Cervical cancer screening decentralized policy adaptation: an African rural-context-specific systematic literature review

Figures & data

Figure 1. PRISMA flow diagram.

Table 1. Description of studies (n = 19).

	n	%
Type of study
Descriptive Research	10	53
Correlation Study	5	26
Semi-Experimental Design	4	21
Experimental Design	0	0
Policy	0	0
Years published
2010 - 2015	17	89
2005 - 2009	2	11
2000 - 2004	0	0
<2000	0	0
Location of Study - 8 unique African countries
Nigeria	5	26
Malawi	2	11
Mozambique	2	11
Tanzania	2	11
Zambia	2	11
Ghana	1	5
Uganda	1	5
Zimbabwe	1	5
Study Includes Multiple Countries of Interest (at least one African country)	3	16
Ghana and Thailand	1	5*
Uganda and El Salvador	1	5*
Uganda, Peru, and Vietnam	1	5*
Country Income Groups According to World Bank
Classifications	10	53
Low income	9	47
Lower middle income	0	0
Upper middle income	0	0
High income
Clinical Approach
Visual Inspection with Cryotherapy as a Single Approach	12	63
Visual Inspection Only - with Cryotherapy Upon Later Visit	1	5
Visual Inspection Only - No Explicit Link to Cryotherapy	6	32

* Percentage is reflective of the three articles within the ‘Multiple countries of interest’ category.

Table 2. Partnerships table.

		Mangoma 2006	Sanghvi 2008	Peters 2010	Fort 2011	Levine 2011	Mwanahamuntu 2011	Quentin 2011	Audet 2012	Moon 2012	White 2012	Adetokunbi 2013	Chigbu 2013	Paul 2013	Perng 2013	Abiodun 2014	Chigbu 2014	Chigbu 2014	Maseko 2014	Osingada 2014	Total
Partnership Type	Academic institution - International			x	x	x	x	x		x	x			x	x					x	10
	Academic institution - National	x	x			x	x	x		x		x				x		x	x	x	11
	NGO - International		x		x	x			x			x									5
	NGO - Local									x		x			x						3
	Government / Health system - International						x		x					x							3
	Government / Health system - Local	x	x	x	x		x	x	x	x	x	x	x	x	x						13
	Government / Health system - National	x	x			x	x	x	x	x							x			x	9
	Total:	3	4	2	3	4	5	4	4	5	2	4	1	3	3	1	1	1	1	3

Table 3. Articles reporting demand-side barriers to access (n = 17).

	Articles		Mentions
	n	%	n = 62
Perceive	13	76
Health Llteracy – Patient awareness, knowledge, or education deficiency			12
Beliefs related to health and sickness – Pain or discomfort during the procedure			4
Trust and expectations – Distrust of screening methodology or efficacy or quality			4
Beliefs related to health and sickness – Side effects on sexual performance			2
Beliefs related to health and sickness – Stereotyped risk			1
Seek	10	59
Personal and social values – Permission required from family/lacking social support			9
Gender – Embarrassment or anxiety in the clinical setting			4
Culture – Belief that cervical cancer is a curse by foreigners/witchcraft			2
Reach	11	65
Geographic reach – Access challenges (e.g. multiple visits, distance)			9
Occupational flexibility – Do not have time			5
Living environment – Drought			1
Pay	12	71
Income vs poverty – Inability to pay (significant cost to the patient)			12
Engage	9	47
Self-management – Preventive care low priority/not primary reason to visit clinic			6
Caregiver support – Communication challenges (encouragement, teaching mode)			4

*Categories in bold font represent the Levesque framework, categories in italic font represent Levesque framework subcategories, and categories without boldface or italics represent the specific barrier mentioned in the papers.

**(n) = the number of papers reporting in this category. (%) = the percentage of 17 papers reporting demand-side barriers. (mentions) = the number of mentions in subcategories (note that one paper may include multiple subcategory mentions).

Table 4. Articles reporting supply-side barriers to access (n = 17).

	Articles		Mentions
	n	%	n = 62
Approachability	8	47
Outreach – Lack of outreach			8
Acceptability	3	18
Gender of provider – Female provider preferred but unavailable			3
Availability and accommodation	14	82
Providers – Health workforce shortages or low daily presence of service providers			11
Appointments, modes of service provision – Lack of follow-up			8
Facility characteristics – Lack of supplies or electricity needed for screening			7
Appointments, modes of service provision – Long wait			4
Providers – Burnout and turnover			4
Geographic location and context – Distance or spread in rural populations			3
Providers – Lack of administrative oversight of screening program			3
Facility characteristics – Functionality of equipment			2
Affordability	6	35
Direct costs of services and related expenses – Cost of screening			5
Indirect costs – Clinical space repairs and renovations			1
Appropriateness	3	18
Technical and interpersonal quality – Lack of training programs or advancement			3

*Categories in bold font represent the Levesque framework, categories in italic font represent Levesque framework subcategories, and categories without boldface or italics represent the specific barrier mentioned in the papers.

**(n) = the number of papers reporting in this category. (%) = the percentage of 17 papers reporting demand-side barriers. (mentions) = the number of mentions in subcategories (note that one paper may include multiple subcategory mentions).