In Uganda, cervical cancer is the most common cause of both cancer-related incidence (54.8 per 100,000) and cancer-related deaths (40.5 per 100,000). Eighty percent of patients present late with advanced stage (often terminal) disease. Late patient presentations are attributed to low levels of knowledge among health care providers and the public about cervical cancer and prevention strategies and minimal access to available (and free) public screening services. The 2010 National Strategic Plan for Cervical Cancer Prevention and Control prioritized 3 areas. The first 2 of these include an emphasis on health education and awareness-raising:
Human Papillomavirus (HPV) vaccination of 10-14-year-old girls
Low-cost screening using Visual Inspection with Acetic Acid (VIA)
Treatment of early dysplasia (cervical intraepithelial neoplasia) using cryotherapy
While HPV vaccination has become the primary preventive intervention in high income settings, Uganda's HPV vaccination program, targeting girls aged 10-14 in primary schools, has achieved only about 20% uptake. Progress has been substantially impacted by the immediate and long-term effects of extended school closures during the COVID-19 pandemic and subsequent Ebola outbreaks. For the foreseeable future, this implies continued emphasis on screen-and-treat programs working in parallel with HPV vaccination. A key goal of Priorities 2 and 3 was to have 80% of eligible women screened and treated for precancerous lesions. Despite these intentions, Uganda's national screening program faces considerable implementation gaps. In practice, screening in Uganda is erratic and absent in many regions. Unfortunately, there is very limited (or no) public funding for such programs which suffer from acute donor-dependency. Uptake of screening services that do exist are negatively impacted by limited access to facilities, compounded by the costs associated with services, travel, and wait times. There is also a shortage of trained screening providers. This explains the low lifetime screening rate of between 4.8 and 30%, and the continued prevalence of advanced disease and mortality.
Cervical screening guidelines in Uganda are based on a 'see-and-treat' approach targeting women aged 25 to 49 years. VIA is the main screening procedure used. In theory, women diagnosed with positive mild-moderate precancerous lesions (diagnosed through VIA) should then be treated, in the community, using cryotherapy. In practice, even Non-Governmental Organizations (NGOs) that constitute the private 'not-for-profit', sector levy significant charges for such treatment. National Guidelines (until recently) stipulated that women who test positive for Human Immunodeficiency Virus (HIV) should be screened annually while HIV-negative women should undergo cervical screening every 3 years. Midwives and nurses are the primary providers of cervical cancer screening as well as treatment.
Knowledge for Change (K4C) is a UK and Ugandan registered NGO focused on health systems change.1 At the time of the commencement of the Knowledge for Change (K4C) screen-and-treat service in Fort Portal (Uganda), the city had no public facility offering free cervical screening services. This paper presents a Community Case Study documenting a complex intervention (defined through a series of action-research cycles) drawing out the potential for scale-out of see-and-treat cervical cancer prevention in Low- and Middle-Income Countries (LMICs).