Cervical cancer management in Zimbabwe (2019-2020).

BACKGROUND: Globally, cervical cancer is the fourth most commonly diagnosed cancer amongst women, and it is especially common in low- and middle-income countries (LMICs). The aim of the study was to determine the current patterns and characteristics of CC management in Zimbabwe in the HIV pandemic era, including the knowledge, attitude and practice of patience. METHODS: The study was a mixed method which incorporated a cross-sectional survey of 408 CC patients which was conducted from October 2019 to September 2020 using an interviewer administered paper questionnaire. The study was conducted at Parirenyatwa hospital, the only cancer treating public health facility in Harare, Zimbabwe. Differences in study outcome by categorical variables were assessed using the Person Chi-square (χ2) test. Odds ratios (unadjusted and adjusted) and 95%CIs for potential risk factors associated with the outcome were estimated using logistic regression model. RESULTS: From a total of 408 CC patients recruited into the study no prevention mechanism was available or known to these patients and only 13% knew that CC is caused by Human papillomavirus. Only 87 (21%) had ever been screened for CC and 83 (97%) of those who had been screened had the visual inspection with acetic acid procedure done. Prevention (screening uptake) is statistically high among the educated (with secondary education OR = 9.497, 95%CI: 2.349-38.390; with tertiary OR = 59.381, 95%CI: 11.937-295.380). Late presentation varied statistically significantly with marital status (high among the divorced, OR = 2.866; 95% CI: 1.549-5.305 and widowed OR = 1.997; 95% CI: 1.112-3.587), was low among the educated (Tertiary OR = .393; 95% CI: .166-.934), low among those living in the rural (OR = .613; 95% CI: .375-.987), high among those with higher parity OR = 1.294; 95% CI: 1.163-1.439). Less than 1% of the patients had surgery done as a means of treatment. Radiotherapy was administered to 350 (86%) of the patients compared to chemotherapy administered to 155 (38%). A total of 350 (86%) have failed to take medication due to its unavailability, while 344 (85%) missed taking medication due to unaffordability. Complementary and alternative medicines were utilized by 235 (58%). Majority, 278 (68%) were HIV positive, mainly pronounced within age (36-49 years OR = 12.673; 95% CI: 2.110-76.137), among those with higher education (secondary education OR = 4.981; 95%CI: 1.394-17.802 and in those with no co-morbidities (893.956; 95%CI: 129.611-6165.810). CONCLUSION: CC management was inadequate from prevention, screening, diagnosis, treatment and palliative care hence there is need to improve CC management in Zimbabwe if morbidity and mortality are to be reduced to acceptable levels. Education helped improve prevention, but reduces chances of diagnosis, working as a doubled edged sword in CC management Prevention was high among the educated. Those in rural areas experience poor CC management. It should be noted that general education is good; however it must be complimented by CC awareness to improve CC management outcomes holistically. Cervical cancer management services need to be decentralized so that those in rural areas have easy access. Given that those with co-morbidities and high parity have better CC management, CC services need to be tied to co-morbidity and antenatal/post-natal care and management services.

Mapping Evidence on Management of Cervical Cancer in Sub-Saharan Africa: Scoping Review.

Cervical cancer (CC) is the most common viral infection of the reproductive tract and in Sub-Saharan Africa (SSA), its morbidity and mortality rates are high. The aim of this review was to map evidence on CC management in SSA. The scoping review was conducted in accordance with Arksey and O'Malley's scoping review framework. The review included studies on different aspects of CC management. The review was also done following the steps and guidelines outlined in the PRISMA-Extension for Scoping Reviews (PRISMA-ScR) checklist. The following databases were searched: PubMed, EBSCOhost, Scopus and Cochrane Database of Systematic Review. A total of 1121 studies were retrieved and 49 which were eligible for data extraction were included in the review. The studies were classifiable in 5 groups: 14 (28.57%) were on barriers to CC screening, 10 (20.41%) on factors associated with late-stage presentation at diagnosis, 11 (22.45%) on status of radiotherapy, 4 (8.20%) on status of chemotherapy and 10 (20.41%) on factors associated with high HPV coverage. High HPV vaccine coverage can be achieved using the class school-based strategy with opt-out consent form process. Barriers to CC screening uptake included lack of knowledge and awareness and unavailability of screening services. The reasons for late-stage presentation at diagnosis were unavailability of screening services, delaying whilst using complementary and alternative medicines and poor referral systems. The challenges in chemotherapy included unavailability and affordability, low survival rates, treatment interruption due to stock-outs as well as late presentation. Major challenges on radiotherapy were unavailability of radiotherapy, treatment interruption due to financial constraints, and machine breakdown and low quality of life. A gap in understanding the status of CC management in SSA has been revealed by the study implying that, without full knowledge of the extent of CC management, the challenges and opportunities, it will be difficult to reduce infection, improve treatment and palliative care. Research projects assessing knowledge, attitude and practice of those in immediate care of girls at vaccination age, situational analysis with health professionals and views of patients themselves is important to guide CC management practice.

Knowledge, attitude and practice towards cervical cancer prevention among mothers of girls aged between 9 and 14 years: a cross sectional survey in Zimbabwe.

BACKGROUND: Cervical cancer (CC) morbidity and mortality is still high in developing countries like Zimbabwe. Treatment for CC is out of reach for many women, hence the need to maximise on prevention which mainly includes screening and administering human papillomavirus (HPV) vaccine. Knowledge about CC prevention is a prerequisite for utilisation of all the available options for CC prevention, yet little is known about its levels and the corresponding attitudes and practices on cancer prevention methods within the society. METHODS: A cross sectional survey was done to assess knowledge, attitude and practice (KAP) on CC prevention among mothers of girls aged between 9 and 14 years in Zimbabwe as well as factors explaining the KAP. Four hundred and six mothers participate. Descriptive and inferential statistics (binary logistic regression and Chi-Square test of association) were applied to determine participant characteristics with KAP using STATA version 16 software. FINDINGS: Overall KAP of cervical cancer prevention is in a poor state. The knowledge was poor with 24% being able to say CC is caused by HPV; the attitude is negative with 58% being of the opinion that CC is caused by witchcraft and it is a death sentence, while the bad practices of relying only on traditional means were being practiced. Factors associated with knowledge are: not having medical aid (odds: 0.17, 95%CI: 0.05-0.59, p = 0.005) and high levels of education (secondary level odds: 4.20; 95%CI: 2.25-7.84 p < 0.001 and tertiary odds: 7.75; 95%CI: 2.04-29.45, p-value: 0.003 compared to primary education). Attitude towards CC management was driven by levels of education (secondary level odds: 0.39, 95%CI: 0.20-0.78, p = 0.007 and tertiary odds: 0.12, 95%CI: 0.04-0.33, p < 0.001), the same factor increases odds of good practice (secondary odds: 3.78, 95%CI: 1.99-7.18, p < 0.001 and tertiary odds: 3.78, 95%CI: 1.99-7.18, p < 0.001). On the other hand, HPV vaccine knowledge was also very moderate (with majority of mothers not knowing the right age of vaccination; vaccine acceptability was high (90%), but uptake was very low (8% had their daughter vaccinated). CONCLUSION: KAP about CC prevention was poor with factors necessary for improvement of KAP identified as education, medical insurance coverage. Making health education easily accessible in schools, primary health facilities and various media platforms will help to address the myths on causes of CC and how it can be treated. Health education and availability of free screening services and free vaccine will improve CC prevention out outcomes.

Mapping evidence on management of cervical cancer in sub-Saharan Africa: scoping review protocol.

BACKGROUND: Cancer is a non-communicable disease and is the number 2 leading cause of death globally. Among all cancers, cervical cancer is the number 1 killer of women in low-income countries (LICs). Cervical cancer is a well understood preventable cancer. The rates of cervical cancer are very varied and inversely proportional to the effectiveness of disease management policies. Management of cervical cancer includes prevention, screening, diagnosis and treatment. The main objective of this scoping review is to map the evidence on cervical cancer management in sub-Saharan Africa (SSA) to understand the coverage of cervical cancer prevention and treatment services and provide an opportunity to generate knowledge on the risk factors, attitudes and practices extendable globally. METHODS AND ANALYSIS: This review will be guided by Arksey and O'Malley's framework recommended for conducting scoping review studies. The Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews (PRISMA-Scr) checklist will also be completed to ensure that the review adheres to the sound methodological rigour acceptable for scoping review studies. The following electronic databases will be searched for potentially eligible articles: PubMed, Ebsco Host, Scopus and Cochrane Database of Systematic Reviews. Study screening procedures recommended by Higgins and Deeks will be followed. A narrative synthesis will be used, with data synthesised and interpreted using sifting, charting and sorting based on themes and key issues. DISCUSSION: Cervical cancer can become a disease of the past with a proper control strategy in place. It is therefore imperative to map available evidence on the management of cervical cancer to inform policy and advocacy action. More knowledge on the status quo will guide policymakers in ensuring cancer management guiding policies are formulated/updated/revised accordingly. SYSTEMATIC REVIEW REGISTRATION: Not registered with PROSPERO (not needed). PROTOCOL AND REGISTRATION: This scoping review was not registered.

Calcium supplementation commencing before or early in pregnancy, for preventing hypertensive disorders of pregnancy.

BACKGROUND: The hypertensive disorders of pregnancy include pre-eclampsia, gestational hypertension, chronic hypertension, and undefined hypertension. Pre-eclampsia is considerably more prevalent in low-income than in high-income countries. One possible explanation for this discrepancy is dietary differences, particularly calcium deficiency. Calcium supplementation in the second half of pregnancy reduces the serious consequences of pre-eclampsia, but has limited effect on the overall risk of pre-eclampsia. It is important to establish whether calcium supplementation before, and in early pregnancy (before 20 weeks' gestation) has added benefit. Such evidence could count towards justification of population-level interventions to improve dietary calcium intake, including fortification of staple foods with calcium, especially in contexts where dietary calcium intake is known to be inadequate. This is an update of a review first published in 2017. OBJECTIVES: To determine the effect of calcium supplementation, given before or early in pregnancy and for at least the first half of pregnancy, on pre-eclampsia and other hypertensive disorders, maternal morbidity and mortality, and fetal and neonatal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Trials Register (31 July 2018), PubMed (13 July 2018), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP; 31 July 2018), and reference lists of retrieved studies. SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCT) of calcium supplementation, including women not yet pregnant, or women in early pregnancy. Cluster-RCTs, quasi-RCTs, and trials published as abstracts were eligible, but we did not identify any. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. They assessed the quality of the evidence for key outcomes using the GRADE approach. MAIN RESULTS: Calcium versus placeboWe included one study (1355 women), which took place across multiple hospital sites in Argentina, South Africa, and Zimbabwe. Most analyses were conducted only on 633 women from this group who were known to have conceived, or on 579 who reached 20 weeks' gestation; the trial was at moderate risk of bias due to high attrition rates pre-conception. Non-pregnant women with previous pre-eclampsia received either calcium 500 mg daily or placebo, from enrolment until 20 weeks' gestation. All participants received calcium 1.5 g daily from 20 weeks until birth.Primary outcomes: calcium supplementation commencing before conception may make little or no difference to the risk of pre-eclampsia (69/296 versus 82/283, risk ratio (RR) 0.80, 95% confidence interval (CI) 0.61 to 1.06; low-quality evidence). For pre-eclampsia or pregnancy loss or stillbirth (or both) at any gestational age, calcium may slightly reduce the risk of this composite outcome, however the 95% CI met the line of no effect (RR 0.82, 95% CI 0.66 to 1.00; low-quality evidence). Supplementation may make little or no difference to the severe maternal morbidity and mortality index (RR 0.93, 95% CI 0.68 to 1.26; low-quality evidence), pregnancy loss or stillbirth at any gestational age (RR 0.83, 95% CI 0.61 to 1,14; low-quality evidence), or caesarean section (RR 1.11, 95% CI 0.96 to 1,28; low-quality evidence).Calcium supplementation may make little or no difference to the following secondary outcomes: birthweight < 2500 g (RR 1.00, 95% CI 0.76 to 1.30; low-quality evidence), preterm birth < 37 weeks (RR 0.90, 95% CI 0.74 to 1.10), early preterm birth < 32 weeks (RR 0.79, 95% CI 0.56 to 1.12), and pregnancy loss, stillbirth or neonatal death before discharge (RR 0.82, 95% CI 0.61 to 1.10; low-quality evidence), no conception, gestational hypertension, gestational proteinuria, severe gestational hypertension, severe pre-eclampsia, severe pre-eclamptic complications index. There was no clear evidence on whether or not calcium might make a difference to perinatal death, or neonatal intensive care unit admission for > 24h, or both (RR 1.11, 95% CI 0.77 to 1.60; low-quality evidence).It is unclear what impact calcium supplementation has on Apgar score < 7 at five minutes (RR 0.43, 95% CI 0.15 to 1.21; very low-quality evidence), stillbirth, early onset pre-eclampsia, eclampsia, placental abruption, intensive care unit admission > 24 hours, maternal death, hospital stay > 7 days from birth, and pregnancy loss before 20 weeks' gestation. AUTHORS' CONCLUSIONS: The single included study suggested that calcium supplementation before and early in pregnancy may reduce the risk of women experiencing the composite outcome pre-eclampsia or pregnancy loss at any gestational age, but the results are inconclusive for all other outcomes for women and babies. Therefore, current evidence neither supports nor refutes the routine use of calcium supplementation before conception and in early pregnancy.To determine the overall benefit of calcium supplementation commenced before or in early pregnancy, the effects found in the study of calcium supplementation limited to the first half of pregnancy need to be added to the known benefits of calcium supplementation in the second half of pregnancy.Further research is needed to confirm whether initiating calcium supplementation pre- or in early pregnancy is associated with a reduction in adverse pregnancy outcomes for mother and baby. Research could also address the acceptability of the intervention to women, which was not covered by this review update.

Participant recruitment and retention in longitudinal preconception randomized trials: lessons learnt from the Calcium And Pre-eclampsia (CAP) trial.

BACKGROUND: The preconception period has the potential to influence pregnancy outcomes and randomized controlled trials (RCTs) are needed to evaluate a variety of potentially beneficial preconception interventions. However, RCTs commencing before pregnancy have significant participant recruitment and retention challenges. The Calcium And Pre-eclampsia trial (CAP trial) is a World Health Organization multi-country RCT of calcium supplementation commenced before pregnancy to prevent recurrent pre-eclampsia in which non-pregnant participants are recruited and followed up until childbirth. This sub-study explores recruitment methods and preconception retention of participants of the CAP trial to inform future trials. METHODS: Recruiters at the study sites in Argentina, South Africa and Zimbabwe completed post-recruitment phase questionnaires on recruitment methods used. Qualitative data from these questionnaires and quantitative data on pre-pregnancy trial visit attendance and pregnancy rates up to September 2016 are reported in this paper. RStudio (Version 0.99.903 https://www.rstudio.org ) statistical software was used for summary statistics. RESULTS: Between July 2011 and 8 September 2016, 1354 women with previous pre-eclampsia were recruited. Recruitment took 2 years longer than expected and was facilitated mainly through medical record/register and maternity ward/clinic-based strategies. Recruiters highlighted difficulties associated with inadequate medical records, redundant patient contact details, and follow-up of temporarily ineligible women as some of the challenges faced. Whilst the attendance rates at pre-pregnancy visits were high (78% or more), visits often occurred later than scheduled. Forty-five percent of participants became pregnant (614/1354), 33.5% (454/1354) within 1 year of randomization. CONCLUSIONS: In preconception trials, both retrospective and prospective methods are useful for recruiting eligible women with certain conditions. However, these are time-consuming in low-resource settings with suboptimal medical records and other challenges. Trial planners should ensure that trial budgets cover sufficient on-site researchers with pre-trial training, and should consider using mobile phone and web-based electronic tools to optimize recruitment and retention. This should lead to greater efficiency and shorter trial durations. TRIAL REGISTRATION: Pan-African Clinical Trials Registry, Registration Number: PACTR201105000267371 . The trial was registered on 6 December 2016.

Calcium supplementation commencing before or early in pregnancy, or food fortification with calcium, for preventing hypertensive disorders of pregnancy.

BACKGROUND: Pre-eclampsia is considerably more prevalent in low- than high-income countries. One possible explanation for this discrepancy is dietary differences, particularly calcium deficiency. Calcium supplementation in the second half of pregnancy reduces the serious consequences of pre-eclampsia and is recommended by the World Health Organization (WHO) for women with low dietary calcium intake, but has limited effect on the overall risk of pre-eclampsia. It is important to establish whether calcium supplementation before and in early pregnancy has added benefit. Such evidence would be justification for population-level fortification of staple foods with calcium. OBJECTIVES: To determine the effect of calcium supplementation or food fortification with calcium, commenced before or early in pregnancy and continued at least until mid-pregnancy, on pre-eclampsia and other hypertensive disorders, maternal morbidity and mortality, as well as fetal and neonatal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Trials Register (10 August 2017), PubMed (29 June 2017), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (10 August 2017) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials of calcium supplementation or food fortification which include women of child bearing age not yet pregnant, or in early pregnancy. Cluster-RCTs, quasi-RCTs and trials published in abstract form only would have been eligible for inclusion in this review but none were identified. Cross-over designs are not appropriate for this intervention.The scope of this review is to consider interventions including calcium supplementation with or without additional supplements or treatments, compared with placebo or no intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: This review is based on one RCT (involving 60 women) which looked at calcium plus additional supplements versus control. The women (who had low antioxidant status) were in the early stages of pregnancy. We did not identify any studies where supplementation commenced pre-pregnancy. Another RCT comparing calcium versus placebo is ongoing but not yet complete. We did not identify any studies looking at any of our other planned comparisons. Calcium plus antioxidants and other supplements versus placeboWe included one small study (involving 60 women with low antioxidant levels) which was conducted in an academic hospital in Indondesia. The study was at low risk of bias for all domains with the exception of selective reporting, for which it was unclear. Women in the intervention group received calcium (800 mg) plus N-acetylcysteine (200 mg), Cu (2 mg), Zn (15 mg), Mn (0.5 mg) and selenium (100 mcg) and vitamins A (1000 IU), B6 (2.2 mg), B12 (2.2 mcg), C (200 mg), and E (400 IU) versus the placebo control group of women who received similar looking tablets containing iron and folic acid. Both groups received iron (30 mg) and folic acid (400 mcg). Tablets were taken twice daily from eight to 12 weeks of gestation and then throughout pregnancy.The included study found that calcium supplementation plus antioxidants and other supplements may slightly reduce pre-eclampsia (gestational hypertension and proteinuria) (risk ratio (RR) 0.24, 95% confidence interval (CI) 0.06 to 1.01; low-quality evidence), but this is uncertain due to wide confidence intervals just crossing the line of no effect, and small sample size. It appears that earlypregnancy loss before 20 weeks' gestation (RR 0.06, 95% CI 0.00 to 1.04; moderate-quality evidence) may be slightly reduced by calcium plus antioxidants and other supplements, but this outcome also has wide confidence intervals, which just cross the line of no effect. Very few events were reported under the composite outcome, severe maternal morbidity and mortality index and no clear difference was seen between groups (RR 0.36, 95% CI 0.04 to 3.23; low-quality evidence). However, the included study observed a reduction in the composite outcome pre-eclampsia and/or pregnancy loss at any gestational age (RR 0.13, 95% CI 0.03 to 0.50; moderate-quality evidence), and pregnancy loss/stillbirth at any gestational age (RR 0.06, 95% CI 0.00 to 0.92; moderate-quality evidence) in the calcium plus antioxidant/supplement group.Other outcomes reported (placental abruption, severe pre-eclampsia and preterm birth (less than 37 weeks' gestation)) were too infrequent for meaningful analysis. No data were reported for the outcomes caesarean section, birthweight < 2500 g, Apgar score less than seven at five minutes, death or admission to neonatal intensive care unit (ICU), or pregnancy loss, stillbirth or neonatal death before discharge from hospital. AUTHORS' CONCLUSIONS: The results of this review are based on one small study in which the calcium intervention group also received antioxidants and other supplements. Therefore, we are uncertain whether any of the effects observed in the study were due to calcium supplementation or not. The evidence in this review was graded low to moderate due to imprecision. There is insufficient evidence on the effectiveness or otherwise of pre- or early-pregnancy calcium supplementation, or food fortification for preventing hypertensive disorders of pregnancy.Further research is needed to determine whether pre- or early-pregnancy supplementation, or food fortification with calcium is associated with a reduction in adverse pregnancy outcomes such as pre-eclampsia and pregnancy loss. Such studies should be adequately powered, limited to calcium supplementation, placebo-controlled, and include relevant outcomes such as those chosen for this review.There is one ongoing study of calcium supplementation alone versus placebo and this may provide additional evidence in future updates.