Loading [MathJax]/extensions/MathML/content-mathml.js
info@auctorespublishing.com
+1-(302)-520-2644
+1-(302)-520-2644

Cervical Cancer Prevention Paradox: Unveiling Screening Barriers and Solutions

  1. Home
  2. Journals
  3. Cancer Research and Cellular Therapeutics
  4. Archives
Submit Guidelines

Review Article | DOI: https://doi.org/10.31579/2640-1053/182

Cervical Cancer Prevention Paradox: Unveiling Screening Barriers and Solutions

  • Esther Ugo Alum 1
  • Okechukwu P. C. Ugwu 1
  • Emmanuel Ifeanyi Obeagu 2*

1 Department of Publications and Extension, Kampala International University, P. O. Box 20000, Uganda.

2 Department of Medical Laboratory Science, Kampala International University, Uganda.

*Corresponding Author: Emmanuel Ifeanyi Obeagu, Department of Medical Laboratory Science, Kampala International University, Uganda

Citation: Esther Ugo Alum, Okechukwu P. C. Ugwu, and Emmanuel Ifeanyi Obeagu, (2024), Cervical Cancer Prevention Paradox: Unveiling Screening Barriers and Solutions, J, Cancer Research and Cellular Therapeutics, 8(2); DOI:10.31579/2640-1053/182

Copyright: ©2024, Emmanuel Ifeanyi Obeagu. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 14 January 2024 | Accepted: 22 January 2024 | Published: 27 February 2024

Keywords: cervical cancer; human papillomavirus; HPV infection; developing countries; early detection; healthcare system

Abstract

Cervical cancer is still a major worldwide health concern, particularly in areas with high rates of infection and little resources. The important connection between human papillomavirus (HPV) infection and cervical cancer is examined in this publication, which also highlights the need for early screening and detection and highlights the rising incidence among teenagers and young adults. Women continue to confront numerous obstacles to cervical cancer screening and treatment, even in spite of the World Health Organization's strategy to eradicate the disease through prompt detection and treatment. Personal concerns, cultural and religious beliefs, and a lackluster healthcare system are a few of these obstacles. It is critical to identify and eliminate obstacles to screening uptake in developing countries in order to lower the incidence of cervical cancer. Therefore, this paper outlined the obstacles to cervical cancer screening in developing countries, provided mitigation strategies, and emphasized the need for better policy and campaign measures in order to eradicate cervical cancer. This study used relevant published research from reliable databases. 

Introduction

A sexually transmitted infection with the human papillomavirus (HPV) is the cause of cervical cancer. Estimated to be the fourth most frequent cancer in women worldwide, 341 831 deaths and 604 127 new cases are expected in 2020 [1]. With rates seven to ten times greater than in industrialized nations, cervical cancer is the second most frequent malignancy in Africa [1]. In Sub-Saharan Africa, it is the leading cause of death for women [1]. Sadly, the number of adolescents and young adults with cervical cancer is rising, notably in the 21–30 age range, among patients under 30 [2]. To stop cervical dysplasia from developing into cervical cancer, precancerous abnormalities can be screened for, detected, and treated globally to prevent cervical cancer [3, 4]. According to cervical cancer screening guidelines, women should have a Pap test every three years if they are between the ages of 21 and 29; women between the ages of 30 and 65 should get an HPV test every five years or a Pap test every three years if they have spoken with their doctor; and women over the age of 66 should inquire with their doctors about the need for ongoing screening every five years [5]. In the case that preventive services are not rapidly expanded, estimates indicate that by 2040, the disease's death toll will increase to around 460,000 [6]. Regrettably, less people are getting screened in nations with limited resources [7]. More so, the high rate of HIV infection in these regions is fueling this menace. HIV infection enhances the risk of cervical cancer [8-13]. Generally, early screening and detection of cancers enhances treatment outcomes [14-20]. The majority of cases (72.3%) of cervical cancer are detected at an advanced stage [21]. Women often use cervical cancer screening services between the ages of 37 and 49 [22], which is a relatively late period for them to do so. Low socioeconomic position [5], fear and shame [23, 24], as well as unpleasant previous screening experiences [25], may all be factors in the low uptake. Women have to utilize cervical screening services to check for HPV and stop precancerous cells from turning into cancerous cells in order to lessen the incidence of cervical cancer. This is especially important in nations where access to human papillomavirus vaccinations is limited. A key element of prevention that will increase screening uptake and ultimately lower the worldwide incidence of cervical cancer is the implementation of efficient screening programs tailored to the requirements of women. As a result, the World Health Organization's global strategy to expedite the elimination of cervical cancer offers a vision of a world in which women's needs, social circumstances, and the structural, personal, cultural, and financial barriers preventing them from accessing health services are all taken into consideration when implementing policies to eradicate cervical cancer as a public health issue [26]. Since human papillomavirus (HPV) infection is linked to almost all cases of cervical cancer (99%), HPV vaccination is an important primary preventive strategy. Screening, or secondary prevention, is still an important tool in the toolkit for eradicating cervical cancer, particularly in areas with low uptake, availability, and access to HPV vaccination. In contrast to 63% in industrialized nations, the average screening coverage of eligible women is 19% in the majority of developing nations [27]. In order to reduce the incidence of cervical cancer in developing nations, it is crucial to identify and remove obstacles to screening uptake. Therefore, in order to eradicate the illness, this article highlights the need for improved campaigns and policy initiatives while identifying obstacles to cervical cancer screening in underdeveloped nations. Studies on women's barriers to cervical cancer screening that were published between 2010 and 2023 were collected and synthesized from Google Scholar, PubMed, Scopus, and Web of Science databases.

Obstacles to the Adoption of Cervical Cancer Screening

Barriers in the health system

Health system barriers to the uptake of cervical cancer screening include capacity constraints, inadequate service organization, a lack of awareness about cervical cancer among healthcare professionals, a lack of screening promotion, unfriendly attitudes of healthcare professionals toward patients, and a lack of public trust in the health system. Insufficient healthcare facilities are a widespread issue plaguing developing nations worldwide, particularly those residing in rural areas. Due to the dearth of screening facilities, personnel shortages, hurried and short consultations, and equipment and material shortages in these areas, women are frequently referred for screening far from their homes, which results in expensive and time-consuming screening procedures [28, 29]. As a result, some rural inhabitants seek treatment for cervical cancer from traditional medical professionals. Plant-based remedies are used in traditional medicine to preserve health. It is a long-standing worldwide custom [30-32]. Remarkably, studies have shown that plants offer medicinal potential for treating a wide range of conditions, including cancer [15, 18], rheumatoid arthritis [33-35], diabetes mellitus [36-41], malaria [42,43], anemia [44, 45], and liver illnesses [46-48]. Although there have been many reports of plants having potential medicinal uses, it is advised to use caution when using them as the toxicity profile of such plants has not been well studied by science.  Women from Uganda and South Africa and revealed that the low uptake of cervical cancer screening was due to a lack of privacy in healthcare facilities [49, 50]. Malawian women cited a hurdle as the lack of room in healthcare institutions for screening services according to Munthali et al. [51]. Nigerian women said that one of the barriers was their lack of trust in the healthcare system [52]. Recently, Ari et al. [53] found that good cervical screening experiences increased the uptake of cervical screening by Nigerian women. In South Africa, Kenya, Uganda, and China, lengthy wait times in medical institutions have been noted as a deterrent to screening [54-57]. 

Barriers based on customs and culture

Numerous studies have revealed that women were not examined due to restrictions and religious or cultural reasons [58, 59]. Conflicts between traditional and western perspectives on cervical cancer screening were noted by Nugus et al. [60]. Similarly, reports from South Africa and Ghana [50, 59] indicated a preference for traditional treatment and a skepticism of western medicine. Additionally, there have been stories of males disliking their wife' cervical cancer screenings [28, 29]. Furthermore, according to a different study, women's health issues—including those related to sexual and reproductive health—were not given the same urgency or priority as other health issues [61]. Furthermore, because cervical cancer is perceived as a terminal illness, stigma is said to contribute to low screening uptake [58, 61]. Adewumi et al. [63] claim that the stigma stems from its link to sexual transmission, since women who undergo screenings are occasionally thought to be having an extramarital affair. According to a qualitative study of women's experiences with cervical cancer screening in South Africa, stigma resulting from concurrent HIV testing and the connection between HIV infection and cervical cancer has been documented [64].

Structural Barriers

Several authors have highlighted structural constraints that contribute to the low acceptance of cervical cancer screening. These barriers include high screening costs, poor transport networks, and large travel distances to screening centers and the related travel expenditures. All continents face screening costs, but impoverished countries are more affected [59, 61]. Prolonged wait periods also lead to higher lunch expenses, which raises the total cost of screening. Researchers have also found that insecurity, obstacles to freedom of movement, and inadequate road networks to screening facilities exist in Nigeria and Uganda [65, 66]. Women who live in rural communities in developing nations tend to be poor and have low levels of education, which are other structural difficulties that have been noted [67]. Interestingly, Baussano et al. [68] reported that free screening resulted to an increase in seeking behavior of women resident in rural Bhutan. Similarly, Antinyan et al. [68] also reported that timely reminders and offering transportation cost boosts cervical cancer screening uptake. Ari et al. [53] state that free screening, raising awareness of the condition and screening, providing assistance with transportation, and using influencers to promote screening are among the strategies to increase screening participation depending on women's needs.

Individual obstacles to the acceptance of cervical cancer screening

The most often mentioned personal obstacles to the uptake of cervical cancer screening are: ignorance of the disease, screening, and its advantages [29, 50, 51, 56], anxiety over positive test results because many people view a positive result as a death sentence [24, 50], discomfort from the screening process, and fear of potential consequences like getting cancer or injuring one's cervix or uterus during screening [58, 59]. Some women are deterred from screening for cervical cancer by the simultaneous testing for HIV infection and cervical cancer [24]. Another disadvantage is that some women find it embarrassing to be inspected by a man or a young healthcare professional [57, 70]. 

Conclusion

Given the detailed analysis of barriers to cervical cancer screening in developing countries, it's evident that multifaceted challenges exist at systemic, cultural, structural, and individual levels. These barriers encompass healthcare system limitations, cultural beliefs, financial constraints, and personal fears surrounding the screening process. To confront these challenges, a comprehensive approach integrating targeted policies, improved healthcare infrastructure, culturally sensitive awareness campaigns, and tailored interventions is imperative. Efforts should focus on enhancing healthcare accessibility, dispelling cultural misconceptions, reducing financial burdens, and addressing individual concerns to encourage greater uptake of cervical cancer screening. By acknowledging and dismantling these obstacles, progress can be made toward the World Health Organization's vision of eradicating cervical cancer through proactive screening, timely detection, and effective treatment, especially in regions with limited resources and high disease burdens. 

References

  1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, et. al., (2021). Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin.,1(3):209-249.
    View at Publisher | View at Google Scholar
  2. Obeagu GU, Obeagu EI. (2023). An update on premalignant cervical lesions and cervical cancer screening services among HIV positive women. Journal of Public Health and Nutrition. 6(2):141.
    View at Publisher | View at Google Scholar
  3. Adebayo IA. (2021). Prevalence of high-risk HPV types in women with cervical cancer in Eastern Uganda. Journal of Biomedical and Clinical Sciences (JBCS), 6(1), 45-56.
    View at Publisher | View at Google Scholar
  4. Bogani G, Lalli L, Sopracordevole F, Ciavattini A, Ghelardi A, et al. (2022). Development of a Nomogram Predicting the risk of Persistence/Recurrence of cervical dysplasia. Vaccines (Basel). 10(4):1-11.
    View at Publisher | View at Google Scholar
  5. US Preventive Services Task Force. Screen Cerv Cancer. 2018;52242(7):674-86.
    View at Publisher | View at Google Scholar
  6. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, (2018). Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 68(6):394-424.
    View at Publisher | View at Google Scholar
  7. Achampong Y, Kokka F, Doufekas K, Olaitan A, Achampong Y, et al. (2018). Prevention of Cervical Cancer. J Cancer Ther.9(1):79-88.
    View at Publisher | View at Google Scholar
  8. Alum EU, Ugwu OPC, Obeagu EI, et al. (2023). Curtailing HIV/AIDS spread: impact of religious leaders. Newport Int J Res Med Sci (NIJRMS). 3:28-31.
    View at Publisher | View at Google Scholar
  9. Obeagu EI, Nwosu DC, Ugwu OPC, Alum EU. (2023). Adverse Drug Reactions in HIV/AIDS Patients on Highly Active Antiretro Viral Therapy: A Review of Prevalence. NEWPORT INTERNATIONAL JOURNAL OF SCIENTIFIC AND EXPERIMENTAL SCIENCES (NIJSES). 4(1):43-47.
    View at Publisher | View at Google Scholar
  10. Alum EU, Obeagu EI, Ugwu OPC, Okon MB. (2023). HIV infection and cardiovascular diseases: the obnoxious duos. Newport Int J Res Med Sci (NIJRMS). 3:95-99.
    View at Publisher | View at Google Scholar
  11. Obeagu EI, Alum EU, Obeagu GU. (2023). Factors associated with prevalence of HIV among youths: a review of Africa perspective. Madonna Univ J Med Health Sci. 3:13–18.
    View at Publisher | View at Google Scholar
  12. Alum EU, Obeagu EI, Ugwu OPC, Samson AO, Adepoju AO, (2023). Inclusion of nutritional counseling and mental health services in HIV/AIDS management: A paradigm shift. Medicine. 102:41(e35673).
    View at Publisher | View at Google Scholar
  13. Alum EU, Ugwu OPC, Obeagu EI, Aja PM, Okon MB, Uti DE. (2023). Reducing HIV Infection Rate in Women: A Catalyst to reducing HIV Infection pervasiveness in Africa. International Journal of Innovative and Applied Research. 11(10):01-06.
    View at Publisher | View at Google Scholar
  14. Obeagu EI, Omar DE, Bunu UO, Obeagu GU, Alum EU, (2023). Leukaemia burden in Africa. Int. J. Curr. Res. Biol. Med., (1): 17- 22.
    View at Publisher | View at Google Scholar
  15. Ibiam UA, Uti DE, Ejeogo CC, Orji OU, Aja PM, et al. (2023). In Vivo and in Silico Assessment of Ameliorative Effects of Xylopia aethiopica on Testosterone Propionate-Induced Benign Prostatic Hyperplasia. Pharmaceut Fronts. 5: e64–e76.
    View at Publisher | View at Google Scholar
  16. Alum EU, Obeagu EI, Ugwu OPC, Orji OU, Adepoju AO, et. al., (2023). Exploring natural plant products in breast cancer management: A comprehensive review and future prospects. International Journal of Innovative and Applied Research. 11(12):1-9.
    View at Publisher | View at Google Scholar
  17. Obeagu EI, Ahmed YA, Obeagu GU, Bunu UO, Ugwu OPC, (2023). Biomarkers of breast cancer: Overview. Int. J. Curr. Res. Biol. Med., (1): 8-16.
    View at Publisher | View at Google Scholar
  18. Aja PM, Agu PC, Ezeh EM, Awoke JN, Ogwoni HA, et al. (2021). Prospect into therapeutic potentials of Moringa oleifera phytocompounds against cancer upsurge: de novo synthesis of test compounds, molecular docking, and ADMET studies. Bulletin of the National Research Centre. 45(1): 1-18.
    View at Publisher | View at Google Scholar
  19. Obeagu EI, Obeagu GU, Alum EU, Ugwu OPC. (2023). Prostate Cancer: Review on Risk Factors. Eurasian Experiment Journal of Public Health (EEJPH). 4(1): 4-7.
    View at Publisher | View at Google Scholar
  20. Obeagu EI, Omar DE, Bunu UO, Obeagu GU, Alum EU, (2023). Benign Prostatic Hyperplasia: A Review. Eurasian Experiment Journal of Public Health (EEJPH). 4(1): 1-3.
    View at Publisher | View at Google Scholar
  21. Musa J, Nankat J, Achenbach CJ, Shambe IH, Taiwo BO, et al. (2016). Cervical cancer survival in a resource-limited setting-North Central Nigeria. Infect Agent Cancer. 11(1):1-7.
    View at Publisher | View at Google Scholar
  22. Musa J, Achenbach CJ, Evans CT, Jordan N, Daru PH, et al. (2019). HIV status, age at cervical Cancer screening and cervical cytology outcomes in an opportunistic screening setting in Nigeria: a 10-year Cross sectional data analysis. Infect Agent Cancer. 14(1). 
    View at Publisher | View at Google Scholar
  23. Vhuromu EN, Goon T, Maputle D, Lebese MS, Okafor RT. (2018). Utilization of Cervical Cancer Screening Services among women in Vhembe District, South Africa: a cross-sectional study. Open Public Health J. 11(1):451-463.
    View at Publisher | View at Google Scholar
  24. Momberg M, Botha MH, Van Der Merwe FH, Moodley J. (2017). Women’s experiences with cervical cancer screening in a colposcopy referral clinic in Cape Town, South Africa: a qualitative analysis. BMJ Open. 7(2):1–6.
    View at Publisher | View at Google Scholar
  25. Al-Amoudi S, Cañas J, Hohl SD, Distelhorst SR, Thompson B. (2015). Breaking the silence: breast Cancer knowledge and beliefs among somali muslim women in Seattle, Washington. Health Care Women Int. 36(5):608–616.
    View at Publisher | View at Google Scholar
  26. World health Organization (2020). Global strategy to accelerate the elimination of cervical cancer as a public health problem. 
    View at Publisher | View at Google Scholar
  27. Arbyn M, Weiderpass E, Bruni L, de Sanjosé S, Saraiya M, Ferlay J, (2020). Estimates of incidence and mortality of Cervical cancer in 2018: a worldwide analysis. Lancet Glob Health. 8(2): e191-203. 
    View at Publisher | View at Google Scholar
  28. Nyamambi E, Murendo C, Sibanda N, Mazinyane N. (2020). Knowledge, attitudes and barriers of Cervical cancer screening among women in Chegutu rural district of Zimbabwe. Cogent Soc Sci. 6(1):1766784. 
    View at Publisher | View at Google Scholar
  29. Getachew S, Getachew E, Gizaw M, Ayele W, Addissie A, (2019). Cervical cancer screening knowledge and barriers among women in Addis Ababa, Ethiopia. PLoS One. 4(5): e0216522.
    View at Publisher | View at Google Scholar
  30. Alum EU, Famurewa AC, Orji OU, Aja PM, Nwite F, et. al., (2023). Nephroprotective effects of Datura stramonium leaves against methotrexate nephrotoxicity via attenuation of oxidative stress-mediated inflammation and apoptosis in rats. Avicenna J Phytomed. 13(4): 377-387.
    View at Publisher | View at Google Scholar
  31. Alum EU, Inya JE, Ugwu OPC, Obeagu IE, Aloke C, et. al., (2023). Ethanolic leaf extract of Datura stramonium attenuates Methotrexate-induced Biochemical Alterations in Wistar Albino rats. RPS Pharmacy and Pharmacology Reports.; 2(1):1–6.
    View at Publisher | View at Google Scholar
  32. Alum EU, Ugwu OPC. (2023). Beyond Nutrients: Exploring the Potential of Phytochemicals for Human Health. IAA Journal of Applied Sciences. 10(3):1-7.
    View at Publisher | View at Google Scholar
  33. Aloke C, Ibiam UA, Obasi NA, Orji OU, Ezeani NN, (2019). Effect of ethanol and aqueous extracts of seed pod of Copaifera salikounda (Heckel) on complete Freund's adjuvant-induced rheumatoid arthritis in rats. J Food Biochem. 43(7):e12912.
    View at Publisher | View at Google Scholar
  34. Ezeani NN, Ibiam UA, Orji OU, et al. (2019). Effects of Aqueous and Ethanol Root Extracts of Olax subscopioidea on Inflammatory Parameters in Complete Freund’s Adjuvant-Collagen Type II Induced Arthritic Albino Rats. Pharmacog J. 11(1):16-25.
    View at Publisher | View at Google Scholar
  35. Alum EU, Ibiam UA, Ugwuja EI, Aja PM, Igwenyi I.O, et al. (2022). Antioxidant Effect of Buchholzia coriacea Ethanol Leaf Extract and Fractions on Freund’s Adjuvant-induced Arthritis in Albino Rats: A Comparative Study. Slovenian Veterinary Research.; 59 (1): 31-45.
    View at Publisher | View at Google Scholar
  36. Egwu CO, Offor CE, Alum EU. (2017). Anti-diabetic effects of Buchholzia coriacea ethanol seed Extract and Vildagliptin on Alloxan-induced diabetic albino Rats. International Journal of Biology, Pharmacy and Allied Sciences (IJBPAS). 6 (6): 1304-1314.
    View at Publisher | View at Google Scholar
  37. Agbafor KN, Onuoha SC, Ominyi MC, Orinya OF, Ezeani N, (2015). Antidiabetic, Hypolipidemic and Antiathrogenic Properties of Leaf Extracts of Ageratum conyzoides in Streptozotocin-Induced diabetic rats. International Journal of Current Microbiology and Applied Sciences. 4 (11):816-824.
    View at Publisher | View at Google Scholar
  38. Aja PM, Igwenyi IO, Ugwu OPC, Orji OU, Alum EU. (). Evaluation of Anti-diabetic Effect and Liver Function Indices of Ethanol Extracts of Moringa oleifera and Cajanus cajan Leaves in Alloxan Induced Diabetic Albino Rats. Global Veterinaria. 2015;14(3): 439-447. DOI: 10.5829/idosi.gv.2015.14.03.93129.
    View at Publisher | View at Google Scholar
  39. Ugwu OPC, Alum EU, Okon MB, Aja PM, Obeagu EI, (2023). Ethanol root extract and fractions of Sphenocentrumjollyanum abrogate hyperglycemia and low body weight in Streptozotocin-induced diabetic Wistar albino Rats, RPS Pharmacy and Pharmacology Reports. 2,1-6.
    View at Publisher | View at Google Scholar
  40. Offor CE, Ugwu OPC, Alum EU. (2014). The Anti-Diabetic Effect of Ethanol Leaf-Extract of Allium sativum on Albino Rats. International Journal of Pharmacy and Medical Sciences. 4 (1): 01-03.
    View at Publisher | View at Google Scholar
  41. Uti DE, Igile GO, Omang WA, Umoru GU, Udeozor PA, et. al., (2021). .Anti-Diabetic Potentials of Vernonioside E Saponin; A Biochemical Study. Natural Volatiles and Essential Oils. 8(4): 14234-14254.
    View at Publisher | View at Google Scholar
  42. Kungu E, Inyangat R, Ugwu OPC, (2023). Alum EU. Exploration of Medicinal Plants Used in the Management of Malaria in Uganda. NEWPORT INTERNATIONAL JOURNAL OF RESEARCH IN MEDICAL SCIENCES. 4(1):101-108.
    View at Publisher | View at Google Scholar
  43. Ekpono E U, Aja PM, Ibiam UA, Alum EU, Ekpono UE. (2019). Ethanol Root-extract of Sphenocentrum jollyanum Restored Altered Haematological Markers in Plasmodium berghei-infected Mice. Earthline Journal of Chemical Sciences. 2 (2):189203. 
    View at Publisher | View at Google Scholar
  44. Aja, P. M., Uzuegbu, U. E., Opajobi, A. O., Udeh, S. M. C., Alum, E. U., et. al., (2017). Comparative effect of ethanol leaf-extracts of ficus capensis and moringa oleifera on some haematological indices in normal albino rats. Indonesian American Journal of Pharmaceutical Sciences, 4(2), 471–476.
    View at Publisher | View at Google Scholar
  45. Alum EU, Ugwu OPC, Aja PM, Obeagu EI, Inya JE, et al. (2023). Restorative effects of ethanolic leaf extract of Datura stramonium against methotrexate-induced hematological impairments, Cogent Food & Agriculture. 9:1,
    View at Publisher | View at Google Scholar
  46. Aja PM, Igwenyi IO, Ugwu OPC, Orji OU, Alum EU. (2015). Evaluation of Anti-diabetic Effect and Liver Function Indices of Ethanol Extracts of Moringa oleifera and Cajanus cajan Leaves in Alloxan Induced Diabetic Albino Rats. Global Veterinaria. 14(3): 439-447.
    View at Publisher | View at Google Scholar
  47. Ugwu OPC, Obeagu EI, Alum EU, Okon BM, Aja PM, et. al., (2023). Effect of Ethanol Leaf extract of Chromolaena odorata on hepatic markers in streptozotocin-induced diabetic wistar albino rats. IAA Journal of Applied Sciences, 9(1):46-56.
    View at Publisher | View at Google Scholar
  48. Alum EU, Umoru GU, Uti DE, Aja PM, Ugwu OP, et. al., (2022). Hepato-protective effect of Ethanol Leaf Extract of Datura stramonium in Alloxan-induced Diabetic Albino Rats. Journal of Chemical Society of Nigeria.; 47 (3): 1165 – 1176.
    View at Publisher | View at Google Scholar
  49. Keneema M. Factors Affecting Uptake of Cervical Cancer Screening Services Among Women Aged 25-49 Attending Antenatal Clinic At Rukunyu Health Center Iv, Kamwenge District (Doctoral dissertation, International Health Sciences University); 2018.
    View at Publisher | View at Google Scholar
  50. Learmonth D, Hakala S, Keller M. “I can't carry on like this”: barriers to exiting the street-based sex trade in South Africa. Health Psychol Behav Med. 2015;3(1):34-65.
    View at Publisher | View at Google Scholar
  51. Munthali AC, Ngwira BM, Taulo F. (2015). Exploring barriers to the delivery of Cervical cancer screening and early treatment services in Malawi: some views from service providers. Patient Preference Adherence. 9:501–518
    View at Publisher | View at Google Scholar
  52. Mwaka AD, Wabinga HR, Mayanja-Kizza H. Mind the gaps: a qualitative study of perceptions of healthcare professionals on challenges and proposed remedies for Cervical cancer help-seeking in post conflict northern Uganda. BMC Fam Pract. 2013; 14:193.
    View at Publisher | View at Google Scholar
  53. Ari ES, Dioso RIP, Sotunsa JO. Improving care seeking behavior toward cervical cancer screening participation among Gwafan community women, North-Central Nigeria. BMC Women's Health 23, 356 (2023).
    View at Publisher | View at Google Scholar
  54. Harries J, Scott SE, Walter FM, et al. (2020). Women’s appraisal, interpretation and help-seeking for possible symptoms of breast and Cervical cancer in South Africa: a qualitative study. BMC Womens Health. 20:251. 
    View at Publisher | View at Google Scholar
  55. Kangmennaang J, Onyango EO, Luginaah I, Elliott SJ. (2018). The next Sub-Saharan African epidemic? A case study of the determinants of Cervical cancer knowledge and screening in Kenya. Soc Sci Med. 197:203.
    View at Publisher | View at Google Scholar
  56. Ndejjo R, Mukama T, Musabyimana A, Musoke D. (2016  ). Uptake of Cervical cancer Screening and Associated Factors among Women in Rural Uganda: A Cross Sectional Study. PLoS One.
    View at Publisher | View at Google Scholar
  57. Gu C, Chan CW, Chow KM, Yang S, Luo Y, (2018). Understanding the cervical screening behaviour of Chinese women: The role of health care system and health professions. Appl Nurs Res. 39:58-64.
    View at Publisher | View at Google Scholar
  58. Megersa BS, Bussmann H, Bärnighausen T, Muche AA, Alemu K, et. al., (2020). Community Cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study. PLoS ONE. 15(12):
    View at Publisher | View at Google Scholar
  59. Ampofo AG, Adumatta AD, Owusu E, Awuviry-Newton K. (2020). A cross-sectional study of barriers to Cervical cancer screening uptake in Ghana: An application of the health belief model. PLoS One. 15(4): e0231459.
    View at Publisher | View at Google Scholar
  60. Nugus P, Désalliers J, Morales J, Graves L, Evans A, et. al., (2018). Localizing Global Medicine: Challenges and Opportunities in Cervical Screening in an Indigenous Community in Ecuador. Qual Health Res. 28(5):800–12.
    View at Publisher | View at Google Scholar
  61. Gottschlich A, Rivera-Andrade A, Bevilacqua K, et al. (2020). Using self-collection HPV testing to increase engagement in Cervical cancer screening programs in rural Guatemala: a longitudinal analysis. BMC Public Health. 20:1406. 
    View at Publisher | View at Google Scholar
  62. Oketch SY, Kwena Z, Choi Y, et al. (2019). Perspectives of women participating in a Cervical cancer screening campaign with community-based HPV self-sampling in rural western Kenya: a qualitative study. BMC Women’s Health. 19:75. 
    View at Publisher | View at Google Scholar
  63. Adewumi K, Oketch SY, Choi Y, et al. (2019). Female perspectives on male involvement in a human-papillomavirus-based Cervical cancer-screening program in western Kenya. BMC Womens Health. 19:107. 
    View at Publisher | View at Google Scholar
  64. Gwavu Z, Murray D, Okafor UB. Perception of Women's Knowledge of and Attitudes towards Cervical Cancer and Papanicolaou Smear Screenings: A Qualitative Study in South Africa. Healthcare (Basel). 2023 Jul 21;11(14):2089. doi: 10.3390/healthcare11142089.
    View at Publisher | View at Google Scholar
  65. Stewart K, Li M, Xia Z, et al. (2020). Modeling spatial access to Cervical cancer screening services in Ondo State, Nigeria. Int J Health Geogr. 19:28.
    View at Publisher | View at Google Scholar
  66. Hasahya OT, Berggren V, Sematimba D, Nabirye RC, Kumakech E. (2016). Beliefs, perceptions and health-seeking behaviours in relation to Cervical cancer: a qualitative study among women in Uganda following completion of an HPV vaccination campaign. Glob Health Action. 9:29336. 
    View at Publisher | View at Google Scholar
  67. Tiruneh FN, Chuang KY, Ntenda P, Chuang YC. (2017). Individual-level and community-level determinants of Cervical cancer screening among Kenyan women: a multilevel analysis of a Nationwide survey. BMC Womens Health. 17(1):109. 
    View at Publisher | View at Google Scholar
  68. Baussano I, Tshering S, Choden T, Lazzarato F, Tenet V, et al. (2017). Cervical cancer screening in rural Bhutan with the care HPV test on self-collected samples: an ongoing cross-sectional, population-based study (REACH-Bhutan). BMJ Open. 7(7):1–10.
    View at Publisher | View at Google Scholar
  69. Antinyan A, Bertoni M, Corazzini L. (2021). Cervical cancer screening invitations in low and middle income countries: Evidence from Armenia. Soc Sci Med [Internet]
    View at Publisher | View at Google Scholar
  70. Spagnoletti B, Bennett LR, Wahdi AE, Wilopo SA, Keenan CA. A (2019). Qualitative Study of Parental Knowledge and Perceptions of Human Papillomavirus and Cervical cancer Prevention in Rural Central Java, Indonesia: Understanding Community Readiness for Prevention Interventions. Asian Pac J Cancer Prev. 20(8):2429–2434
    View at Publisher | View at Google Scholar
a