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Table 3 Table of evidence

From: Implementation strategies to improve cervical cancer prevention in sub-Saharan Africa: a systematic review

First author, year Purpose Country Program Strategy Outcome Results Quality
Randomized control trials
 Adonis 2017 [79] To evaluate what type of framed email messaging has the best impact on Pap smear uptake among health-insured females South Africa Pap smear Educate: educational email Penetration: Pap smear screening coverage Screening rate in the control group was 9.58%, 5.71% in the gain-framed group, and 8.53% in the loss-framed group. Statistically, there was no difference between groups. Fair
 Modibbo 2017 [82] To investigate whether self-collection of cervicovaginal samples for HPV DNA tests would be associated with increased uptake and quality of screening compared with clinic-based collection of samples Nigeria HPV DNA test Restructure: remote self-collection vs. clinic-based physician collection Fidelity: sensitivity and specificity between clinician- and self- collected samples Most participants in the self-collection arm (93%) submitted their samples while only 56% of those invited to the hospital for sample collection attended and were screened during the study period (p < 0.001) Fair
 Okeke 2013 [80] Determine the effect of cost on screening uptake by providing randomly priced subsidies to eligible women Nigeria VIA Finance: lottery for varied prices of screening and treatment subsidies (0, 50, and 100 Naira) Penetration: VIA screening coverage Price of screening had a significant effect on the demand for screening: reducing the price by 10 cents increased uptake by 1%. Fair
 Risi 2004 [77] Evaluate the effectiveness of two media interventions—a photo-comic and a radio-drama—in increasing cervical screening uptake South Africa Pap smear Educate: educational photo-comic and radio-drama Penetration: Pap smear screening coverage 7% (18 of 269) of women who received the intervention photo-comic reported cervical screening during the 6-month follow-up, compared with 6% (25 of 389) of controls (p = 0.89). Women who recalled hearing the radio-drama were more likely to report attending screening (9 of 53, 17%) than those who did not (19 of 429, 4%; p < 0.001). Good
 Rosser 2015 [78] Evaluate a health talk’s impact on cervical cancer knowledge, attitudes, and screening rates in a rural setting Kenya Unspecified screening Educate: 30-min didactic lecture Acceptability: reasons for refusal Adoption: willingness to screen
Penetration: screening coverage
Mean knowledge scores increased by 26.4% in the intervention arm compared to only 17.6% in the control arm (p < 0.01). Screening uptake was moderate in both the intervention and control arms, with no difference between the groups (58.9 vs. 60.9%, p = 0.60). Fair
 Sossaeuer 2014 [26] Evaluate whether an educational intervention would improve women’s knowledge and confidence in the Self-HPV method Cameroon HPV DNA test Educate: individual counseling (all), educational video (intervention group Acceptability: confidence, embarrassment, pain, anxiety, discomfort, degree of relaxation and confidence Participants who received the educational intervention had significantly higher knowledge about HPV and cervical cancer than the control group but no significant difference on self-HPV acceptability and confidence in the method. Fair
 Van Wijgert 2006 [29] Assess the validity, feasibility, and acceptability of two methods of self-sampling (tampon or vaginal swab) compared to clinician sampling during a speculum examination South Africa HPV DNA test Restructure: self-administration with tampon or vaginal swab vs. clinician collected swabs Acceptability: perceived pain, satisfaction
Feasibility: proportion of invalid labs
Fidelity: sensitivity and specificity between clinician-and self-collected samples
Sensitivity for high-risk HPV was good for vaginal swabs (79.8%) and moderate for tampons (59.5%). Self- and clinician- sampling were rated as good or okay by the majority of women Poor
 Watson-Jones 2012 [81] Compare coverage achieved by two different delivery strategies (class-based vs. age-based) for HPV vaccine among schoolgirls Tanzania HPV vaccine Educate: community outreach with lectures, pamphlets, posters, radio messages, and dramas
Restructure: change delivery models class-based vs. age-based
Acceptability: reasons for refusal
Penetration: HPV vaccine coverage and 3 dose adherence
For each dose, coverage was higher in class-based schools than in age-based schools (dose 1: 86.4 vs 82.0% [p = .30]; dose 2: 83.8 vs 77.8% [p = .05]; and dose 3: 78.7 vs 72.1% [p = .04]). Poor
Nonrandomized control trials
 Mutyaba 2009 [83] Evaluate the efficacy of male partner involvement in reducing loss to follow-up among women in Uganda referred for colposcopy after a positive cervical cancer screening test Uganda VIA,VILI, colposcopy Educate: group lecture, incentivize follow-up with inclusion of male partner by sending educational pamphlet home for partners Penetration: screening coverage, loss to follow-up Intervention group was significantly more likely to return for colposcopy than the control group, with 16 and 34%, respectively, lost to follow-up. Poor
Pre-post tests
 Abiodun 2014 [67] Determine the effect of health education on the awareness, knowledge and perception of cervical cancer and screening among women in rural communities Nigeria Unspecified screening Educate: 1-day health education intervention with group didactic lectures and an educational movie Penetration: screening coverage There was a statistically significant difference in cervical cancer awareness, perception, knowledge and screening uptake between intervention and control groups. Proportion of women in the intervention group who had undertaken screening rose from 4.3 to 8.3% (p = .038). Good
 Adamu 2012 [70] Assess the effect of health education on the knowledge, attitude, and uptake of Pap smear among female teachers Nigeria Pap smear Educate: individual counseling on cervical cancer, complications, cost, importance of screening
Finance: free coupon for pap test
Penetration: Pap smear screening coverage The proportion of respondents with a reported practice of Pap smear was low and similar in both groups (1.1 in the intervention group and 4.9% in the control group, p = 0.16). Uptake was poor at post-intervention phase for both groups (p = .45). Good
 Caster 2017 [71] Assess the acceptability, feasibility and effectiveness of a tablet-based cervical cancer educational intervention Malawi Unspecified screening Educate: 30-min tablet-based education Acceptability: participants’ preference for tablet vs. in-person education
Feasibility: ease of tablet use, number of times participants need assistance with tablet
Adoption: intention to screen
The median pretest score was 11 out of 20 and the median posttest score was 18 (p < 0.001). 226 participants (93%) stated that they would like to obtain cervical cancer screening Fair
 Chigbu 2017 [72] Determine the impact of trained community health educators on the uptake of cervical and breast cancer screening and HPV vaccine in rural communities Nigeria HPV vaccine Educate: house-to-house education given on a one-on-one basis by community health workers on cervical and breast cancer prevention Penetration: screening and HPV vaccination coverage Of the 1327 enrolled women, 42 (3.2%) had undergone screening pre-intervention and 897 (67.6%) received screening afterwards (p < .0001). Only 2 (0.9%) of 214 children eligible for HPV vaccination had received the vaccine before versus 71 (33.2%) after the intervention (p < .001). Fair
 De Groot 2017 [73] Provide information on STI knowledge and vaccine acceptance after an educational session Mali HPV vaccine Educate: educational session to inform adults and adolescents about HPV and cervical cancer, symptoms and causes, benefits and availability of the HPV vaccine Adoption: parent and child reported willingness to accept the HPV vaccine The education session increased the HPV vaccine acceptance in all groups, especially among adolescents (from 75.3 to 91.8%, p < .01). Fair
 Dreyer 2015 [68] Measure changes in knowledge and screening behavior after an educational intervention provided to mothers of adolescent HPV vaccine recipients South Africa Pap smear, HPV DNA test Educate: 15 min didactic lecture and educational pamphlets
Restructure: integrate screening of mothers into child HPV vaccination program
Penetration: screening coverage Knowledge about symptoms (p < .005), screening (p < .005), and vaccination (p < .05) improved significantly at 6 month retesting. Improvement for reported screening in the past 12 months was more favorable in Gauteng (41%) with self-sample than in Western Cape with Pap smear (26%). Fair
 Levine 2011 [75] Determine the effectiveness of an educational program in VIA knowledge and skills retention among healthcare providers in 2 countries Uganda VIA Educate: 5 day educational program for providers with didactic lectures and procedural training in VIA Acceptability: provider reported comfort with skills
Sustainability: skill assessment at 6-month follow-up
Mean test scores increased significantly after participation in the training session (62% vs. 81%, p < .001). Self-reported comfort level for identifying cellular abnormalities also increased (2.1 vs. 3.3; p < 0.001 There was no significant difference between initial and 6-month follow-up test scores (80 vs. 79%). Poor
 Mbachu 2017 [74] Assess the effectiveness of peer health education on perception, willingness to screen and uptake of cervical cancer screening of women during Anglican church meetings Nigeria Pap Smear, VIA, VILI Educate: three 45–60 min sessions repeated monthly of peer health education on cervical cancer burden, risk factors, symptoms and prevention Penetration: Pap smear and VIA/ VILI screening coverage
Adoption: willingness to screen
Screening rate increased by 6.8% and the observed difference was statistically significant (p = 0.02). Fair
 Miller 2007 [76] Evaluate a train the trainer program for cervical screening implementation and assess pre-post knowledge of the implementation process Nigeria VIA, VILI, Pap smear, Cryotherapy Educate: train the trainer in implementation None Of the 41 evaluable exams, 9 saw no change, 31 showed improvement, 1 scored worse. Poor
 Wright 2010 [69] Evaluate the effect of a health education program on knowledge of cervical cancer among market women in an urban area Nigeria Pap smear Educate: develop pamphlets, community outreach None Significant increase in proportions were found in the intervention/experimental group on awareness of cervical cancer (61.7%), associated symptoms and risk factors such as early sexual debut, promiscuity and smoking. Fair
Cross-sectional studies
 Adamson 2015 [42] Determine the acceptability and accuracy of tampon-based self-collection for hrHPV mRNA testing in HIV-infected women South Africa HPV RNA test Restructure: self- vs. physician-HPV RNA sampling Acceptability: care, privacy, embarrassment, discomfort, pain, preference
Fidelity: concordance between physician- and self- collected samples
There was no difference in test positivity between clinician-collection, 36.7%, and tampon- collection, 43.5% (p value = 0.08). Using clinician-collection as the reference, the sensitivity and specificity for hrHPV mRNA of tampon-collection were 77.4 and 77.8%, respectively. Good
 Adepoju 2016 [59] Determine sociodemographic characteristics, awareness and uptake of a free cancer screening program Nigeria Pap smear Educate: public sensitization with women groups and mass media campaign
Finance: free screening
Penetration: Pap smear screening coverage 287 women were screened but uptake of cervical cancer screening was low since most women did not come for the program despite the public sensitization. Poor
 Asgary 2016 [22] Evaluate the feasibility and efficacy of ongoing, smartphone-based support in sustaining VIA skills for community health nurses Ghana VIA, digital imaging Educate: 2-week didactic and procedural training for VIA and digital imaging, ongoing consultation
Quality: audit and feedback for digital images via smartphone messaging within 24 h
Fidelity: inter-rater agreement for VIA between nurses and expert physician
Feasibility: VIA picture quality
Agreement rate between all VIA diagnoses made by all CHNs and the expert reviewer was 95%. Cohen κ statistic was 0.67 (95% CI = 0.450.88). Images for 9 patients, taken by 6 CHNs, were unclear. Fair
 Awua 2017 [49] Compare the uptake of screening between a community-based vs. hospital-based strategies for collecting HPV DNA samples Ghana HPV DNA test Educate: community lectures at churches
Restructure: community-based vs. hospital-based specimen collection
Quality: patient phone reminders
Penetration: HPV DNA testing coverage Response rates were higher for community-based (95.1%) than short-term (46.6%) or long-term (38.5%) hospital-based appointments Fair
 Catarino 2015 [48] Evaluate the use of smartphone telemedicine for off-site diagnosis of cervical intraepithelial neoplasia Madagascar VIA, VILI, HPV DNA test, Digital imaging Restructure: on-site vs. off-site evaluation of VIA digital images Fidelity: sensitivity and specificity between on-site physician diagnosis and off-site assessment via digital images The on-site physician had a sensitivity of 66.7% and a specificity of 85.7%; the off-site physician consensus sensitivity was 66.7% with a specificity of 82.3%. Good
 Crofts 2015 [61] Report on women’s acceptance of HPV self-sampling following an education intervention on cervical cancer and HPV Cameroon HPV DNA test Educate: 20 min didactic lecture and educational pamphlet with instructions for HPV self-samplings Acceptability: embarrassment, pain, anxiety, confidence, discomfort, relaxation, complexity Overall, participants showed high acceptability scores for HPV self-testing (6.986 of 24), with lower scores being more favorable. However, there was no difference in acceptability between participants with good vs. poor knowledge scores. Fair
 DeGregorio 2017 [57] Evaluate a nurse-led, fee-for-service cervical cancer screening program using visual inspection with acetic acid-enhanced by digital cervicography in the setting of a large faith-based health care system Cameroon VIA, VILI, Digital imaging, Cryotherapy, LEEP, Biopsy Quality: quarterly meeting to review cervicographs with expert clinician
Educate: peer educators with group lectures in the community
Finance: fee-for-service sliding scale based on community demographics
Restructure: integrate with family planning, breast exams, STI testing
Penetration: VIA screening coverage In 8 years, 44,979 women were screened for cervical cancer. Poor
 Dim 2015 [62] Assess willingness to pay out-of-pocket for Pap smear among HIV positive women after provided information about cervical cancer and screening Nigeria Pap smear Educate: individual counseling on increased risk for cervical cancer, Pap smear protocol, and costs Adoption: willingness to pay for Pap smear 378 (94.5%) respondents were willing to pay for Pap smear, irrespective of the cost. Willingness to pay showed no trend across age groups (p = . 148), marital status groups (p = . 890), educational status groups (p = . 337), and parity groups (p = . .611). Fair
 Firnhaber 2015 [41] Determine whether a quality assurance program using digital cervicography improved the performance of VIA to detect cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) in HIV-infected women South Africa VIA, digital imaging Educate: 2-week VIA training
Quality: audit and feedback of VIA cervical images by expert gynecologist in weekly QA meetings
Fidelity: sensitivity and specificity of VIA compared between nurses’ visual assessment and physician digital image assessment There was substantial agreement between the VIA real-time readings of the nurse and that of the physician with digital cervicography (k statistic = 0.69). There was no statistical difference between the ability of nurses to detect CIN 2+ at the beginning and at the end of the study. Poor
 Goldhaber-Fiebert 2009 [65] Determine the relationship between investment in community health worker (CHW) home visits and increased attendance at cervical cancer screening appointments South Africa Unspecified screening, colposcopy, biopsy Quality: patient reminder system with community health worker (CHW) home visits to encourage attendance to follow-up appointments Costs: total CHW program cost, average cost per women screened
Penetration: screening coverage, total CHW home visits completed, patient adherence to appointments
Adherence increased from 74 to 90%; 55 to 87%; 48 to 77%; and 56 to 80% for 6-, 12-, 24-, and 36-month appointments. The CHW program cost R194,018 with 1576 additional appointments attended. Average per-woman costs increased by R14–R47. Good
 Horo 2012 [23] Determine effect of a phone based tracking system on follow-up rates Cote d’Ivoire VIA, VILI, colposcopy, biopsy Educate: individual counseling, group patient teaching, and educational pamphlets
Quality: phone based patient reminder system with maximum of 3 calls (one per week)
Acceptability: patient reasons for loss to follow-up
Penetration: colposcopy loss to follow-up rates
The use of a phone-based tracking enabled a significant reduction of women not attending medical consultation after initial positive screening from 36.5 to 19.8% (p < 10–4). Reasons for not following up include cost, transportation, fear and time Poor
 Huchko 2011 [50] Assess the impact of a cervical cancer screening prevention pilot project implemented into an established AIDS program Kenya VIA, colposcopy, biopsy, LEEP Educate: 1-week training for providers in VIA, colposcopy, and lab specimen processing, individual patient counseling and community outreach
Restructure: increase lab capacity, embed in HIV program
Quality: ongoing for consultation for program protocol through CCSP
Acceptability: reasons for patients refusing screening, provider satisfaction with training and program implementation
Penetration: VIA screening coverage, provider training coverage
Feasibility: challenges to implementing the program
High coverage (87%). Reasons for declining screening included partner support, menstruation, and fear. 28 (90%) clinical officers underwent training in VIA and colposcopy.
The main challenges reported were related to infrastructure limitations (lack of water, electricity and supplies; and long waits in the clinic) and perceived patient barriers
Poor
 Kapambwe 2013 [60] To evaluate knowledge transfer after training of traditional marriage counselors (alangizi) to integrate cervical cancer lessons into their routine counseling Zambia VIA, Digital imaging Plan: develop trust between alangizi and research team
Educate: one-day training on basic cervical cancer knowledge for traditional marriage counselors
Restructure: integrate cervical cancer messaging into marriage counseling
Feasibility: perceived barriers and facilitators of integrating screening A majority of the trainees correctly associated cervical
cancer with HPV (35.6%) and multiple sexual partnerships (28.9%).
Poor
 Khozaim 2014 [51] Determine the challenges and successes of integrating a public-sector cervical screening program into a large HIV care system Kenya VIA, VILI, digital imaging, colposcopy, biopsy, cryotherapy, LEEP Educate: community outreach, mass media
Restructure: embed in HIV care
Quality: patient reminder system with calls and text messages for upcoming appointments
Penetration: loss to follow-up rates 31.5% lost to follow-up (27.9% colposcopy to biopsy, 49.3% biopsy to LEEP, 59.6% colposcopy to chemo or hysterectomy) Poor
 Lack 2005 [31] Compare two
self-administered techniques for detecting HPV (tampons and swabs) with a clinician directed technique (cervical cytobrush)
Gambia HPV DNA test Restructure: self-administration- vs. physician-collected swabs Fidelity: sensitivity and specificity compared between self- and physician collected cervical swabs
Penetration: screening coverage
Self-administered swabs showed a sensitivity of 63.9% and tampons showed a sensitivity of 72.4% compared to the cervical cytobrush as the gold standard. The acceptability of these two tests was 97.1 and 84.6%, respectively. Poor
 Ladner 2012 [44] Assess the effectiveness of school vs. clinic based delivery models on HPV vaccine coverage in 7 different countries Cameroon HPV vaccine Restructure: change service sites of HPV vaccination (school, clinic, and mixed models) Penetration: Vaccine coverage and adherence High coverage (88%) and adherence (91%) across programs. Mixed model in both school and clinic settings was most effective. Fair
 LaMontagne 2011 [45] Assess the effectiveness of school vs. clinic based delivery models on HPV vaccine coverage in 4 different countries Uganda HPV vaccine Educate: community outreach and educational pamphlets
Restructure: change service sites of HPV vaccination (health center, school, and integrated with other health program)
Acceptability: reasons for vaccine acceptance or refusal
Penetration: HPV vaccination coverage
High school coverage (88.9%) but low health center coverage. Reasons for accepting the HPV vaccine that: (i) it protects against cervical cancer; (ii) it prevents disease, or (iii) vaccines are good. Refusal was more often driven by programmatic considerations (e.g., school absenteeism) than by opposition to the vaccine. Poor
 Maree 2012 [53] Determine whether cervical screening uptake could be improved when breast and cervical screening are combined South Africa VIA Educate: one-on-one patient counseling
Restructure: combine cervical cancer and breast cancer screenings
Acceptability: patient reasons for screening refusal
Penetration: VIA screening coverage
Moderate coverage (65.4). Major reason for refusal was menstruation. Good
 Megevand 1996 [46] Determine the feasibility of providing a cervical screening facility to the underprivileged communities through an educational program and mobile clinic South Africa Pap smear, colposcopy, LEEP Educate: community outreach
Restructure: change service site to mobile clinic with same day Pap smear results and treatment if indicated
Quality: audit and feedback for 100 of every 300 cytology slides
Penetration: loss to follow-up rates Loss to follow-up rates were much lower for minimal delay, mobile delivery (3%) compared to longer delay, clinic delivery (66%) Poor
 Mehotra 2014 [58] Assess the impact of enrollment in an incentive program on receipt of eight preventive care services including Pap smear South Africa Pap smear Finance: insurance incentive program Penetration: Pap smear screening coverage 65.5% (2,742,268) of health plan members enrolled in the incentive program at some point. Odds ratio for receipt of Pap test is 2.17 Good
 Michelow 2006 [66] Determine if rapid review of reportedly negative cervical smears is a useful internal quality assurance modality in an unscreened population with very high rates of cervical carcinoma South Africa Pap smear Quality: quality monitoring system for randomly selected Pap smear slides by a senior cytotechnologist Fidelity: sensitivity and specificity An amended report was sent out in 373 (0.59%) of the 62,866 cervical smears. The false-negative proportion for HSIL and ASC-H (combined) in this study was 5.76%. Fair
 Moodley 2013 [52] Demonstrate the capacity of school health teams to carry out vaccinations within a school environment South Africa HPV vaccine Restructure: integrated with cervical cancer screening program for mothers
Educate: staff training in program policy, sensitize school leadership, community outreach
Penetration: HPV vaccine coverage and 3 dose adherence High coverage and adherence of the vaccine was found to be high: 99.7, 97.9, and 97.8% for the first, second, and third doses, respectively. Poor
 Moon 2013 [54] Assess the feasibility, successes and challenges of integrating a VIA program into an existing HIV program Mozambique VIA, Cryotherapy, LEEP, Colposcopy Educate: 1-week didactic and procedural training in VIA and cryotherapy Restructure: change service sites—embed in HIV care Feasibility: reasons for delay in treatment provision
Penetration: cryotherapy and LEEP follow-up rates
Sustainability: percentage of providers still performing VIA in 1 year
High and improved follow-up rates between first (53%) and the last quarter
(96%) cryotherapy same day coverage rates. High (88%) referral follow-up rates. 0% physicians and 50% nurses continued VIA screening 1 year after training. Delays in treatment include equipment theft and malfunction.
Poor
 Obiri-Yeboah 2017 [43] Determine the acceptability, feasibility and performance of alternative self-collected vaginal samples for HPV detection Ghana HPV DNA test Restructure: self- vs. physician-HPV DNA sampling Acceptability: ease of use, preference
Fidelity: concordance between physician- and self- collected samples
The overall HPV detection concordance was 94.2% and kappa value of 0.88 (p < 0. 0001), showing excellent agreement. 57.7% preferred self- to physician collection. Fair
 Ogembo 2014 [47] Inform the Cameroon Ministry of Health of the acceptability, feasibility, and optimal delivery strategies for HPV vaccine Cameroon HPV vaccine Educate: community awareness campaign using mass media, pamphlets, and posters
Restructure: change delivery sites (clinic, school, community/mobile), integrate with screening of mothers
Quality: patient reminder system with peer tracking (school)
Feasibility: vaccines lost/damaged/expired, adverse events
Penetration: vaccine coverage, refusal rate, 3 dose adherence
Total of 6851, 6517 and 5796 girls were immunized with the first, second and third doses of HPV vaccine, respectively, achieving 84.6% full dosage coverage of the adolescents who received the first dose. Only 63 of the 19,200 doses received were lost, damaged or expired. CBCHS charged a fee of US$8 per 3-dose series only to those who were able to pay. Despite the fee, 84.6% of the 6851 girls who received the first dose received all three doses. Poor
 Quinley 2011 [25] Examine the diagnostic agreement between off-site expert diagnosis using photographs of the cervix (photographic inspection with acetic acid, PIA) and in-person VIA Botswana HPV DNA test, VIA, digital imaging Quality: quality assurance for digital cervical images Feasibility: rate of equipment malfunction
Fidelity: inter-rater reliability with expert, concordance between VIA and PIA
Moderate to high agreement (69–100%) with expert, varied for each nurse
High concordance (70%) between PIA and VIA results
31 images were insufficient for reading.
Fair
 Ramogola-Masire 2012 [24] Determine the feasibility and efficiency of the see and treat approach using visual inspection acetic acid (VIA) and enhanced digital imaging (EDI) for cervical cancer prevention in HIV-infected women Botswana VIA, VILI, cryotherapy, digital imaging Educate: 3-day didactic teaching and 8 weeks of procedural training in VIA, digital imaging, and cryotherapy
Restructure: embed in HIV care
Quality: audit and feedback of cervical images by expert gynecologist in weekly quality control meetings
Fidelity: sensitivity, specificity, inter-rater reliability of VIA assessments between nurses and expert gynecologist
Penetration: cryotherapy follow-up rates
High agreement between nurses and the gynecologist in the evaluation of digital pictures (83.3%)
Overall follow-up 709 of 842 (84.2%)
Fair
 Safaeian 2007 [28] Compare human papillomavirus (HPV) DNA testing between self-administered vaginal swabs and physician-administered cervical swabs Uganda HPV DNA test Restructure: self-administration vs. physician collected swabs Fidelity: sensitivity and specificity between self- and physician- collected samples
Penetration: screening coverage
Compliance with self-collected swabs was > 86%; however, only 51% accepted a pelvic examination. Agreement among paired observations was 92% with a kappa statistic of 0.75. Good
 Synman 2015 [55] Investigate the feasibility of linking HPV self-testing for mothers with a two-dose HPV vaccination schedule of their daughters South Africa HPV DNA test, HPV vaccine Educate: educational pamphlets sent home with children for mothers
Restructure: integrate HPV DNA self-sample kit for mothers into vaccination program for daughters
Penetration: HPV DNA self-testing coverage Of the 1135 self-screen kits handed out to eligible girls to be passed on to their female guardians, 160 women participated in the self-screening (14.1%). Poor
 Ting 2013 [27] Compare the performance of hrHPV mRNA testing of physician- and self-collected specimens for detecting cytological high-grade squamous intraepithelial lesions or more severe (QHSIL) and examined risk factors for hrHPV mRNA positivity in female sex workers Kenya HPV RNA test, Pap smear Restructure: self-administration vs. physician-collected swabs Fidelity: sensitivity and specificity compared between self- and physician collected cervical swabs Overall sensitivity of hrHPV testing for detecting QHSIL was similar in physician-collected (86%) and self-collected specimens (79%). Overall specificity of hrHPV mRNA for QHSIL was similar in both physician-collected (73%) and self-collected (75%) specimens. Good
 Tum 2013 [64] Determine if a community health worker and education intervention could increase screening uptake South Africa Unspecified screening Educate: health worker training, community education Acceptability: patient perceived value of community health worker
Penetration: screening coverage
Low coverage (3%). All found value in health worker through informing, teaching, and motivating. Fair
 Untiet 2014 [30] Test differences in performance between self-HPV versus physician-HPV and their ability to detect abnormal cytology results Cameroon HPV DNA test Restructure: self-administration vs. physician collected swabs Fidelity: sensitivity and specificity compared between self- and physician collected cervical swabs HPV prevalence was 14.6 and 12.7% for self-HPV and physician-HPV, respectively (Cohen’s kappa = 0.74). HPV positivity by cytological diagnosis for ASC-US+ was similar with the two tests Good
 Wamai 2012 [63] Evaluate the effectiveness of a campaign in sensitizing parents to HPV vaccination and influencing uptake of vaccine for their children Cameroon HPV vaccine, VIA, digital imaging Educate: Community outreach, mass media, education program Acceptability: reasons to vaccinate or not
Adoption: willingness to vaccinate
Penetration: VIA screening coverage, sensitization campaign coverage
High willingness to vaccinate among parents. Low coverage (35.3%) of VIA screening among parents. Low education program coverage with 5.9% surveyed parents learning about cervical cancer from program. Top reasons not to vaccinate include effectiveness (31.8%), safety (18.4%), provider recommendations (17.8%) and cost (16.6%). Fair
 Were 2010 [56] Pilot test and assess the feasibility of integrating VIA screening into an existing maternal child health and family planning program Kenya VIA, VILI Educate: VIA/VILI training
Restructure: change service- embed in maternal child health and family planning
Penetration: VIA/VILI screening coverage and loss to follow-up Moderate coverage and follow-up. 435 invited—216 declined 219 accepted. 24 of 40 went for colposcopy. Poor