Abstract
Cervical cancer is currently the second leading cause of cancer death among women in Ghana. Previous studies have identified lack of awareness, lack of perceived susceptibility, and stigmatizing beliefs as significant sociocultural barriers to cervical cancer screening among Ghanaian women. The purpose of this study was to assess the acceptability of evidence and theory-based, culturally relevant cervical cancer education intervention materials among Ghanaian healthcare providers. Central-location intercept questionnaires were completed by providers (n = 60) in the Greater Accra region of Ghana. Providers reviewed a poster, an audio message, and a brief educational video. The variables assessed included the reaction to the materials, the ability of the materials to attract the attention of the intended audience, the ability of the materials to communicate the main point of the cancer education message, and the reaction to cultural characteristics of the materials. The mean age of the providers (n = 60) was 30.6 years, and the majority (70.8%) were females. Most of the providers had a positive general reaction to the poster, audio message, and video. The majority found the materials to be motivating. Most of the providers found the information in the materials to be attention-getting, interesting, useful, direct/to the point, and related to someone like them. Very few providers (5%) indicated that they were confused by the images or messages used in the materials. The culturally relevant cervical cancer education materials were acceptable to Ghanaian healthcare providers. These materials may be effective in shared decision-making for cervical cancer screening.
Keywords: Cervical cancer prevention, Health communication, Ghana
Introduction
The global cervical cancer mortality rate has declined significantly over the last 20 years [1–4]. However, women in Low- and Middle-Income Countries (LMICs), such as Ghana, continue to experience elevated rates of cervical cancer mortality [1, 3, 5]. Cervical cancer can be prevented if precancerous lesions, cervical intraepithelial neoplasia (CIN), are detected and treated before they progress [6, 7]. Furthermore, early-stage cervical cancer is highly treatable, even in low resource settings [8, 9]. In Ghana, the incidence of CIN and early-stage cervical cancer are low in comparison to the incidence of late stage, invasive cervical cancer [10–13]. Cervical cancer also causes an excessively high age-standardized rate of Years Lived with Disability (YLDs) among Ghanaian women (46/100,000 women in Ghana vs. 28/100,000 women globally) [4, 10].
The cost of the treatment for late-stage cervical cancer is prohibitive for many Ghanaian women [10, 11]. Therefore, the early detection and treatment of CIN and early-stage cervical cancer should be the paramount goal of cervical cancer prevention and control in Ghana. However, less than 4% of Ghanaian women adhere to the World Health Organization’s cervical cancer screening guidelines [14]. Previous studies have shown that there are significant sociocultural barriers to cervical cancer screening among Ghanaian women, including (1) the lack of awareness about cervical cancer and cervical cancer screening, (2) the stigmatization of women with cervical cancer, and (3) the minimization of perceived susceptibility to cervical cancer due to stigmatizing beliefs [15–18]. These sociocultural barriers were found to be common among Ghanaian women of all education levels [16].
Evidence- and theory-based cervical cancer education interventions implemented in LMICs have been shown to increase cervical cancer awareness and intentions for getting screened [19–21]. Evidence has shown that health education interventions are most effective when they are culturally sensitive by being tailored to the surface structure and deep structure characteristics of the target audience [22–25]. In addition, to be effective, health promotion messages must be delivered through channels that will reach the target audience [26, 27]. Healthcare providers are an important channel for the dissemination of cancer education materials [28]. Currently, in Ghana, there is a significant lack of culturally sensitive cervical cancer education interventions that could be used by healthcare providers to engage their patients in shared decision-making about cervical cancer screening. A culturally sensitive cervical cancer education intervention was developed to fill that gap.
The goal of this study is to assess healthcare providers’ perceptions of culturally sensitive cervical cancer education intervention messages and materials. Sixty healthcare providers in the Greater Accra Region of Ghana participated in the study.
Methods
Design, Setting, and Participant Selection
A cross-sectional study was conducted in the Greater Accra Region of Ghana over a 2-week period during the Summer of 2023. A purposive sampling strategy was used to recruit healthcare providers to participate in the study. A sample size calculation was not warranted since the goal of the study was to assess the effectiveness of a health communication technique and was not intended to make interferences about a population [29]. We aimed to recruit 60 participants. A member of the research team who was a Ghanaian healthcare provider recruited participants and collected the data. The participants were recruited from health centers, polyclinics, district hospitals, and teaching hospitals through direct-person-to-person contact. Healthcare providers who expressed interest in participating in the study completed an eligibility screening assessment. Healthcare providers were eligible to participate in the study if they were at least 18 years old; currently working at a healthcare facility; could speak, hear, and comprehend English and Twi; and had no hearing, speaking or cognitive difficulties.
Message Testing
The cancer education intervention materials that were tested included a printed poster, an audio message, and a brief video presentation (Fig. 1). The intervention materials were developed based on findings from previous research conducted in Ghana by the senior member of the research team [18, 30, 31]. The messages in the materials were based on the Cultural Empowerment domain of the PEN-3 Model [32]. Positive, existential, and negative beliefs about cervical cancer risk factors and cervical cancer prevention were the focal points of the messages. For example, messages addressed cultural beliefs related to the causes of cervical cancer, for example, cervical cancer is caused by a curse.
Fig. 1.
Sample of the storyboard from the cervical cancer education video
The poster contained messages focused on aimed at increasing awareness about cervical cancer risk factors and the importance of early detection. The audio message was recorded in Twi and contained messages aimed at promoting the early detection of cervical cancer and debunking myths about cervical cancer risk factors. The video presentation used a photomatic format. The video was narrated in English by a Ghanaian. The messages in the video were focused on increasing awareness about HPV and the risk factors for cervical cancer. Participants were asked to complete a set of questionnaires after reviewing each of the materials.
The participants’ general reaction to the intervention material was assessed using a 5-point Likert scale. The responses ranged from “I like it very much” to “I do not like it at all.” A 3-point Likert scale ranging from “Agree” to “Disagree” was used to assess the participants’ thoughts about the following attributes of the intervention material: interesting, attention-getting, direct/to the point, useful information, and relatable. Close-ended questions that allowed participants to select multiple answers were used to determine whether the materials were able to effectively communicate the main point of the cancer education messages. The ability of the materials to motivate the participants to engage in cervical cancer prevention behaviors or seek additional information about cervical cancer screening was also assessed using a combination of close-ended and open-ended questions.
Data Analysis
Analysis of the data was done using IBM SPSS software for windows, Version 29.0. Descriptive statistics were computed for the responses to the close-ended questions and the sociodemographic data. The research team used a qualitative approach to assess the responses to the open-ended questions. The qualitative data was coded as favorable or unfavorable. There are no standards or guidelines to determine the appropriateness of health communication messages; therefore, the research team deemed the message to be appropriate or effective if the majority of participants (51% or more) responded favorably.
Ethical approval to conduct the study was received from the Ghana Health Service Ethics Review Committee, and the Institutional Review Board at the research team’s university in the United States. Verbal consent was obtained from each participant before participating in the study. Each participant received 100GHC ($10 USD) as honorarium for participating in study.
Results
Demographic Characteristics of the Participants
A total of 60 participants who met the eligibility criteria completed the message testing questionnaires for the intervention materials. The demographic characteristics of the participants are displayed in Table 1. The mean age of the participants was 30.6 years old. The majority of the participants (78.3%) were females. Most of the participants were nurses (42.9%), physicians (17.9%), or physician assistants (10.7%).
Table 1.
Demographic characteristics of the participants
| Demographic characteristic | n (%) |
|---|---|
| Age, mean ± SD | 30.58 ± 5.014 |
| Type of healthcare provider | |
| Nurse | 24 (42.9%) |
| Physician | 10 (17.9%) |
| Physician Assistant | 6 (10.7%) |
| Health assistant | 2 (3.3%) |
| Other | 4 (6.7%) |
| Midwife | 5 (8.3%) |
| Pharmacy assistant | 5 (8.3%) |
| Marital status | |
| Single | 37 (61.7%) |
| Married | 21 (35.0%) |
| Cohabitation | 2 (3.3%) |
| Ethnic group | |
| Akan | 34 (56.7%) |
| Ewe | 10 (16.7%) |
| Ga | 11(18.3%) |
| Hausa and other northern tribe | 4 (6.7%) |
| Other southern tribe | 1 (1.7%) |
| Religion | |
| Christian | 59 (98.3%) |
| Muslim | 1 (1.7%) |
| Gender | |
| Female | 47 (78.3%) |
| Male | 13 (21.7%) |
Poster
Approximately 82% of the participants liked the poster, half of whom said that they liked it very much. Nearly 87% of the participants found the messages on the poster to be motivating. Over 70% of participants were either motivated to get a cervical cancer screening or to learn more about cervical cancer. Four out of the 8 female participants who did not find the messages to be motivating said that the poster had good information, but they did not feel the need to take any action. Most of the female participants (91.5%) said that they were likely or somewhat likely to get cervical cancer screening, or to tell someone to get cervical cancer screening after viewing the poster. Over 78% of the participants agreed that the message on the poster had useful information and was direct/to the point, interesting, and attention-getting. Most of the female participants (86.4%) said that the message on the poster was related to them. Most of the participants were able to identify the main point of the poster. For example, 80% of the participants said that the main point of the poster is that every woman should have a cervical cancer screening, and 50% said that cervical cancer is preventable. Less than 10% of the participants said that the message on the poster was confusing. Some (3.3%) said the poster was not clear, and others (5.0%) were either confused about the images on the poster, or about certain facts such as the age at which a woman should begin getting screened.
Audio Message
Most of the participants (95%) liked the audio message, and more than half of whom (56.7%) said they liked it very much. All participants said the audio message was motivating. Most of the female participants indicated that the audio message motivated them to get a cervical cancer screening (80%) or motivated them to learn more about cervical cancer (66.7%). Most of the female participants (80.9%) said that they were either very likely, or somewhat likely (17.0%), to get screened or tell someone to get a cervical cancer screening after listening to the message. The majority of the participants (94.8%) agreed that the audio message was interesting, direct/to the point, attention-getting, and had useful information. Over 91% of the female participants agreed that the message was related to them. Over 96% of participants said there was nothing confusing in the audio message. Less than 2% of the participants were confused in general. For example, one participant stated that the message on the mode of getting infected with cervical cancer was not clear.
Video Lesson
Most of the participants who liked the video lesson (73.3%) said that they liked it very much.
All the participants said that they understood the terms used in the instructions for getting a cervical cancer screening. Almost all the participants (96.6%) agreed that the video presented good medical information. More than half of the participants (65%) said that some of the information in the video was new to them, while 10% of the participants said all the information was new to them. Almost all the participants (96.7%) said the video had very useful information. More than half of the participants (57.1%) said that the pictures in the video reminded them of people they know. Over 85% of the female participants said that they were very likely to get screened or tell someone about cervical cancer screening after viewing the video. While a few participants (about 5%) said that the video had too much information, the majority of participants (96.7%) found nothing confusing about the video.
Discussion
The cervical cancer education intervention materials that we developed were tailored to be culturally specific to the cervical cancer screening barriers that were identified in previous studies [30, 18, 31]. Our assessment of the participants’ general reactions to the intervention materials indicated that the majority of the participants believed that the messages in the poster, the video, and the audio recording were motivating. Nearly all of the participants were able to accurately identify the main point of the messages that were tested. The majority of the female participants indicated that the messages motivated them to get a cervical cancer screening or tell someone about it. Our findings are aligned with the results of other studies aimed at evaluating the effectiveness of culturally appropriate cancer education interventions. For example, Martei and her colleagues [33] found that culturally appropriate video narratives of Batswana breast cancer survivors had a high degree of acceptability and usability among breast cancer patients.
Based on frameworks for developing culturally sensitive health communication messages, we included value-based messages and images of people of African descent in the intervention poster and video [24, 25]. The central value-based messages in the intervention materials were aimed at debunking myths about cervical cancer and increasing knowledge about the importance of cervical cancer screening. Only a few participants in our study found the messages to be confusing. However, some participants indicated that the images of people did not look like people they know. Further probing of responses to that question suggests that the question was misconstrued by the participants. While we wanted to know if the pictures were representative of Ghanaian people, some participants thought that we were asking “Are these pictures of people you actually know?” Surface structure is a dimension of cultural sensitivity that is centered on increasing the face validity of health communication messages by including observable characteristics of a population [25]. The results of a prior study conducted by Singelis et al. [22] indicate that surface structure has an independent effect on the effectiveness of health communication messages. Therefore, further investigation into the acceptability of the surface structure of our cancer education materials is warranted.
Implications
Cervical cancer is a leading cause of cancer death among women in Ghana and other LMICs [34]. In 2020, the World Health Organization (WHO) launched an initiative aimed at eliminating cervical cancer globally by 2050 [35]. Experts suggest that increasing adherence to the WHO cervical cancer prevention guidelines for women in LMICs is a cost-effective way to avert DALYs due to cervical cancer [35–38]. Cervical cancer education interventions have shown promising results in some LMICs [20, 28]. Culturally sensitive cervical cancer education interventions should be a component of innovative multi-level strategies in order to have the greatest impact on the increasing adherence to cervical cancer prevention recommendation among women in Ghana and other LMICS [19, 39]. The findings of this study suggest that there is a need for cervical cancer education materials that are targeted towards the multiple cultural deep structure and surface structure characteristics of Ghanaian women.
Limitations
A strength of this study was that we included a variety of different types of healthcare providers to ensure that our sample was representative of the different types of healthcare providers in Ghana. We also included female and male healthcare providers, since male healthcare providers should be engaging their patients in shared decision making regarding cervical cancer screening. One limitation of the study is the possibility of social desirability bias. Another limitation of our study is that all of participants worked in the Greater Accra Region of Ghana. Therefore, the results of this study may not be transferable to people in other contexts.
Conclusion
Cervical cancer education interventions are an important component of multi-level strategies for eliminating cervical cancer in LMICs. Our culturally sensitive cervical cancer education intervention materials were found to be acceptable and effective at conveying cervical cancer prevention messages. The value-based messages were effective at motivating female participants to get a cervical cancer screening or tell someone about it. Further investigation into the effectiveness of the surface characteristics of the intervention materials is needed to ensure that the Ghanaians are properly represented in the intervention materials.
Acknowledgements
The authors would like to thank all of the healthcare providers that participated in this program.
Disclaimer
The contents this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of George Mason University.
Competing Interests
The authors do not have any competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Ginsburg O, Bray F, Coleman MP, Vanderpuye V, Eniu A, Kotha SR et al (2017) The global burden of women’s cancers: a grand challenge in global health. Lancet 389(10071):847–860. 10.1016/s0140-6736(16)31392-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Bruni L, Diaz M, Castellsague X, Ferrer E, Bosch FX, de Sanjose S (2010) Cervical human papillomavirus prevalence in 5 continents: meta-analysis of 1 million women with normal cytological findings. J Infect Dis 202:1789–1799. Meta-AnalysisResearchSupport,Non-U.S.Gov't [DOI] [PubMed] [Google Scholar]
- 3.Arbyn M, Castellsagué X, de Sanjosé S, Bruni L, Saraiya M, Bray F et al (2011) Worldwide burden of cervical cancer in 2008. Ann Oncol 22:2675–2686. 10.1093/annonc/mdr015 [DOI] [PubMed] [Google Scholar]
- 4.Bruni L, Barrionuevo-Rosas L, Albero G, Serrano B, Mena M, Gómez D, et al. (2017) Human papillomavirus and related diseases in Ghana. Summary Report ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre)
- 5.Olson B, Gribble B, Dias J, Curryer C, Vo K, Kowal P et al (2016) Cervical cancer screening programs and guidelines in low- and middle-income countries. Int J Gynaecol Obstet 134(3):239–246. 10.1016/j.ijgo.2016.03.011 [DOI] [PubMed] [Google Scholar]
- 6.(2013) WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. WHO Guidelines Approved by the Guidelines Review Committee. Geneva
- 7.Arrossi S, Temin S, Garland S, Eckert LO, Bhatla N, Castellsague X et al (2017) Primary prevention of cervical cancer: American Society of Clinical Oncology Resource-Stratified Guideline. J Glob Oncol 3(5):611–634. 10.1200/JGO.2016.008151 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Jeronimo J, Castle PE, Temin S, Denny L, Gupta V, Kim JJ et al (2017) Secondary prevention of cervical cancer: ASCO Resource-Stratified Clinical Practice Guideline. J Glob Oncol 3(5):635–657. 10.1200/JGO.2016.006577 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Comprehensive Cervical Cancer Control: A Guide to Essential Practice. (2014). 2nd edn. World Health Organization. [PubMed]
- 10.Nartey Y, Hill PC, Amo-Antwi K, Nyarko KM, Yarney J, Cox B (2017) Cervical cancer in the greater Accra and Ashanti regions of Ghana. J Glob Oncol 3(6):782–790. 10.1200/jgo.2016.005744 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Nartey Y, Hill PC, Amo-Antwi K, Nyarko KM, Yarney J, Cox B (2017) factors contributing to the low survival among women with a diagnosis of invasive cervical cancer in Ghana. Int J Gynecol Cancer 27(9):1926–1934. 10.1097/igc.0000000000001088 [DOI] [PubMed] [Google Scholar]
- 12.Nartey Y, Hill PC, Amo-Antwi K, Nyarko KM, Yarney J, Cox B (2018) Characteristics of women diagnosed with invasive cervical cancer in Ghana. Asian Pac J Cancer Prev 19(2):357–363. 10.22034/apjcp.2018.19.2.357 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Vulpe H, Asamoah FA, Maganti M, Vanderpuye V, Fyles A, Yarney J (2018) External beam radiation therapy and brachytherapy for cervical cancer: the experience of the National Centre For Radiotherapy in Accra, Ghana. Int J Radiat Oncol Biol Phys 100(5):1246–1253. 10.1016/j.ijrobp.2017.12.270 [DOI] [PubMed] [Google Scholar]
- 14.ICO/IARC HPV Information Centre (2023) Ghana human papillomavirus and related cancers, Fact Sheet 2023
- 15.Williams MS, Kenu E, Dzubey I, Dennis-Antwi JA, Fontaine K (2018) A qualitative study of cervical cancer and cervical cancer screening awareness among nurses in Ghana. Health Care Women Int 39(5):584–594. 10.1080/07399332.2018.1424169 [DOI] [PubMed] [Google Scholar]
- 16.Williams MS, Kenu E, Adanu A, Yalley RA, Lawoe NK, Dotse AS et al (2019) Awareness and beliefs about cervical cancer, the HPV vaccine, and cervical cancer screening among Ghanaian women with diverse education levels. J Cancer Educ 34(5):897–903. 10.1007/s13187-018-1392-y [DOI] [PubMed] [Google Scholar]
- 17.Williams MS (2014) A qualitative assessment of the social cultural factors that influence cervical cancer screening behaviors and the health communication preferences of women in Kumasi, Ghana. J Cancer Education 29(3):555–562. 10.1007/s13187-014-0611-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Williams M, Kuffour G, Ekuadzi E, Yeboah M, El Duah M, Tuffour P (2013) Assessment of psychological barriers to cervical cancer screening among women in Kumasi, Ghana using a mixed methods approach. Afr Health Sci 13:1048–1055 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Johnson LG, Armstrong A, Joyce CM, Teitelman AM, Buttenheim AM (2018) Implementation strategies to improve cervical cancer prevention in sub-Saharan Africa: a systematic review. Implement Sci 13(1):28. 10.1186/s13012-018-0718-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Lott BE, Trejo MJ, Baum C, McClelland DJ, Adsul P, Madhivanan P et al (2020) Interventions to increase uptake of cervical screening in sub-Saharan Africa: a scoping review using the integrated behavioral model. BMC Public Health 20(1):654. 10.1186/s12889-020-08777-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Mariño JM, Nunes LMP, Ali Y, Tonhi LDC, Salvetti MG (2023) Educational interventions for cervical cancer prevention: a scoping review. Rev Bras Enferm 76(5):e20230018. 10.1590/0034-7167-2023-0018 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Singelis TM, Garcia RI, Barker JC, Davis RE (2018) An experimental test of the two-dimensional theory of cultural sensitivity in health communication. J Health Commun 23(4):321–328. 10.1080/10810730.2018.1443526 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Betsch C, Böhm R, Airhihenbuwa CO, Butler R, Chapman GB, Haase N et al (2016) Improving medical decision making and health promotion through culture-sensitive health communication: an agenda for science and practice. Med Decis Making 36(7):811–833. 10.1177/0272989x15600434 [DOI] [PubMed] [Google Scholar]
- 24.Griffith DM, Efird CR, Baskin ML, Webb Hooper M, Davis RE, Resnicow K (2023) Cultural sensitivity and cultural tailoring: lessons learned and refinements after two decades of incorporating culture in health communication research. Annu Rev Public Health. 10.1146/annurev-publhealth-060722-031158 [DOI] [PubMed] [Google Scholar]
- 25.Resnicow K, Baranowski T, Ahluwalia JS, Braithwaite RL (1999) Cultural sensitivity in public health: defined and demystified. Ethn Dis 9:10–21 (ResearchSupport,U.S.Gov't,P.H.S.Review) [PubMed] [Google Scholar]
- 26.Kreuter MW, Lukwago SN, Bucholtz RD, Clark EM, Sanders-Thompson V (2003) Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Educ Behav 30:133–146 [DOI] [PubMed]
- 27.Iwelunmor J, Newsome V, Airhihenbuwa CO (2014) Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions. Ethn Health 19(1):20–46. 10.1080/13557858.2013.857768 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Okyere J, Aboagye RG, Seidu AA, Asare BY, Mwamba B, Ahinkorah BO (2022) Towards a cervical cancer-free future: women’s healthcare decision making and cervical cancer screening uptake in sub-Saharan Africa. BMJ Open 12(7):e058026. 10.1136/bmjopen-2021-058026 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.U. S. Department of Health and Human Services (2008) Pink book-making health communication programs work. National Cancer Institute
- 30.Williams M, Amoateng P (2012) Knowledge and beliefs about cervical cancer screening among men in Kumasi, Ghana. Ghana Med J 46(3):147–151 [PMC free article] [PubMed] [Google Scholar]
- 31.Williams MS (2014) A qualitative assessment of the social cultural factors that influence cervical cancer screening behaviors and the health communication preferences of women in Kumasi, Ghana. J Cancer Education 2014:1–8. 10.1007/s13187-014-0611-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Airhihenbuwa CO (1990) A conceptual model for culturally appropriate health education programs in developing countries. Int Quart Commun Health Education 11:53–62. 10.2190/LPKH-PMPJ-DBW9-FP6X [DOI] [PubMed] [Google Scholar]
- 33.Martei YM, Mokokwe L, Ngwako N, Kebuang K, Setlhako DI, Gabaatlhole G et al (2024) Development, acceptability and usability of culturally appropriate survivor narrative videos for breast cancer treatment in Botswana: a pilot study. BMJ Open 14(1):e073867. 10.1136/bmjopen-2023-073867 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Singh D, Vignat J, Lorenzoni V, Eslahi M, Ginsburg O, Lauby-Secretan B et al (2023) Global estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO Global Cervical Cancer Elimination Initiative. Lancet Glob Health 11(2):e197–e206. 10.1016/s2214-109x(22)00501-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.World Health Organization (2020) Global strategy to accelerate the elimination of cervical cancer as a public health problem. World Health Organization
- 36.Kim JJ, Campos NG, O’Shea M, Diaz M, Mutyaba I (2013) Model-based impact and cost-effectiveness of cervical cancer prevention in sub-Saharan Africa. Vaccine 31(Suppl 5):F60–F72. 10.1016/j.vaccine.2012.07.093 [DOI] [PubMed]
- 37.Simms KT, Keane A, Nguyen DTN, Caruana M, Hall MT, Lui G et al (2023) Benefits, harms and cost-effectiveness of cervical screening, triage and treatment strategies for women in the general population. Nat Med 29(12):3050–3058. 10.1038/s41591-023-02600-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Simms KT, Steinberg J, Caruana M, Smith MA, Jie-Bin L, Soerjomataram I et al (2019) Impact of scaled up human papillomavirus vaccination and cervical screening and the potential for global elimination of cervical cancer in 181 countries, 2020–99: a modelling study. Lancet Oncology 20(3):394–407. 10.1016/S1470-2045(18)30836-2 [DOI] [PubMed] [Google Scholar]
- 39.Atnafu DD, Khatri R, Assefa Y (2024) Drivers of cervical cancer prevention and management in sub-Saharan Africa: a qualitative synthesis of mixed studies. Health Res Policy Syst 22(1):21. 10.1186/s12961-023-01094-3 [DOI] [PMC free article] [PubMed] [Google Scholar]