Vibeke Rasch

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.

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.

The association between human papillomavirus and cervical high‐grade cytology among HIV‐positive and HIV‐negative Tanzanian women: A cross‐sectional study

AbstractIntroductionHuman papillomavirus (HPV) is the causative agent of precancerous lesions and cervical cancer, cervical cancer being the leading cause of deaths in Tanzanian women. Early detection and treatment of precancerous lesions are important in the prevention of cervical cancer cases.Material and methodsWe conducted a cross‐sectional study among 3390 Tanzanian women aged 25‐60 years. Information on lifestyle habits was collected, and women underwent gynecological examination with collection of cervical cells for conventional cytological and HPV testing. Blood samples were tested for HIV. The association between cervical high‐grade cytology (HGC) and potential risk factors was examined using multivariable logistic regression adjusting for age and high‐risk HPV (HR‐HPV).ResultsThe prevalence of HGC was 3.6% and of low‐grade cytology was 8.3%. In women who were both HR‐HPV‐positive and HIV‐positive, the prevalence of HGC was 28.3%. It increased by age and was 47% among women aged 50‐60 years. Women, who had their sexual debut at age 9‐15 years and 16‐18 years, respectively, had 2.5 and 2.4 times increased odds of HGC compared with women whose sexual debut was at age 21 years and older. HIV‐positive women had increased odds of HGC in comparison with HIV‐negative women after adjustment for age (odds ratio [OR] 2.95, 95% CI 1.92‐4.54). HR‐HPV‐positive women had nearly 100‐fold increased odds of HGC compared with HR‐HPV‐negative women (OR 96.6, 95% CI 48.0‐194), and this estimate was higher among HIV‐positive women (OR 152.2, 95% CI 36.1‐642.0).ConclusionsIncreasing age, early age at first intercourse, HR‐HPV, and HIV infections were associated with a substantially increased risk of HGC.

Agreement between careHPV and hybrid capture 2 in detecting high‐risk HPV in women in Tanzania

AbstractIntroductionVisual inspection of the cervix with acetic acid is used to control the burden of cervical cancer in low‐ and middle‐income countries. This method has some limitations and HPV DNA testing may be an alternative, but it is expensive and requires a laboratory setup. Cheaper and faster HPV tests have been developed. This study describe the agreement between a fast HPV test (careHPV) and hybrid capture 2 (HC2) in detection of high‐risk HPV among Tanzanian women.Material and methodsThe study involved women attending routine cervical cancer screening at the Ocean Road Cancer Institute and Kilimanjaro Christian Medical Centre in Tanzania. The women were offered HIV testing. Two cervical samples were subsequently obtained; the first sample was processed at the clinics using careHPV and the second sample was transported to Denmark and Germany for cytology and HC2 analysis. Kappa statistic was calculated to assess the agreement between careHPV and HC2. The sensitivity, specificity and predictive values of careHPV were calculated using HC2 as reference. The analyses were done for the overall study population and stratified by testing site and HIV status.ResultsA total of 4080 women were enrolled, with 437 being excluded due to invalid information, lack of careHPV or HC2 results. Overall agreement between the tests was substantial with a kappa value of 0.69 (95% confidence interval [CI] 0.66‐0.72). The sensitivity and specificity of careHPV was 90.7% (95% CI 89.6‐91.8) and 84.2% (95% CI 81.2–86.8), respectively. The agreement was similar in the stratified analyses where the kappa values were 0.75 (95% CI 0.70‐0.79) in women aged 25‐34, 0.66 (95% CI 0.62‐0.70) in women aged 35–60, 0.73 (95% CI 0.70‐0.77) at the Ocean Road Cancer Institute, 0.64 (95% CI 0.60‐0.69) at the Kilimanjaro Christian Medical Center, 0.73 (95% CI 0.68‐0.79) in HIV‐positive and 0.66 (95% CI 0.63‐0.70) in HIV‐negative women. The kappa value of 0.64 (95% CI 0.39‐0.88) for cervical high‐grade lesions indicates a substantial agreement between careHPV and HC2 in detecting HPV among women with cervical high‐grade lesions.ConclusionsA substantial agreement was found between careHPV and HC2 in detecting HPV overall as well as detecting HPV among women with cervical high‐grade lesions. However, given the limited resources available in low and middle‐income countries, the HPV testing assay should be weighed against the cost‐effectiveness of the test.

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.