i. Health education, utilizing a 20-page long photo-comic with information about cervical cancer and stages of cervical cancer, administered door-to-door.
a.ii. Health education, in the format of a radio-drama, broadcast on a local radio station 10 times over 1 month.
b.i. Photo-comic with educational information on personal finances and no health care messages.
b.ii. Retrospective cohort design; comparison are participants who did not recall hearing the radio-drama.
Follow-up: 6 months
Uptake: No significant difference in uptake of Pap smear during the study period between intervention and control groups (6.4% vs. 6.7%, p = 0.89). At baseline, 45% of women reported “ever had smear”.
Of the 43 women who reported uptake, most (44.2%) did not recall the photo-comic or radio-drama; 25.6% recalled the photo-comic alone; 20.9% recalled the radio-drama alone; 11.8% recalled both.
No evidence of interaction between the two interventions.
Rosser 2015
[32]
Women, aged 23+, in rural Kenya a. A 30-min health education intervention consisting of an interactive talk about cervical cancer and guided discussion about barriers to screening and fears/stigma associated with screening. The intervention was guided by a flip-chart and script, and delivered by community health workers to groups of 4–6 women recruited from health facilities waiting areas.
b. Standard of care; women were informed that screening was available, no health education.
Follow-up: 3 months
Uptake: No significant difference in screening during the study period between intervention and control groups (58.9% vs. 60.9%, p = 0.60). Measure of “ever screened” not reported.
Awareness: Mean awareness score increased by 1.4 points (2.6 to 4.0) in intervention vs. 0.9 points (2.4 to 3.3) in control (p < 0.01).
Knowledge: Mean cervical cancer knowledge score increased by 2.3 points (8.7 to 11.0) in intervention vs. 1.5 points (8.5 to 10.0) in control (p < 0.01).
Wright 2011
[33]
Women, registered with the local market association, in urban Nigeria a. Health education on cervical cancer screening tests, with emphasis on Pap smear, its benefits and procedure, and facilities where services are provided. The intervention included counseling and culturally-tailored and reader-friendly educational materials and was delivered during weekly market meeting periods.
b. Health education on hypertension with blood pressure measurements provided.
Follow-up: 3 months
Uptake: No significant difference in “ever had Pap smear test” from pre- to post-intervention in intervention (1.1 to 1.7%) or control group (p > 0.05).
Awareness: 49.7% difference in awareness of Pap smear from pre- to post-intervention (6.9 to 56.6%) in intervention vs. 2.3% difference in control (p < 0.001).
Willingness to screen: 19.5% difference from pre- to post-intervention (63.4 to 82.9%) in intervention vs. 3.4% increase in control (p < 0.01).
Economic Incentive Interventions
Mehrotra 2014
[26]
Women, aged 16+, enrolled in a health plan and the plan’s optional paid incentive program, in South Africa a. A preventive health incentivization program, offered by a health insurance plan, that offers rewards like movie tickets or international airfare, for receipt of 8 qualifying preventive health services including cervical screening.
b. Plan members not enrolled in the incentivization scheme.
Follow-up: 1 year
Uptake: The intervention group had increased odds of annual receipt of Pap smear, compared to the non-enrolled group (OR = 2.17, p < 0.01). The average annual receipt for the intervention group was 19.7%. Measure of “ever screened” not reported.
Okeke 2013
[30]
Females, aged 18–64, in Nigeria a.i. Health education about cervical cancer and screening benefits + a subsidy to receive screening for 0 Naira (N), 50 N, or 100 N, as determined by playing a lottery scratch card game administered during a home-visit.
a.ii. Same health education, as well as information about cancer prevalence + a cancer treatment subsidy to cover the cost of care if cancer was found during screening (up to N100,000), as determined by playing a lottery scratch card game administered during a home-visit.
b. Health education only, without subsidy (those who “lost” the lottery game).
Follow-up: Unclear
Uptake: 4.5% difference in intervention that received the treatment subsidy compared to control (17% vs. 12.5%). A N10 price increase of screening, reduced uptake by about 0.6 percentage points (N0: 18%, N50: 15%, N100: 11.2%).
Innovative Service Delivery Interventions
Dreyer 2015
[19]
Mothers of girls in grades 4–7, who were in a school-based HPV vaccination program, in South Africa a. A school-based educational intervention, consisting of a 15-min powerpoint presentation by a medical doctor and information leaflets, targeting school girls eligible for HPV vaccination and their parents. Mothers were invited to screen at a clinic or with a self-screening kit, based on study site.
b. Before-and-after study design; each participant is their own control.
Follow-up: 6 months
Uptake: 15.3% difference in “ever screened” from pre- to post-intervention (53.6 to 68.9%, p < 0.005). Screening scores were also assigned based on how long women were screened and if they had been screened more than once. The intervention was associated with significantly more recent screening. A more favorable change was observed for the self-collection intervention group; 45.3% of the self-collection group returned a screening kit.
Knowledge: “Adequate” knowledge of cervical cancer increased 32.3% pre- to post-intervention (30.6 to 62.9%, p < 0.005).
Hewett 2016
[22]
Males and females, aged 18+, seeking select health services in catchment area, in urban/semi-urban Zambia a.i. Enhanced client-centered counseling, referral to add-on services (including cervical screening) for the patient and their partner, with client follow-up by phone. A standardized assessment form, informational materials about the add-on services, and motivational interviewing were used at time of care seeking and 7 days later if the client failed to access referral services.
a.ii. Same intervention + additional offer of immediate escort to the add-on service. Escorts guide the client at the time of referral, to the site of the add-on service.
b. Standard of care for family planning, HIV testing and counseling, and voluntary medical male circumcision services. Normal client assessment and counseling, ad-hoc referrals (usually client-initiated), no direct transition or linkage between services, no follow-up of clients.
Follow-up: 6 weeks and 6 months
Uptake: Significant increase in both interventions vs. control (p < 0.001; 22.2% uptake at 6 months vs. 9.7%, AOR 2.75, 95% CI: 1.94–3.91 intervention 1 vs. control; 23.6% vs. 9.7%, AOR = 2.98, 95% CI: 2.10–4.22 intervention 2 vs. control). There was little meaningful difference between the intervention arms, escort services are not very important for improving cervical screening uptake.
Huchko 2017
[23]
Women, aged 25–65, in rural Kenya a. HPV screening was offered through periodic community health campaigns (CHCs), that utilized pop-up tents to offer community-based screening. Community health volunteers conducted community outreach and mobilization, screening, and result notification and feedback over a 6-week period, in select communities.
b. Community outreach and educational information in control communities was the same, with offer of HPV self-testing, but community-based tents were not used. Instead, women were referred to their local government health facilities.
Follow-up: 6 weeks
Uptake: 23% difference in screening during intervention period in intervention vs. control communities (60% vs. 37%, p < 0.001). Measure for “ever screened” not reported.
Lafort 2018
[24]
Female sex workers, aged 30+, in South Africa, Mozambique, and Kenya a. Somewhat different “diagonal” interventions were implemented over 18 months in each site with four shared components: facilitating access to general health facilities, targeted peer outreach, targeted clinical services, and female sex worker empowerment.
b. Before-and-after study design; each participant is their own control.
Follow-up: Unclear
Uptake: 28.2% difference in “ever screened” from pre- to post-intervention (31.8 to 60.0%, p = 0.001) in South Africa; difference of 25.2% (0 to 25.2%, p = 0.001) in Mozambique; non-significant increase in Kenya (18.1 to 25.5%, p = 0.347).
Modibbo 2017
[27]
Women, aged 30–65, in semi-urban Nigeria a. Health education on cervical cancer and its risk factors + self-sampling kit for at-home collection of HPV samples, to be mailed in or dropped-off at designated collection points.
b. Same health education + an appointment for screening at a designated clinic.
Follow-up: 1 month after last enrollment
Uptake: 91% difference in “ever screened” from pre- to post-intervention (1.5 to 92.5%) in intervention vs. 55.5% increase (1 to 56.5%) in control (p < 0.001).
Moses 2015
[28]
Women, aged 30–65, in Uganda a. Outreach workers collected HPV specimens from women either in their home or a private area in their place of work using self-collection kits, transported samples to the laboratory each day, and shared results with participants by phone.
b. Outreach workers gave women an appointment for VIA screening at the local health facility. Phone call reminders were placed 1 day before the appointment.
Follow-up: Unclear
Uptake: 50.8% difference between intervention and control groups (99.2% vs. 48.4%, p < 0.001). Of the HR-HPV-positive women referred to the clinic for follow-up VIA testing, 45.2% attended the appointment.
  1. aIntervention(s)
  2. bComparison(s)
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