Ditte Søndergaard Linde

Barriers and facilitators for implementation of HPV-based cervical cancer screening in Tanzania: a qualitative study among healthcare providers, stakeholders, and Tanzanian women

Cervical cancer is the leading cause of cancer-related deaths in Tanzania and the most common form of cancer among Tanzanian women. Screening attendance remains among the lowest globally, necessitating improved attendance and screening methods. This study aims to assess the feasibility of implementing the World Health Organization's 2021 hPV-based screening guideline in Tanzania by identifying potential barriers and facilitators to HPV-based screening among screening clients, healthcare providers, and stakeholders. From October 2022 to February 2023, 25 semi-structured interviews were conducted with screening clients ( Barriers and facilitators emerged across all levels of the Social Ecological Model. At the individual level, clinic-based screening and a one-visit approach were barriers, while HPV-self-sampling was a facilitator. Interpersonal barriers included limited social support, while referrals served as facilitators. Community-level barriers included fear and misconceptions, countered by facilitators such as increased awareness and health education. Health system challenges included restrictive age limits and urbanization of human resources, with uptake through other health services acted as a facilitator. Political barriers highlighted the need for a steady local supply chain, while cost reduction could serve as a facilitator for guideline implementation. WHO's 2021 hPV-based screening guideline shows promise in Tanzania, but barriers such as clinic availability, fear, misconceptions, and supply chain issues must be addressed to ensure successful implementation.

Comprehensive Cervical Cancer Prevention in Tanzania (CONCEPT) study: Cohort profile

Purpose Cervical cancer is a major cause of death among women in Eastern Africa, and the distribution of human papillomavirus (HPV) according to HIV status is inadequately characterised in this region. In order to guide future cervical cancer preventive strategies that involve HPV testing, the Comprehensive Cervical Cancer Prevention in Tanzania (CONCEPT) study was established in 2015. The CONCEPT cohort aims to investigate the natural history of HPV and determine acquisition and persistence patterns of high-risk (HR) HPV among HIV-positive and HIV-negative women. Further, the influence of lifestyle and sexual/reproductive factors will be investigated. The main objective of this article is to describe how the CONCEPT cohort was established. Participants Women aged 25–60 years were enrolled from cervical cancer screening clinics in Dar-es-Salaam and Moshi, Tanzania. Data were collected at baseline, at 14 months (first follow-up) and at 28 months (second follow-up). Biological samples included two cervical swabs for care HPV DNA testing, cytology, Hybrid Capture 2, genotyping and blood samples for HIV. Visual inspection with acetic acid was performed, and sociodemographic, lifestyle and sexual/reproductive characteristics were collected through a standardised questionnaire. Findings to date 4043 women were included in the cohort from August 2015 to May 2017. At baseline, 696 (17.1%) women were HR HPV positive, and among these, 31.6% were HIV positive; 139 women (3.4%) had high-grade squamous intraepithelial lesions. 3074 women (81%) attended the first follow-up. The majority attended after receiving a phone call reminder (35%) or from home via self-samples (41%). At first follow-up, 438 (14.4%) were HR HPV positive and 30.4% of these were HIV positive. Future plans A second follow-up is underway (17 December 2018–October 2020). We plan to integrate our data with a previous cross-sectional HPV study from Tanzania to increase the power of our findings. Researchers interested in collaborating are welcomed, either by extracting data or jointly requesting further investigation from the cohort.

Effectiveness of One-Way Text Messaging on Attendance to Follow-Up Cervical Cancer Screening Among Human Papillomavirus–Positive Tanzanian Women (Connected2Care): Parallel-Group Randomized Controlled Trial

Background Rapid human papillomavirus (HPV) DNA testing is an emerging cervical cancer screening strategy in resource-limited countries, yet it requires follow-up of women who test HPV positive. Objective This study aimed to determine if one-way text messages improved attendance to a 14-month follow-up cervical cancer screening among HPV-positive women. Methods This multicenter, parallel-group randomized controlled trial was conducted at 3 hospitals in Tanzania. Eligible participants were aged between 25 and 60 years, had tested positive to a rapid HPV test during a patient-initiated screening, had been informed of their HPV result, and had a private mobile phone with a valid number. Participants were randomly assigned in a 1:1 ratio to the intervention or control group through an incorporated algorithm in the text message system. The intervention group received one-way text messages, and the control group received no text messages. The primary outcome was attendance at a 14-month health provider-initiated follow-up screening. Participants were not blinded, but outcome assessors were. The analysis was based on intention to treat. Results Between August 2015 and July 2017, 4080 women were screened for cervical cancer, of which 705 were included in this trial—358 women were allocated to the intervention group, and 347 women were allocated to the control group. Moreover, 16 women were excluded before the analysis because they developed cervical cancer or died (8 from each group). In the intervention group, 24.0% (84/350) women attended their follow-up screening, and in the control group, 23.8% (80/335) women attended their follow-up screening (risk ratio 1.02, 95% CI 0.79-1.33). Conclusions Attendance to a health provider-initiated follow-up cervical cancer screening among HPV-positive women was strikingly low, and one-way text messages did not improve the attendance rate. Implementation of rapid HPV testing as a primary screening method at the clinic level entails the challenge of ensuring a proper follow-up of women. Trial Registration ClinicalTrials.gov NCT02509702; https://clinicaltrials.gov/ct2/show/NCT02509702. International Registered Report Identifier (IRRID) RR2-10.2196/10.2196/15863

Acceptability and feasibility of self‐sampling and follow‐up attendance after text message delivery of human papillomavirus results: A cross‐sectional study nested in a cohort in rural Tanzania

AbstractIntroductionThe objective was to determine if self‐collection of vaginal samples for human papillomavirus (HPV) testing was acceptable and feasible in rural Tanzania and to assess the extent of attendance at a follow‐up appointment among women who tested HPV‐positive after delivery of HPV results via text messages.Material and methodsA combined cross‐sectional and cohort study was conducted among women aged 25‐60 years from rural Kilimanjaro, Tanzania. Women were offered HPV self‐sampling or traditional visual inspection of the cervix with acetic acid. If HPV self‐sampling was preferred, participants received instructions on self‐collection with an Evalyn Brush. A questionnaire was used to assess the acceptability and feasibility of the self‐sampling procedure for the participants and delivery of HPV results via text messages. A mobile text message platform was used to send private text messages with the screening results to the participants.ResultsA total of 1108 women were enrolled and self‐collected an HPV sample; 11.8% tested positive for high‐risk HPV. The majority (98.9%) agreed that they had no trouble in understanding the instructions on how to perform the self‐collection and that they would recommend it to a friend (94.5%) or as a standard screening method in Tanzania (95.5%). A minority of women experienced bleeding (2.4%) or pain (6%) while collecting the sample, while some were worried that they would get hurt (12.7%) or felt embarrassed (3.5%). The majority (98.4%) of women would like to receive the screening test results via text messages. Eighty‐two per cent of those who tested positive for high‐risk HPV attended the follow‐up appointment after receiving a text message reminder and an additional 16% attended after receiving both a text message and a phone call reminder whereas 2% did not attend follow up at all. Attendance was not influenced by age, marital status, education level, parity, or HIV status.ConclusionsHuman papillomavirus self‐sampling and text‐message feedback delivery are generally well‐perceived and accepted among rural Tanzanian women, and the majority of HPV‐positive women attended a follow‐up appointment after receiving their HPV results and follow‐up appointment via text messages. This screening method may have potential to be transferrable to other low‐income countries with a high incidence of cervical cancer and so improve cervical cancer screening attendances.

Acceptability of text messages and knowledge change for cervical cancer screening: a Tanzanian mixed methods study

ObjectivesTo investigate the acceptability of a text message intervention and evaluate if text messages could increase knowledge of cervical cancer and screening.DesignThis study was a substudy of a randomised controlled trial that used a mixed methods research design combining a quantitative questionnaire dataset and qualitative interview data. A before and after assessment was made of questionnaire responses. Acceptability was measured on a 6-point Likert scale and knowledge was measured through 16 binary true/false knowledge questions concerning cervical cancer and screening. Qualitative data were coded using a combined inductive–deductive approach.SettingOcean Road Cancer Institute in Dar es Salaam as well as Kilimanjaro Christian Medical Center and Mawenzi Regional hospital in the Kilimanjaro Region in Tanzania.ParticipantsHuman papillomavirus (HPV) positive women who had been randomised to the intervention group and received educative and reminder messages. Qualitative interviews were conducted with a subgroup of women in the intervention group.Interventions15 one-way educative and reminder text messages.ResultsA total of 115 women in the intervention group responded to both the baseline and follow-up questionnaire. Overall, women found it highly acceptable to receive text messages, and there was a trend towards acceptability rising between baseline and follow-up (mean: 0.22; 95% CI 0.00 to 0.44; p=0.05; t-statics=1.96). A significant increase in acceptability was found among the lowest educated and those who had not previously been screened. The qualitative interviews showed that the underlying reasons for the high acceptability rate were that the women felt someone cared for them and that the text messages were for their own benefits. The text messages did not improve the women’s knowledge on cervical cancer and screening.ConclusionsEducative and reminder text messages are highly acceptable among HPV-positive Tanzanian women; however, they do not increase the women’s knowledge of cervical cancer and screening.Trial registration numberclingov (NCT02509702).

Use of SMSs to Improve Attendance to Cervical Cancer Follow-up Screening

This study evaluates the effect of the SMS intervention 'Connected2Care' on the attendance rate to cervical cancer screening follow-up appointments.