A new model for cervical cancer screening in Cambodian garment workers

Abstract

Introduction

Cervical cancer remains a major health concern in low-resource settings, with Cambodian women experiencing some of the highest rates due to limited screening access. 15% of all Cambodian women work in the garment industry; very few of which have ever been screened for cervical cancer. Achieving the WHO’s 90–70–90 cervical cancer elimination target will require new service-delivery models capable of reaching large numbers of women in high-risk or underserved populations.

Methods

A cross-sectional feasibility study was conducted, screening 2690 female garment workers aged 25–49 across nine factories in Cambodia. Mobile clinics were set up in factories to facilitate the screening and treatment process. Participants self-collected swabs for human papillomavirus (HPV) testing and results were communicated directly to participants via text message. Women with positive results were scheduled for digital colposcopy and concurrent treatment with thermal ablation or large loop excision of the transformation zone.

Results

Of the 2690 workers screened, 341 (12.7%) tested positive for HPV, of whom 314 (92%) underwent colposcopy and 311 had biopsies. Only seven of the 2690 self-swab specimens were found to be inadequate (ie, insufficient DNA) for testing (0.26%). There were 17 cases of CIN2+ lesions (cervical intraepithelial neoplasia), including one adenocarcinoma.

Conclusions

This study demonstrates that implementing HPV-based cervical cancer screening with mobile clinics in garment factories is feasible and highly accepted among workers. Such programmes not only enhance early detection and treatment of cervical lesions but also improve workforce stability and could serve as a model for other industrial sectors in low-resource settings. This screening model, which facilitates large numbers of women to be efficiently screened with self-swab HPV testing, may help Cambodia progress toward achieving the WHO’s 70% screening target. Integration of workplace-based models with national referral systems for more advanced treatment (when necessary) may reduce loss-to-follow-up and strengthen continuity of care.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Cervical cancer is a leading cause of cancer-related mortality in low-resource settings such as Cambodia, where traditional cytology-based screening is often infeasible, resulting in the need for simplified, high-volume screening approaches targeting underserved populations like garment factory workers.

WHAT THIS STUDY ADDS

• This study demonstrates that a rapid, large-scale cervical cancer screening programme using human papillomavirus (HPV) self-collection, onsite testing, and same-day triage and treatment is both feasible and highly acceptable in Cambodian garment factories. By integrating novel technologies and close collaboration with factory management and worker advocacy groups, our approach achieved strong uptake and follow-up for HPV-positive cases, highlighting a practical model for other industrial settings.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Workplace-based screening may help Cambodia move toward the WHO’s 70% screening target. Integration with national referral and treatment systems for advanced care could strengthen programme continuity. This model may be adaptable to other large female workforce settings in low-income and middle-income countries.

Introduction

Cervical cancer is the third most common cancer among women worldwide with an estimated 662 301 new cases annually and 348 874 deaths.¹ Due to increased prevention measures in developed countries, up to 85% of the disease burden lies in developing countries with limited resources for both human papillomavirus (HPV) vaccination and cervical cancer screening.² In Cambodia, cervical cancer is the leading female cancer with 1515 new cases diagnosed each year and 795 deaths.³ Cervical cancer rates are specifically high in Cambodia due to lack of widespread prevention; cervical cancer deaths have surpassed maternity-related deaths, making it a leading healthcare priority.⁴ Prior population-based studies in Cambodia have shown that the high-risk HPV (hrHPV) positivity rate is approximately 5%, which is similar to or slightly lower than the global average for women with normal cytology.^{5 6} The most commonly detected hrHPV types in Cambodian screening cohorts include HPV-16, along with regionally prevalent types such as HPV-52 and HPV-51, reflecting patterns observed across East and Southeast Asia.⁶ Despite these comparable infection rates, Cambodia experiences a higher-than-average cervical cancer incidence, estimated at approximately 15 cases per 100 000 women, compared with the global mean of about 13 per 100 000.⁷ Evidence consistently indicates that this elevated disease burden is not driven by increased HPV prevalence or higher prevalence of more oncogenic strains, but instead by historically limited cervical cancer screening and delayed access to treatment. Due to limited healthcare resources throughout Cambodia, the vast majority of women have never been screened for cervical cancer.^{3 4} Additionally, due to limited economic resources and scarcity of trained healthcare providers, the traditional multi-step strategy of cytology (Pap smear), colposcopy, biopsy and subsequent treatment of women diagnosed with cervical dysplasia is not feasible for the vast majority of Cambodian women.^{3 4}

In 2020, the WHO launched its global cervical cancer elimination initiative. This initiative calls for 90% of girls to be fully vaccinated against HPV by age 15 by the year 2030, 70% of women to be screened with a high-performance test at ages 35 and again at 45 by 2030, and 90% of women identified with cervical precancer or cancer to receive appropriate treatment by 2030.⁸ These milestones were selected because modelling studies conducted in 2019–2020 showed that achieving them would place all countries on a trajectory toward eliminating cervical cancer as a public health problem within the 21st century. The WHO emphasised equitable access and prioritising low-income and middle-income countries (LMICs) where the majority of cervical cancer deaths occur. Achieving the 70% screening target and 90% treatment target in Cambodia requires new service-delivery models that reach populations unable to access traditional clinic-based cytology screening.

Several new technologies have been developed to simplify screening for cervical precancer and cancer; these include isothermal PCR HPV testing and digital colposcopy.⁹ These new technologies, when combined, can be used in rapid, high-volume, inexpensive, cervical cancer screening programmes.⁹ The HPV-Automated Visual Evaluation (PAVE) Study is an international consortium study of up to 50 000 women sponsored in part by the US National Cancer Institute designed to evaluate a novel cervical screen-triage-treat strategy for resource-limited settings as part of a global strategy to reduce cervical cancer burden.¹⁰

The Cambodian section of the PAVE study is projected to screen 10 000–15 000 women between the ages of 25 and 49. Several different cohorts of women are being screened to help the Cambodian Ministry of Health identify groups that have the highest disease burden as well as to determine specific barriers to screening in each cohort of women. Specifically, the groups to be studied include women living with HIV enrolled in the country’s established HIV clinics, rural farm workers, female entertainment workers and garment factory workers.

The foundation of this study, and the broader PAVE study, is its reliance on HPV detection on self-swab specimens. Prior studies from Cambodia and the broader Asian region demonstrate that women are generally comfortable performing HPV self-swabbing. A recent cross-sectional study at Cambodia’s National Maternal and Child Health Centre found high concordance between self-collected and clinician-collected HPV samples; most women reported that the self-sampling instructions were ‘easy’ or ‘very easy’ to understand, felt confident performing self-collection and described self-sampling as less embarrassing than clinician sampling, indicating good acceptability.⁵ In Malaysia, a Cancer Prevention Research study on vaginal self-sampling for HPV testing reported that self-sampling was highly acceptable and was actually the preferred primary screening method among participating women.¹¹ Complementing these Southeast and East Asian data, Goldstein et al showed in rural Yunnan Province, China, that 98% of women felt comfortable performing HPV self-sampling, 98% found it acceptable and nearly two-thirds preferred self-swabs to provider-collected samples, further supporting that women in diverse Asian settings readily accept and are comfortable with HPV self-sampling when adequately instructed and supported.¹² The Cambodian garment industry has over one million employees and accounts for over 80% of the country’s export revenue. 89% of garment workers are women, and approximately 15% of all Cambodian women work in garment factories.¹³,¹⁵ Garment workers (GW) face barriers including rigid production schedules, transportation challenges, childcare obligations and limited health literacy, all of which lead to low uptake of cervical cancer screening services. The vast majority of GW are between 25 and 49 years old. Implementation of a cervical cancer screening programme in a garment factory setting might be ideal because there are large numbers of women who have never been screened for cervical cancer in the appropriate age range for screening. Additionally, as these jobs are relatively well compensated, these factory jobs have a relatively low turnover, which in turn may lead to a high follow-up rate. Additionally, since Cambodian law requires garment manufacturers to provide basic healthcare to their employees, the economic burden of cervical cancer screening could potentially be assumed by the manufacturers, rather than relying on limited government funding. Lastly, from both a human rights and public health perspective, offering cervical cancer screening in garment factories could be a win-win proposition for both employees and employers.

The purpose of this work is to evaluate the feasibility of a factory-based, see-and-treat cervical screening programme for female GW.

Material and methods

The study population consisted of 2690 women working in nine garment factories between the ages of 25 and 49 years who have not been screened for cervical cancer within the past 5 years. Women were excluded if they were pregnant, had previous treatment for cervical cancer or had a hysterectomy. The sample size was determined by the number of women working in each factory that were willing to consent to screening.

Patient and public involvement

Prior to the initiation of the study, members of the study team had several meetings in a Special Economic Zone (SEZ) with stakeholder groups including the Garment Manufacturers of Cambodia; Sipar (an educational non-governmental organization (NGO) that provides health education to GW); WeHouse (a counselling centre for GW); Better Factories Cambodia (BFC is the foundational programme of Better Work, which is a joint programme between the International Labor Organization and the International Finance Corporation, a member of the World Bank Group) human resource representatives from many of the factories within the SEZ; and GW representatives from each factory. At the suggestion of these stakeholders, educational sessions were held in the SEZ outlining the role of HPV in cervical cancer and methods of cervical cancer screening. Group educational sessions occurred during scheduled breaks or shift transitions, consistent with prior workplace health interventions. Sessions lasted approximately 30 min and included demonstrations on self-collection technique. Additionally, educational videos were produced that covered these topics as well as the procedures that would be followed during the study (online supplemental video 1). Lastly, the protocol was reviewed, modified, approved and supported by the Cambodian Ministry of Health. Subsequent Institutional Review Board (IRB) approval for the study was obtained from the Cambodian National Ethics Committee for Health Research (NECHR).

Mobile clinics were then set up at each garment factory. After watching the aforementioned educational videos, informed consent was obtained from study participants. A trained study provider then explained to the participants how to self-collect a vaginal sample for HPV testing and answered any questions (online supplemental video 1). The women self-collected the vaginal sample using a dry swab FLOQSwab (Copan) in a private single-person tent. If the participant had difficulty in self-collection, a provider was able to assist her in collecting the vaginal sample collection.

The swabs were then tested using the ScreenFire HPV risk-stratification (RS) assay (ScreenFire) (US patent 11091799, Atila Biosystems Inc, Sunnyvale, CA, USA).¹⁶ ScreenFire is an isothermal nucleic acid amplification test designed to qualitatively detect high-risk human papillomavirus (HPV) DNA.¹⁶ It targets 13 high-risk HPV genotypes and reports them in four risk-stratified channels: HPV16; HPV18/45; HPV31/33/35/52/58; and HPV39/51/56/59/68. It was developed for cervical cancer screening in low-resource settings and can run up to 96 samples plus controls in roughly 1 hour of amplification time using standard 96-well plates. ScreenFire is compatible with multiple specimen types, including self-collected or provider-collected vaginal/cervical dry swabs. The assay uses fluorescence output from the four risk channels rather than full genotype-specific results, providing clinically actionable risk stratification aligned with oncogenic potential.¹⁶ Comparative studies show high agreement with established HPV assays and strong sensitivity for detecting high-grade cervical lesions (CIN2+ [cervical intraepithelial neoplasia]). ScreenFire also includes an internal control for sample quality guidance.¹⁶ The cost is approximately US$6 per sample. The test reagents are stable at room temperature for 2 weeks and at 4°C for up to a month. The test platform is small and versatile (the same platform can test for other sexually transmitted infections and COVID-19), making it an ideal choice for high throughput same-day screen-and-treat programmes in low-resource settings.¹⁶

The obtained vaginal self-swabs were placed into an Atila sample tube, heated to 95°C for 30 min to lyse cells and release HPV DNA, and then 5 µL was pipetted directly into ScreenFire reaction wells, eliminating the need for column extraction or multistep purification.

Results of the HPV tests were then sent via text message (SMS (Short Message Service)) to each study participant. Almost all GW had access to a cell phone; however, if a GW did not have a cell phone, or if she were uncomfortable with getting an SMS, she was able to schedule an appointment with a study coordinator to get her results. Women screening HPV-negative were informed of their results, reassured about their low subsequent risk of cervical cancer, and their participation in the study then ended. Women screened HPV-positive were contacted via both SMS and telephone and scheduled for additional testing and treatment at clinics set up at each participating factory.

Women with HPV-positive results underwent a speculum exam with an application of 5% acetic acid. As part of the PAVE protocol, cervical images were collected by a trained study provider using a portable digital colposcope (Iris, Liger Medical LLC, Lehi, UT, USA) (figure 1). Images were obtained prior to the administration of the acetic acid and at 60 s after application of the acetic acid. Clinicians recorded their colposcopic impression based on International Federation of Cervical Pathology and Colposcopy terminology (normal, low-grade (thin acetowhite, fine punctation/mosaicism), high-grade (dense acetowhite, abnormal blood vessels, coarse punctation/mosaicism), suspicious for cancer (exophytic masses, ulceration, necrosis, etc)). The automated visual evaluation (AVE) reading of these images is not being used in this analysis. In this pilot project, as there was a low likelihood of loss to follow-up, colposcopy was performed 3–14 days after initial HPV testing. However, previous studies in rural China, using a very similar protocol, demonstrated that a thousand women a day can be screened and treated on the same day.⁹

Figure 1. Portable digital colposcope (Iris, Liger Medical).

Following image capture, pathology specimens were collected. Exocervical biopsies were obtained in all acetowhite areas using a brush biopsy device Softbiopsy (Histologic LLC, Anaheim, CA, USA). Endocervical biopsy specimens were then obtained with SoftECC if the acetowhite lesion(s) extended into the endocervical canal or if no acetowhite lesions were visible on the exocervix. As such, almost all women with HPV-positive results had a histologic diagnosis. Women who then met the 2019 WHO criteria for thermal ablation of cervical precancerous lesions had thermal ablation using the Iris device.¹⁷

Biopsies were then sent for histopathologic evaluation by a certified pathologist (TV). All histopathologic H&E slides were then scanned by a whole-slide scanner. All H&E slides evaluated initially as CIN1+, cervicitis, and 25% of slides that were initially read as negative for dysplasia were re-reviewed for quality assurance (QA) by an expert pathologist (DG). If either pathologist evaluated the initial biopsy as CIN2+ or carcinoma, the study participant was recontacted and received a large loop excision of the transformation zone (LLETZ). All women with carcinoma on either the initial biopsy specimen or the LLETZ specimen were then referred seamlessly for appropriate care by gynaecologic oncology at a tertiary care governmental hospital.

Results

Between 13 December 2022 and 18 March 2024, 2690 GWs meeting the inclusion criteria were enrolled and screened. The average age was 35 years, and participants had an average parity of 1.7 children (table 1). HPV positivity did not vary significantly by age (data not shown). Only seven of the 2690 self-swab specimens were found to be inadequate (ie, insufficient DNA) for testing (0.26%). Those participants were offered repeat testing.

Table 1. Characteristics of study population and HPV test.

	N (%)	HPV+ve (%)
Age at enrollment
Range	25–49
Mean (Std deviation)	35 (5.8)
Parity
Range	0–7
Mean (Std deviation)	1.7 (1.1)
Factory
A	581 (21.6	49 (8.4)
B	416 (15.5)	46 (11.1)
C	45 (1.7)	7 (15.6)
D	253 (9.4)	32 (12.7)
E	131 (4.9)	31 (23.7)
F	112 (4.2)	25 (22.3)
H	302 (11.2)	55 (18.2)
I	416 (15.5)	50 (12.0)
J	434 (16.1)	46 (10.6)
ALL	2690 (100)	341 (12.7)

HPV, human papillomavirus.

Among all GWs, 341 tested positive for HPV (12.7%), with variability across factories ranging from 8.4% to 23.7%. The two factories closest to Phnom Penh had the highest rates of HPV positivity, suggesting higher rates in urban areas of Cambodia. Table 2 shows the HPV-type distribution among those with a positive test. The data are presented per infection and use a hierarchical approach when more than one channel is positive. HPV-16 was the least common but accounted for 17% of all positives. The most common channel was the one containing HPV types 39, 51, 56, 59 and 68, with 41.9% positivity and 36.7% in the hierarchical approach.

Table 2. Human papillomavirus test positivity by channel, all infections (non-hierarchical) and assigning a hierarchical order when multiple infections were detected (hierarchical).

HPV type	HPV infection number	HPV+ve %	Hierarchical number	Hierarchical HPV %
HPV16	58	15.3	58	17.0
HPV18/45	92	24.2	83	24.3
HPV31+	87	22.8	75	22.0
HPV39+	143	37.6	125	36.7
Total	380	100	341	100

HPV, human papillomavirus.

Women with a positive HPV test were referred for colposcopy and treatment. Of the 341 hrHPV+ women, 314 (92%) underwent colposcopy, and 311 of those who underwent colposcopy had at least one brush biopsy (99%).

Colposcopy was positive in 60.5% of hrHPV+ women. There were 17 cases of CIN2+ lesions, including one adenocarcinoma. 27 hrHPV+ women were either lost to follow-up or refused colposcopy. The maximum number of hrHPV+ women evaluated and treated in 1 day with the Iris device was 62. It should be noted that the HIV status of the women screened was not determined, though a previous study of Cambodian GW showed a HIV prevalence rate of only 0.9%.¹⁸

Table 3 describes the histological results by HPV channel positivity of the 311 women who had both colposcopy and biopsy. One adenocarcinoma was detected, along with seven cases of CIN3 (cervical intraepithelial neoplasia), nine cases of CIN2 and 294 cases (94.1%) with less than CIN2. Compared with women with less than CIN2, cases diagnosed with CIN2+ were more common among those who were HPV16 positive (41.2% vs 14.8%, yield ratio=2.8) and those positive for Channel HPV31+ (29.4% vs 21.5%, yield ratio=1.37). In contrast, Channel 39+ was less prevalent among women with CIN2+ (29.4% vs 39.2%, yield ratio=0.75), although over one-third of the women were positive for this channel (38.7%).

Table 3. Histopathology yield by HPV channel results among women with a positive HPV result and subsequently had colposcopy and biopsy.

	Total	%	HPV16	HPV18/45	HPV31+	HPV39+
CIN2+ (%)	17	5.9	7 (41.2%)	0	5 (29.4%)	5 (29.4%)
Adenocarcinoma	1	0.4	1	0	0	0
CIN3	7	2.4	5	0	2	0
CIN2	9	3.1	1	0	3	5
<CIN2 (%)	294	94.1	43 (14.8%)	72 (24.4%)	64 (21.5%)	115 (39.2%)
CIN1	22	7.0	5	4	6	5
Cervicitis	167	53.7	19	38	38	96
Normal	104	33.5	19	30	20	78
Total (%)	311	100	50 (16.4%)	72 (22.9%)	69 (21.9%)	120 (38.8%)

HPV is grouped based on a hierarchical classification. Bolded groups represent two major subgroups: CIN2+ lesions and <CIN2 lesions.

HPV, human papillomavirus.

Thermal ablation was applied to 147 women; 13 (3/10) had conisation/surgery, and one woman was referred for oncological management. Thermal ablation was applied to women with a positive HPV result for HPV16, 18 or 45, and/or a positive colposcopic evaluation.

There was greater than a 97% concordance in the histopathologic diagnoses between the initial pathologist and the QA pathologist.

Discussion

The results of this study demonstrate that a rapid, high-volume cervical cancer screening programme in Cambodian GW can be highly successful from both medical and public health perspectives. This programme had a high degree of acceptance by the GW, worker advocacy organisations, government health authorities and factory managers.

This screening and treatment model aligns with the WHO’s cervical cancer elimination goals by bringing high-performance HPV testing directly to women who rarely access clinic-based screening. Additionally, in April 2019, the Cambodian Ministry of Health’s Department of Preventative Medicine released a National Action Plan for Cervical Cancer Prevention and Control 2019–2023 which was developed as a collaboration between Cambodian authorities, the WHO and the United Nations Populations Fund.¹⁹ This plan provided for both primary prevention of cervical cancer with vaccination, secondary prevention with cervical cancer screening and treatment of dysplasia, and tertiary treatment and palliative care for advanced cancer. The main strategy for screening in this plan was visualisation with acetic acid (VIA) though there was a provision for an exploratory project of HPV testing. Unfortunately, while a timeline was outlined in the National Action Plan, due to the lack of funding, lack of medical infrastructure, limited trained providers and the COVID-19 pandemic, these ambitious plans have not been initiated in any significant way. However, our study has demonstrated an updated screening and treatment strategy that can be implemented effectively, rapidly and efficiently to screen the millions of Cambodian women who have never been screened for cervical cancer.

PAVE study

The PAVE study is an ongoing large-scale, cervical cancer screening trial in nine LMICs: Brazil, El Salvador, Honduras, Dominican Republic, Nigeria, Tanzania, Malawi, Eswatini and Cambodia. The Cambodian section of PAVE is jointly sponsored by the US National Cancer Institute, the Gynecologic Cancers Research Foundation (a Maryland, US 501c3 non-profit corporation) and Takeo Regional Hospital (Takeo Province). The PAVE study is designed to evaluate a novel cervical screen-triage-treat strategy for resource-limited settings as part of a global strategy to reduce cervical cancer burden.¹⁰ The PAVE strategy involves: (1) screening with self-sampled HPV testing; (2) triage of HPV-positive participants with extended HPV genotyping (3) visual (digital) evaluation of the cervix assisted by deep-learning-based (ie, artificial intelligence, AI) AVE and (4) treatment with thermal ablation or LLETZ.¹⁰

A screening strategy based on new technology

The adoption of several newer technologies aided our ability to perform this high volume, rapid screen and treat programme. Specifically, in addition to the ScreenFire HPV testing system discussed above, our strategy uses the Iris, a combination digital colposcope and thermocoagulation device. This innovative device integrates high-resolution optics with thermal ablation capabilities, allowing clinicians to perform both screening and treatment in a single visit. The digital capabilities of this device were developed specifically for colposcopy and provide enhanced visualisation of lesions. Specifically, it has a 4K video camera, optics optimised for visualising the cervix (25 mm focal distance, F5.6, 1/2″ Cmos Sensor), dual white (4000 Kelvin) Light-Emitting Diode (LED) lights to minimise shadows for reproducible cervical colour representation, image capture strobe LED with an 8-millisecond shutter speed to minimise motion blur, a timer and a green filter. The IRIS’s thermal ablation capability, combined with its portability and battery life sufficient for up to 4 hours of examination time or 30–60 ablation cycles, allows healthcare providers to administer immediate treatment.

Lastly, the Softbiopsy and SoftECC devices used in this study have several advantages over conventional punch biopsy and sharp endocervical curettage (ECC) instruments. These fabric-based frictional biopsy devices can quickly sample all acetowhite areas of the cervix and have been shown to be less painful and cause less bleeding than traditional biopsy methods.¹⁹ This is especially helpful when treatment with thermal ablation is administered immediately after biopsy. An additional advantage is that these devices do not have to be sharpened periodically. However, there are some disadvantages to these devices; the biopsy specimens have to be prepared slightly differently than traditional biopsies and some pathologists have remarked that there is a learning curve to reading the more fragmented biopsy specimens. Lastly, they do create additional medical waste and add approximately US$2–5 to the cost of screening. However, in future screen-and-treat programmes that do not rely on pathology for QA, these devices will not be used.

Human rights and public health perspectives

The worlds’ largest apparel and shoe manufacturers contract with Cambodian garment manufacturers, and purport to follow the United Nations Guiding Principles on Business and Human Rights (UNGP). The UNGP defines human rights obligations of companies including voluntary positive contributions through strategic social investment/philanthropy, public policy engagement/advocacy; special attention to the rights of vulnerable groups, including women, and consideration of support for access to basic health, education and housing for the workers and their families.²⁰,²⁵ Despite the UNGP, substantial lapses in health screening have been noted internationally among garment workers.²⁶,²⁸ Providing cervical cancer screenings addresses a critical health need specific to these employees and a commitment to gender-specific health issues in keeping with the UNGP. Programmes in other health arenas have been demonstrated to be cost-effective and confer meaningful reductions in serious threats to worker health like hypertension, tobacco use and oral cancer; it seems likely that workers could benefit from similarly structured cervical cancer screening initiatives.²⁹,³¹

While such programmes are medically and socially beneficial, they are also beneficial from a productivity standpoint. Medical illnesses in general affect industry by causing both absenteeism and presenteeism, which have substantial effects on productivity.^{32 33} The economic costs of cervical cancer in the developing world are particularly significant and worsened by the tremendous health burdens of preventable later-stage disease.³³,³⁸ By providing cervical cancer screenings, manufacturers can ensure early detection and early intervention, significantly reducing the incidence, morbidity, and mortality, and cost associated with the disease.

In addition to directly improving productivity, health benefits such as cervical cancer screening can have indirect financial benefits by reducing turnover rates and improving absenteeism even in workers unaffected by disease. Regular health-related meetings in a group of textile workers showed diminished absenteeism,³⁹ and garment employees who feel their employers are invested in them and are concerned for their health and safety have lower rates of turnover.^{40 41} Employee sense of empowerment and perception of corporate emotional commitment has also been shown to diminish turnover in other industries.⁴²,⁴⁴ Workforce stability can enhance productivity and reduce the costs associated with recruiting and training new employees.^{44 45} Thus, investing in employee health is an effective strategy for building a sustainable and resilient workforce.

Additionally, companies that invest in the health and well-being of their employees enhance their public image and reputation. Consumers are increasingly aware of corporate social responsibility and may be more likely to support brands that demonstrate genuine concern for their workers.⁴⁶

By implementing cervical cancer screening programmes, manufacturers can contribute vital resources to the overall improvement of public health in the communities where they operate and comply with the UNGP. Not only do such programmes improve the health of the community, but they also are financially responsible for improving worker productivity, diminishing turnover and enhancing corporate consumer perception.

Finally, the socioeconomic impact of cervical cancer should not be understated. Cervical cancer often strikes women in the most economically productive years of life, removing key income earners from households. Families may face immediate financial hardship due to medical expenses, lost wages and the need for relatives—often daughters—to leave school or work to become caregivers. Communities experience reduced workforce participation and long-term economic instability when women who support dependents are unable to work or die prematurely. The emotional toll, coupled with increased poverty risk, perpetuates intergenerational disadvantage and widens existing social inequities.

Strengths and limitations

The strengths of this study include the large sample size, high participation and follow-up rates, and successful implementation of a rapid, workplace-based screen–triage–treat model using HPV self-collection and mobile clinics. Integration of digital colposcopy with concurrent biopsy and treatment enabled timely diagnosis and minimised loss to follow-up in a population with limited prior screening access. An additional strength was strong community involvement throughout the conceptualisation and implementation of this study. Limitations include the cross-sectional design, which precludes assessment of long-term outcomes, and restriction to garment workers, which may limit generalisability. In addition, HIV status was not assessed, although prior data suggest low HIV prevalence in this population.

Conclusion

This study highlights the feasibility of a rapid, high-volume cervical cancer screening strategy that uses self-swabs for HPV testing and a new portable, relatively inexpensive and versatile HPV testing system within garment factory settings. This approach not only significantly enhances the health outcomes for female workers by preventing the progression to invasive cervical carcinoma but also improves workforce stability by reducing health-related absenteeism and turnover. Furthermore, this innovative model can be adapted and replicated in other industrial sectors within low-resource settings, offering a scalable solution to reach WHO’s 70–90–70 cervical cancer goal to reduce the global burden of cervical cancer and improve public health outcomes.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.