High rate of loss to follow-up among patients undergoing treatment for premalignant cervical lesions at Mbarara Regional Referral Hospital, South Western Uganda; a retrospective cohort study

High rate of loss to follow-up among patients undergoing treatment for premalignant cervical lesions at Mbarara Regional Referral Hospital, South Western Uganda; a retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article High rate of loss to follow-up among patients undergoing treatment for premalignant cervical lesions at Mbarara Regional Referral Hospital, South Western Uganda; a retrospective cohort study Rogers Kajabwangu, Frank Ssedyabane, Deusdedit Tusubira, Samuel Maling, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2881926/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background For a cervical cancer control program to be effective in reducing incidence of the disease, there should be a high compliance to treatment and follow-up of the women diagnosed with precursor lesions. Screening programs in low-resource countries like Uganda are challenged by poor adherence to follow-up following treatment for premalignant cervical lesions. This study sought to describe the burden and factors associated with loss to follow-up among women undergoing treatment for premalignant cervical lesions at a tertiary hospital in south-western Uganda Methods This was a retrospective cohort study. We reviewed the registers at the Mbarara Regional Referral Hospital cervical cancer clinic for a period of four years from January 2017 to December 2020. Data was collected on; age, district of residence, diagnosis, date of diagnosis, date and type of initial treatment as well as date of follow up visit. We also captured data on whether patients returned on the scheduled follow up date or within three months after the scheduled follow up date. We defined loss to follow-up as failure to return for follow up either on the scheduled date or within three months after the scheduled date. Results Out of the 298 patients who underwent treatment for premalignant cervical lesions in the study period, 227(76.2%) did not return for follow-up at one year. At bivariate analysis, failure to attend the review visit at 6weeks predicted the loss to follow up at one year following treatment for premalignant lesions almost perfectly (RR = 2.84, 95% CI: 2.18–3.71, p-value < 0.001). Negative HIV serostatus and receiving thermocoagulation, slightly increased the risk of getting lost to follow-up while being more than 45years old reduced the odds. At multi-variate analysis, treatment with thermocoagulation (ARR = 1.21, 95% CI:1.07,1.36, p-value-0.03) was associated with loss to follow-up at one year. Conclusion The proportion of women who don’t return for follow-up at one year following treatment for premalignant cervical lesions at Mbarara regional referral hospital is very high. There is need to implement strategies that prompt patients to return for follow-up following treatment for premalignant cervical lesions. Premalignant cervical lesions loss follow-up adherence south-western Uganda Figures Figure 1 Background World-wide, cervical cancer is the fourth most common cancer among women( 1 ). In 2018, there were 570,000 new cases of cervical cancer and 311000 deaths from the disease. ( 2 ). Approximately 84% of all the new cervical cancers and 88% of all deaths from the disease occurred in low-income countries ( 3 ). Compared with other cancers, the mean age at diagnosis of cervical cancer is quite low(53years), generating a proportionally greater loss of life years ( 3 , 4 ). Preventive measures for cervical cancer were revolutionized by the discovery of the causative relationship of the cancer with persistent high risk HPV infection( 5 ). The World Health Organisation (WHO) has now set a target to eliminate cervical cancer as a public health problem by 2030 ( 6 ). The strategies to meet this target include fully vaccinating 90% of girls with the human papillomavirus (HPV) vaccine by 15 years of age, screening 70% of women with a high-performance test two times per life by 35 and 45 years of age and ensuring that 90% of women identified with cervical disease receive treatment and care ( 6 ). In working towards improved screening for cervical cancer, WHO has recommended a single visit approach where a patient is treated on the same day following a diagnosis of a premalignant lesion( 7 ). This approach has been adapted by the Uganda ministry of health, using mainly visual inspection methods for cervical cancer screening( 8 ). The screening program in Uganda is however challenged by a number of factors including low staffing and poor infrastructure ( 9 ). As a result, few women are screened, with many of them presenting with late-stage cancer at diagnosis( 10 ). Patients who screen positive for premalignant lesions are treated with cryotherapy, thermocoagulation, cold knife conization and Loop electrosurgical excision procedure( 11 ). For a screening program to be effective in terms of reducing cervical cancer incidence, there should be a high compliance to treatment and follow-up of the women diagnosed with the precursor lesions ( 12 ). The WHO recommends a follow-up visit at one year following treatment for premalignant cervical lesions to assess for recurrency ( 13 ). However, many screening programs especially those in low-resource countries like Uganda are challenged by patients’ non-compliance to follow-up visits following treatment for premalignant cervical lesions( 14 – 16 ). These patients may have undetected recurrence of premalignant lesions which may progress to invasive cervical cancer ( 17 ). This study sought to describe the challenge of loss to follow up among women who receive treatment for premalignant lesions at the cervical cancer clinic of Mbarara regional referral hospital and the socio-demographic factors associated with this challenge. Materials and Methods Study setting The study was carried out at the Cervical cancer clinic of Mbarara Regional Referral Hospital, a tertiary hospital located in South-Western Uganda with a catchment area of approximately four million people( 18 ). The clinic runs 5 days a week, attending to over 250 clients per month. It is run by 3 nursing staff, one resident and 3 gynaecologists supervised by a gyne-oncologist. Screening for cervical cancer is done using visual inspection methods with or without colposcopy, conventional cytology and HPV DNA. Those with pre-malignant lesions are treated with cryotherapy and thermocoagulation. Following treatment, the patients are advised to return for a review visit at 6weeks for assessment of possible complications and a follow-up visit after one year to assess for recurrence of disease. Study design and sampling procedure We performed a retrospective records review of the clinic registers of the cervical cancer clinic for a period of four years from January 2017 to December 2020. We purposively selected all patients who had undergone treatment for any cervical lesion and given appointment dates for the week-6 and one-year follow up visits. Data collection We designed a data collection tool in REDCAP to ease management of data extracted from the cervical cancer screening registers. After selecting the registers of interest, we identified the patients who had undergone treatment for premalignant lesions. Data was then collected on their demographic characteristics and the treatment given. We also examined whether or not they returned on the scheduled date or within three months after the scheduled date. Loss to follow-up was defined as failure to return for review on the scheduled date or three months thereafter. Eligibility criteria We included only those patients who had undergone treatment for premalignant cervical lesions and had been given follow up dates for review. We excluded all patients with incomplete clinical records. Data management and analysis Data were imported from REDCAP into a Microsoft Excel spread sheet (Microsoft Office Professional Plus 2013, version 15.0.4675.1003, Microsoft Inc, Redmond, Washington, USA) and then imported into STATA 17 (StataCorp LLC, College Station, Texas, United States) software for analysis. Demographic data were presented in form of frequencies and percentages. The proportion of women who were lost to follow-up was presented as a percentage of all the patients who underwent treatment for premalignant cervical lesions using a bar chart. In the bivariate analysis, we used the log-binomial regression analysis with robust standard errors to determine factors independently associated with loss to follow-up and expressed the results using risk ratio (RR) with the respective 95% confidence interval (CI). The RR was preferred over the odds ratio (OR) because our outcome was frequent. Accordingly, the OR would overestimate the degree of association compared to the RR ( 19 , 20 ). In the multivariate analysis, we considered variables which had p-value < 0.2 at bivariate analysis. A p-value < 0.05 was considered to be statistically significant. We tested for multi-collinearity using variance inflation factor (VIF) ≥ 10. Results Characteristics of participants We extracted data for 298 patients who underwent ablative therapy between January 2017 to December 2020. Their mean age of 32.6 ± 7.7years, and the majority of them (94%, 280/298) were below 45years. The majority of the participants were residents of Mbarara district, where the hospital is located. Most of the women identified, however, resided more than 10km away from the hospital. The majority (73.8%, 220/298) of the participants were HIV negative and were treated with cryotherapy (70.1%, 209/298). Most of them did not come for the review visit at 6weeks. The rest of the details are in Table 1 below. Table 1 Baseline characteristics of the participants Characteristic Categories Frequency n (%) Age Mean age (Standard deviation) 32.6(7.7)* 45 and below 280 (94.0) More than 45 18 (6.0) District of residence Mbarara 163 (54.7) Other districts 135 (45.3) Distance from the hospital Less than 10km 88 (29.5) 10 to 30km 105 (35.2) 30 to 60km 19 (6.4) > 60km 86 (28.9) HIV status Positive 78 (26.2) Negative 220 (73.8) Treatment given Cryotherapy 209 (70.1) Thermocoagulation 89 (29.9) Attendance of review visit at 6weeks Attended 104 (34.9) Did not attend 194 (65.1) *Continuous variable, mean (SD) Proportion of participants lost to follow-up at one year Out of the 298women treated for premalignant lesions at MRRH between 2017 and 2020, 227(76.2%) were lost to follow-up at one year (Fig. 1 ). Factors associated with Loss to follow-up at one year following treatment for premalignant lesions at MRRH At bivariate analysis (at a significance level of p-value < 0.2), negative HIV serology, receiving thermocoagulation and failure to attend the review visit at 6weeks increased the risk of loss to follow-up at one year while being more than 45years old reduced the odds of getting lost to follow-up. The variable “attendance of the review visits at 6weeks” was not included in the multivariate analysis because not attending the review visit at 6weeks predicted loss to follow-up at one year almost perfectly (RR = 2.84, 95% CI: 2.18–3.71, p-value < 0.001). Of the 194 women who did not attend review visit at 6weeks, 191(98.4%) did not attend follow-up at one year. On the other hand, only 36 (34.6%) of the 104women who attended the review visit at 6weeks missed the follow-up visit at one year post treatment. At multi-variate analysis only treatment with thermocoagulation (ARR: 1.21, CI;1.07,1.36, p-value;0.003) was associated with loss to follow-up at one year (Table 2 ). Table 2 Factors associated with loss to follow-up at one year following treatment for pre-malignant lesions Characteristics n (%) loss to follow-up at one-year Logistic regression analysis Unadjusted analysis Adjusted analysis RR 95% CI P-Value aRR 95% CI P-Value Age category (years) 45 and below 217 (77.5) 1 1 More than 45 10 (55.6) 0.72 (0.47,1.09) 0.119 0.74 (0.49,1.12) 0.151 Area of residence Within Mbarara 121 (74.2) 1 Outside Mbarara 106 (78.5) 1.06 (0.93,1.20) 0.384 Distance from the hospital Less than 10km 66 (75.0) 1 10 to 30km 79 (75.2) 1.00 (0.85,1.18) 0.97 30 to 60km 14 (73.7) 0.98 (0.73,1.32) 0.906 > 60km 68 (79.1) 1.05 (0.90,1.24) 0.524 HIV status Positive 64 (82.1) 1 1 Negative 163 (74.1) 0.9 (0.79,1.03) 0.124 0.97 (0.86,1.10) 0.613 Treatment given Cryotherapy 149 (71.3) 1 1 Thermocoagulation 78 (87.6) 1.23 (1.09,1.38) < 0.001 1.21 (1.07,1.36) 0.003 Attendance of review visit at 6weeks yes 36 (34.6) 1 No 191 (98.5) 2.84 (2.18,3.71) < 0.001 Note : 1) RR: unadjusted/crude risk ratio; 2) aRR: Adjusted risk ratio; Discussion Our study found a very high proportion of loss to follow-up at one year following treatment of women for premalignant cervical lesions at Mbarara regional referral hospital. Receiving thermocoagulation and failing to return for the review visit at 6weeks were associated with loss to follow-up at one year. The proportion of women who don’t return for follow-up at one year following treatment for premalignant cervical lesions in this population of Ugandan women is much higher than that found in previous studies( 21 – 23 ).That more than 7 in 10 women who underwent treatment for premalignant cervical lesions did not return for follow-up, is alarming. The effectiveness of screening in preventing cervical cancer lies in prompt diagnosis and treatment of premalignant cervical lesions ( 6 , 12 ). Compared to those who screen negative, women who screen positive for premalignant cervical lesions, have a 2.5 fold risk of developing cervical cancer and this is mainly attributable to poor compliance to follow-up following treatment ( 24 – 26 ). Without proper follow-up following treatment of premalignant lesions, the intended benefit of reducing the incidence of cervical cancer through screening cannot be achieved. Missing the review visit at 6weeks following treatment for premalignant lesions predicted loss to follow-up at one year almost perfectly. of the 194 women who did not attend review visit at 6weeks, 191(98.4%) did not attend follow-up at one year. The visit at 6weeks following treatment is aimed at identifying and treating post-procedural complications such as infection, persistent vaginal discharge, new onset vaginal discharge, fever, and bleeding per vaginum. At the same time, the women are counselled further to return for the follow-up visit at one year. Counselling is a time-tested facilitator of adherence to clinical treatment and follow-up ( 27 ). Compared to those who underwent cryotherapy, women who underwent thermocoagulation were more likely not to return for follow-up at one year. Thermocoagulation has a shorter duration of treatment and a much lower rate of side effects such as excessive vaginal discharge and prolonged bleeding compared to cryotherapy ( 28 – 30 ). It is possible that the women who underwent thermocoagulation had fewer side effects during recovery and potentially thought that follow up was not needed. Thermocoagulation, because of its low cost and portability of equipment, has gained preference over cryotherapy especially in low-income settings ( 31 ). Since most of the patients will be treated with thermocoagulation going forward, measures need to be put in place to enhance patient adherence to follow-up following treatment for premalignant cervical lesions. Contrary to the findings from a previous study in which long distance was identified as a barrier to adherence to follow-up ( 32 ), our study did not find association between distance to the hospital and compliance to follow-up. Also there was no difference in compliance to follow-up in regards to age as was previously found in a study done in North Carolina ( 33 ). Compared to those without HIV, people living with HIV have been found to be more compliant to treatments and follow-up in previous studies( 34 ). Our study however found no relationship between HIV status and loss to follow up. Strengths and Limitations To the best of our knowledge, this is one of the first studies to document the challenge of loss to follow-up following treatment for premalignant cervical lesions in low-income settings. However, although our study was able to properly capture the rate of loss to follow-up, we were limited in the exploration of explanatory patient and system factors. This is because our analysis was limited to the information that was obtainable from the clinic registers. Conclusion The proportion of women who don’t return for follow-up at one year following treatment for premalignant cervical lesions is very high. Women who do not return for the review visit at 6weeks and those who are treated with thermocoagulation, are more likely not to return for follow-up at one year. There is need to implement strategies that prompt patients to return for follow-up following treatment for premalignant cervical lesions. Abbreviations and acronyms MRRH-Mbarara regional referral hospital VIA-Visual inspection under acetic acid Declarations Acknowledgement We acknowledge the staff of the cervical cancer clinic at Mbarara Regional Referral Hospital. Availability of data and materials All data from which this article was generated is available from the corresponding author upon reasonable request. Ethics approval and consent to participate Ethical review and approval was obtained from Mbarara University of Science and Technology Research Ethics Committee (MUST-2022-670). Need of informed consent was waived due to the nature of the study by the Mbarara University of Science and Technology Research Ethics Committee. We obtained administrative clearance from the hospital administration to access the medical records. All methods involved in this study were carried out in accordance with relevant guidelines and regulations. Consent for publication Not applicable Competing interests We, the authors declare that we do not have any competing interests. Author contribution RK conceived the idea and developed the first draft of the protocol. FS, MG, AN, NK, ET, SM, DT, and TCR refined the protocol, provided overall guidance in the entire write up. All authors read and approved the final version of the manuscript prior to submission. Funding This research project was entirely funded by The Government of Uganda, under the Directorate of Research and Graduate Training, Mbarara University of Science and Technology, grant number DRGT/SG/FY22-23/R1/T1P1. References Bhatla N, Aoki D, Sharma DN, Sankaranarayanan R. Cancer of the cervix uteri: 2021 update. International Journal of Gynecology & Obstetrics. 2021;155:28-44. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2021;71(3):209-49. Arbyn M, Weiderpass E, Bruni L, de Sanjosé S, Saraiya M, Ferlay J, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. The Lancet Global Health. 2020;8(2):e191-e203. Yang BH, Bray FI, Parkin DM, Sellors JW, Zhang ZF. 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Compliance and loss to follow up of HIV negative and positive mothers recruited from a PMTCT programme in Zimbabwe. The Central African journal of medicine. 2007;53(5-8):25-30. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2881926","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":198071392,"identity":"0c502cba-93e3-4103-97e3-49198e2ddfd7","order_by":0,"name":"Rogers 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Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nathan","middleName":"","lastName":"Kakongi","suffix":""},{"id":198071397,"identity":"65b16ee1-baac-4cc8-9d6d-c33639381162","order_by":5,"name":"Eleanor Turyakira","email":"","orcid":"","institution":"Mbarara University of Science of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eleanor","middleName":"","lastName":"Turyakira","suffix":""},{"id":198071398,"identity":"72954e36-efc2-4d3c-b7ca-3d42f50d7967","order_by":6,"name":"Alexcer Namuli","email":"","orcid":"","institution":"Mbarara Regional Referral Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alexcer","middleName":"","lastName":"Namuli","suffix":""},{"id":198071399,"identity":"d3d94d3f-aeba-41f7-97f0-a7c1dcf857aa","order_by":7,"name":"Martin Galiwango","email":"","orcid":"","institution":"Mbarara University of Science of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Galiwango","suffix":""},{"id":198071400,"identity":"d79b4d1d-efe0-455e-a021-dafd18006fbd","order_by":8,"name":"Thomas C Randall","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"C","lastName":"Randall","suffix":""}],"badges":[],"createdAt":"2023-05-01 12:14:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2881926/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2881926/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":36784650,"identity":"e10c8a22-0ac6-4223-b526-4e4ad35adb21","added_by":"auto","created_at":"2023-05-10 16:42:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41338,"visible":true,"origin":"","legend":"\u003cp\u003eproportion of women undergoing treatment for premalignant cervical lesions who were lost to follow-up\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2881926/v1/825662c2b1d919e0bda66ee5.jpg"},{"id":41977854,"identity":"8d436270-18fb-4afb-bdfb-f08cfd3d01b8","added_by":"auto","created_at":"2023-08-23 05:07:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":451465,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2881926/v1/589e1856-3f23-4540-be1f-8933d1becee3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"High rate of loss to follow-up among patients undergoing treatment for premalignant cervical lesions at Mbarara Regional Referral Hospital, South Western Uganda; a retrospective cohort study","fulltext":[{"header":"Background","content":"\u003cp\u003eWorld-wide, cervical cancer is the fourth most common cancer among women(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In 2018, there were 570,000 new cases of cervical cancer and 311000 deaths from the disease. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Approximately 84% of all the new cervical cancers and 88% of all deaths from the disease occurred in low-income countries (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Compared with other cancers, the mean age at diagnosis of cervical cancer is quite low(53years), generating a proportionally greater loss of life years (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Preventive measures for cervical cancer were revolutionized by the discovery of the causative relationship of the cancer with persistent high risk HPV infection(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The World Health Organisation (WHO) has now set a target to eliminate cervical cancer as a public health problem by 2030 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The strategies to meet this target include fully vaccinating 90% of girls with the human papillomavirus (HPV) vaccine by 15 years of age, screening 70% of women with a high-performance test two times per life by 35 and 45 years of age and ensuring that 90% of women identified with cervical disease receive treatment and care (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In working towards improved screening for cervical cancer, WHO has recommended a single visit approach where a patient is treated on the same day following a diagnosis of a premalignant lesion(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This approach has been adapted by the Uganda ministry of health, using mainly visual inspection methods for cervical cancer screening(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The screening program in Uganda is however challenged by a number of factors including low staffing and poor infrastructure (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). As a result, few women are screened, with many of them presenting with late-stage cancer at diagnosis(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatients who screen positive for premalignant lesions are treated with cryotherapy, thermocoagulation, cold knife conization and Loop electrosurgical excision procedure(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). For a screening program to be effective in terms of reducing cervical cancer incidence, there should be a high compliance to treatment and follow-up of the women diagnosed with the precursor lesions (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The WHO recommends a follow-up visit at one year following treatment for premalignant cervical lesions to assess for recurrency (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, many screening programs especially those in low-resource countries like Uganda are challenged by patients\u0026rsquo; non-compliance to follow-up visits following treatment for premalignant cervical lesions(\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These patients may have undetected recurrence of premalignant lesions which may progress to invasive cervical cancer (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study sought to describe the challenge of loss to follow up among women who receive treatment for premalignant lesions at the cervical cancer clinic of Mbarara regional referral hospital and the socio-demographic factors associated with this challenge.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch3\u003eStudy setting\u003c/h3\u003e\n\u003cp\u003eThe study was carried out at the Cervical cancer clinic of Mbarara Regional Referral Hospital, a tertiary hospital located in South-Western Uganda with a catchment area of approximately four million people(\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). The clinic runs 5 days a week, attending to over 250 clients per month. It is run by 3 nursing staff, one resident and 3 gynaecologists supervised by a gyne-oncologist. Screening for cervical cancer is done using visual inspection methods with or without colposcopy, conventional cytology and HPV DNA. Those with pre-malignant lesions are treated with cryotherapy and thermocoagulation. Following treatment, the patients are advised to return for a review visit at 6weeks for assessment of possible complications and a follow-up visit after one year to assess for recurrence of disease.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eStudy design and sampling procedure\u003c/h3\u003e\n\u003cp\u003eWe performed a retrospective records review of the clinic registers of the cervical cancer clinic for a period of four years from January 2017 to December 2020. We purposively selected all patients who had undergone treatment for any cervical lesion and given appointment dates for the week-6 and one-year follow up visits.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eWe designed a data collection tool in REDCAP to ease management of data extracted from the cervical cancer screening registers. After selecting the registers of interest, we identified the patients who had undergone treatment for premalignant lesions. Data was then collected on their demographic characteristics and the treatment given. We also examined whether or not they returned on the scheduled date or within three months after the scheduled date. Loss to follow-up was defined as failure to return for review on the scheduled date or three months thereafter.\u003c/p\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eWe included only those patients who had undergone treatment for premalignant cervical lesions and had been given follow up dates for review. We excluded all patients with incomplete clinical records.\u003c/p\u003e\n\u003ch3\u003eData management and analysis\u003c/h3\u003e\n\u003cp\u003eData were imported from REDCAP into a Microsoft Excel spread sheet (Microsoft Office Professional Plus 2013, version 15.0.4675.1003, Microsoft Inc, Redmond, Washington, USA) and then imported into STATA 17 (StataCorp LLC, College Station, Texas, United States) software for analysis. Demographic data were presented in form of frequencies and percentages. The proportion of women who were lost to follow-up was presented as a percentage of all the patients who underwent treatment for premalignant cervical lesions using a bar chart. In the bivariate analysis, we used the log-binomial regression analysis with robust standard errors to determine factors independently associated with loss to follow-up and expressed the results using risk ratio (RR) with the respective 95% confidence interval (CI). The RR was preferred over the odds ratio (OR) because our outcome was frequent. Accordingly, the OR would overestimate the degree of association compared to the RR (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). In the multivariate analysis, we considered variables which had p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.2 at bivariate analysis. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to be statistically significant. We tested for multi-collinearity using variance inflation factor (VIF)\u0026thinsp;\u0026ge;\u0026thinsp;10.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eCharacteristics of participants\u003c/h2\u003e\n\u003cp\u003eWe extracted data for 298 patients who underwent ablative therapy between January 2017 to December 2020. Their mean age of 32.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7years, and the majority of them (94%, 280/298) were below 45years. The majority of the participants were residents of Mbarara district, where the hospital is located. Most of the women identified, however, resided more than 10km away from the hospital. The majority (73.8%, 220/298) of the participants were HIV negative and were treated with cryotherapy (70.1%, 209/298). Most of them did not come for the review visit at 6weeks. The rest of the details are in Table\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e below.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eBaseline characteristics of the participants\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristic\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCategories\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFrequency n (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean age (Standard deviation)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e32.6(7.7)*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45 and below\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e280 (94.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMore than 45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18 (6.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDistrict of residence\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMbarara\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e163 (54.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther districts\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e135 (45.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDistance from the hospital\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLess than 10km\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e88 (29.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 to 30km\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e105 (35.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 to 60km\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e19 (6.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;60km\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e86 (28.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHIV status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePositive\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e78 (26.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNegative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e220 (73.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment given\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCryotherapy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e209 (70.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThermocoagulation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e89 (29.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAttendance of review visit at 6weeks\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAttended\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e104 (34.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDid not attend\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e194 (65.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*Continuous variable, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\n\u003ch2\u003eProportion of participants lost to follow-up at one year\u003c/h2\u003e\n\u003cp\u003eOut of the 298women treated for premalignant lesions at MRRH between 2017 and 2020, 227(76.2%) were lost to follow-up at one year (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch2\u003eFactors associated with Loss to follow-up at one year following treatment for premalignant lesions at MRRH\u003c/h2\u003e\n\u003cp\u003eAt bivariate analysis (at a significance level of p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.2), negative HIV serology, receiving thermocoagulation and failure to attend the review visit at 6weeks increased the risk of loss to follow-up at one year while being more than 45years old reduced the odds of getting lost to follow-up. The variable \u0026ldquo;attendance of the review visits at 6weeks\u0026rdquo; was not included in the multivariate analysis because not attending the review visit at 6weeks predicted loss to follow-up at one year almost perfectly (RR\u0026thinsp;=\u0026thinsp;2.84, 95% CI: 2.18\u0026ndash;3.71, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Of the 194 women who did not attend review visit at 6weeks, 191(98.4%) did not attend follow-up at one year. On the other hand, only 36 (34.6%) of the 104women who attended the review visit at 6weeks missed the follow-up visit at one year post treatment.\u003c/p\u003e\n\u003cp\u003eAt multi-variate analysis only treatment with thermocoagulation (ARR: 1.21, CI;1.07,1.36, p-value;0.003) was associated with loss to follow-up at one year (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eFactors associated with loss to follow-up at one year following treatment for pre-malignant lesions\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en (%) loss to follow-up at one-year\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eLogistic regression analysis\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eUnadjusted analysis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eAdjusted analysis\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRR\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e95% CI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eP-Value\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eaRR\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e95% CI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eP-Value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge category (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45 and below\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e217 (77.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMore than 45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10 (55.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(0.47,1.09)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.119\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(0.49,1.12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.151\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eArea of residence\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWithin Mbarara\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e121 (74.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOutside Mbarara\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e106 (78.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.06\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(0.93,1.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.384\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDistance from the hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLess than 10km\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e66 (75.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 to 30km\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e79 (75.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(0.85,1.18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 to 60km\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14 (73.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(0.73,1.32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.906\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;60km\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e68 (79.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(0.90,1.24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.524\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHIV status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePositive\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e64 (82.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNegative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e163 (74.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(0.79,1.03)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.124\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(0.86,1.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.613\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTreatment given\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCryotherapy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e149 (71.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThermocoagulation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e78 (87.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(1.09,1.38)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(1.07,1.36)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.003\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAttendance of review visit at 6weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e36 (34.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e191 (98.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.84\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(2.18,3.71)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eNote\u003c/strong\u003e: 1) RR: unadjusted/crude risk ratio; 2) aRR: Adjusted risk ratio;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e Our study found a very high proportion of loss to follow-up at one year following treatment of women for premalignant cervical lesions at Mbarara regional referral hospital. Receiving thermocoagulation and failing to return for the review visit at 6weeks were associated with loss to follow-up at one year.\u003c/p\u003e \u003cp\u003eThe proportion of women who don\u0026rsquo;t return for follow-up at one year following treatment for premalignant cervical lesions in this population of Ugandan women is much higher than that found in previous studies(\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).That more than 7 in 10 women who underwent treatment for premalignant cervical lesions did not return for follow-up, is alarming. The effectiveness of screening in preventing cervical cancer lies in prompt diagnosis and treatment of premalignant cervical lesions (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Compared to those who screen negative, women who screen positive for premalignant cervical lesions, have a 2.5 fold risk of developing cervical cancer and this is mainly attributable to poor compliance to follow-up following treatment (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Without proper follow-up following treatment of premalignant lesions, the intended benefit of reducing the incidence of cervical cancer through screening cannot be achieved.\u003c/p\u003e \u003cp\u003eMissing the review visit at 6weeks following treatment for premalignant lesions predicted loss to follow-up at one year almost perfectly. of the 194 women who did not attend review visit at 6weeks, 191(98.4%) did not attend follow-up at one year. The visit at 6weeks following treatment is aimed at identifying and treating post-procedural complications such as infection, persistent vaginal discharge, new onset vaginal discharge, fever, and bleeding per vaginum. At the same time, the women are counselled further to return for the follow-up visit at one year. Counselling is a time-tested facilitator of adherence to clinical treatment and follow-up (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCompared to those who underwent cryotherapy, women who underwent thermocoagulation were more likely not to return for follow-up at one year. Thermocoagulation has a shorter duration of treatment and a much lower rate of side effects such as excessive vaginal discharge and prolonged bleeding compared to cryotherapy (\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). It is possible that the women who underwent thermocoagulation had fewer side effects during recovery and potentially thought that follow up was not needed. Thermocoagulation, because of its low cost and portability of equipment, has gained preference over cryotherapy especially in low-income settings (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Since most of the patients will be treated with thermocoagulation going forward, measures need to be put in place to enhance patient adherence to follow-up following treatment for premalignant cervical lesions.\u003c/p\u003e \u003cp\u003eContrary to the findings from a previous study in which long distance was identified as a barrier to adherence to follow-up (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), our study did not find association between distance to the hospital and compliance to follow-up. Also there was no difference in compliance to follow-up in regards to age as was previously found in a study done in North Carolina (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Compared to those without HIV, people living with HIV have been found to be more compliant to treatments and follow-up in previous studies(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Our study however found no relationship between HIV status and loss to follow up.\u003c/p\u003e\n\u003ch3\u003eStrengths and Limitations\u003c/h3\u003e\n\u003cp\u003eTo the best of our knowledge, this is one of the first studies to document the challenge of loss to follow-up following treatment for premalignant cervical lesions in low-income settings.\u003c/p\u003e \u003cp\u003eHowever, although our study was able to properly capture the rate of loss to follow-up, we were limited in the exploration of explanatory patient and system factors. This is because our analysis was limited to the information that was obtainable from the clinic registers.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe proportion of women who don\u0026rsquo;t return for follow-up at one year following treatment for premalignant cervical lesions is very high. Women who do not return for the review visit at 6weeks and those who are treated with thermocoagulation, are more likely not to return for follow-up at one year. There is need to implement strategies that prompt patients to return for follow-up following treatment for premalignant cervical lesions.\u003c/p\u003e"},{"header":"Abbreviations and acronyms","content":"\u003cp\u003eMRRH-Mbarara regional referral hospital\u003c/p\u003e\n\u003cp\u003eVIA-Visual inspection under acetic acid\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the staff of the cervical cancer clinic at Mbarara Regional Referral Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data from which this article was generated is available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical review and approval was obtained from Mbarara University of Science and Technology Research Ethics Committee (MUST-2022-670). Need of informed consent was waived due to the nature of the study by the Mbarara University of Science and Technology Research Ethics Committee. We obtained administrative clearance from the hospital administration to access the medical records. All methods involved in this study were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe, the authors declare that we do not have any competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRK conceived the idea and developed the first draft of the protocol. FS, MG, AN, NK, ET, SM, DT, and TCR refined the protocol, provided overall guidance in the entire write up. All authors read and approved the final version of the manuscript prior to submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research project was entirely funded by The Government of Uganda, under the Directorate of Research and Graduate Training, Mbarara University of Science and Technology, grant number DRGT/SG/FY22-23/R1/T1P1.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBhatla N, Aoki D, Sharma DN, Sankaranarayanan R. Cancer of the cervix uteri: 2021 update. International Journal of Gynecology \u0026amp; Obstetrics. 2021;155:28-44.\u003c/li\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2021;71(3):209-49.\u003c/li\u003e\n\u003cli\u003eArbyn M, Weiderpass E, Bruni L, de Sanjos\u0026eacute; S, Saraiya M, Ferlay J, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. The Lancet Global Health. 2020;8(2):e191-e203.\u003c/li\u003e\n\u003cli\u003eYang BH, Bray FI, Parkin DM, Sellors JW, Zhang ZF. Cervical cancer as a priority for prevention in different world regions: an evaluation using years of life lost. International journal of cancer. 2004;109(3):418-24.\u003c/li\u003e\n\u003cli\u003eWorking I. Group on the evaluation of carcinogenic risks to humans. Human papillomaviruses. IARC Monogr Eval Carcinog Risks Hum. 2007;90:1-636.\u003c/li\u003e\n\u003cli\u003eGultekin M, Ramirez PT, Broutet N, Hutubessy R. World Health Organization call for action to eliminate cervical cancer globally. International Journal of Gynecological Cancer. 2020;30(4):426-7.\u003c/li\u003e\n\u003cli\u003eShiferaw N, Salvador-Davila G, Kassahun K, Brooks MI, Weldegebreal T, Tilahun Y, et al. The single-visit approach as a cervical cancer prevention strategy among women with HIV in Ethiopia: successes and lessons learned. Global Health: Science and Practice. 2016;4(1):87-98.\u003c/li\u003e\n\u003cli\u003eNakisige C, Schwartz M, Ndira AO. Cervical cancer screening and treatment in Uganda. Gynecologic oncology reports. 2017;20:37-40.\u003c/li\u003e\n\u003cli\u003eChongsuwat T, Ibrahim AO, Evensen AE, Conway JH, Zwick M, Oloya W. Health facility assessments of cervical cancer prevention, early diagnosis, and treatment services in Gulu, Uganda. PLOS Global Public Health. 2023;3(2):e0000785.\u003c/li\u003e\n\u003cli\u003eMwaka AD, Garimoi CO, Were EM, Roland M, Wabinga H, Lyratzopoulos G. Social, demographic and healthcare factors associated with stage at diagnosis of cervical cancer: cross-sectional study in a tertiary hospital in Northern Uganda. BMJ open. 2016;6(1):e007690.\u003c/li\u003e\n\u003cli\u003eBasu P, Taghavi K, Hu S-Y, Mogri S, Joshi S. Management of cervical premalignant lesions. Current problems in cancer. 2018;42(2):129-36.\u003c/li\u003e\n\u003cli\u003eStrategies IWGotEoC-P, Cancer IAfRo, Organization WH. Cervix cancer screening: Diamond Pocket Books (P) Ltd.; 2005.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention: World Health Organization; 2013.\u003c/li\u003e\n\u003cli\u003eCoker AL, Eggleston KS, Meyer TE, Luchok K, Das IP. What predicts adherence to follow-up recommendations for abnormal Pap tests among older women? Gynecologic Oncology. 2007;105(1):74-80.\u003c/li\u003e\n\u003cli\u003ePeterson NB, Han J, Freund KM. Inadequate follow-up for abnormal Pap smears in an urban population. Journal of the National Medical Association. 2003;95(9):825.\u003c/li\u003e\n\u003cli\u003eManga S, Kiyang E, DeMarco RF. Barriers and facilitators of follow-up among women with precancerous lesions of the cervix in Cameroon: a qualitative pilot study. International journal of women\u0026apos;s health. 2019:229-39.\u003c/li\u003e\n\u003cli\u003eSlavkovsky RC, Bansil P, Sandoval MA, Figueroa J, Rodriguez DM, Lobo JS, et al. Health Outcomes at 1 Year After Thermal Ablation for Cervical Precancer Among Human Papillomavirus\u0026ndash;and Visual Inspection With Acetic Acid\u0026ndash;Positive Women in Honduras. JCO Global Oncology. 2020;6:1565-73.\u003c/li\u003e\n\u003cli\u003eUganda Ministry of Health. Mbarara regional referral hospital. 2016.\u003c/li\u003e\n\u003cli\u003eSchmidt OC, Kohlmann T. When to use the odds ratio or the relative risk? Int J Public Health. 2008;53:165-7.\u003c/li\u003e\n\u003cli\u003eSpiegelman D, Hertzmark E. Easy SAS calculations for risk or prevalence ratios and differences. Am J Epidemiol. 2005;162(3):199-200.\u003c/li\u003e\n\u003cli\u003eSrisuttayasathien M, Manchana T. Adherence to follow-up in women with cervical intraepithelial neoplasia grade 1. Taiwanese Journal of Obstetrics and Gynecology. 2021;60(1):56-9.\u003c/li\u003e\n\u003cli\u003eChase DM, Osann K, Sepina N, Wenzel L, Tewari KS. The challenge of follow-up in a low-income colposcopy clinic: characteristics associated with noncompliance in high-risk populations. Journal of lower genital tract disease. 2012;16(4):345.\u003c/li\u003e\n\u003cli\u003eLendrum T, Alston M, Stickrath E, Rockhill K. Patient Adherence to Follow-Up Recommendations Following Cryotherapy for Treatment of High-Grade Cervical Dysplasia. Cureus. 2022;14(10).\u003c/li\u003e\n\u003cli\u003eSoutter W, de Barros Lopes A, Fletcher A, Monaghan J, Duncan I, Paraskevaidis E, et al. Invasive cervical cancer after conservative therapy for cervical intraepithelial neoplasia. The Lancet. 1997;349(9057):978-80.\u003c/li\u003e\n\u003cli\u003eKhalid S, Carcopino X, Michail G, Metchette S, Conroy R, Prendiville W. Compliance with follow up cytology after discharge from the colposcopy clinic. Irish Medical Journal. 2011;104(6):167.\u003c/li\u003e\n\u003cli\u003eStrander B, Andersson-Ellstr\u0026ouml;m A, Milsom I, Spar\u0026eacute;n P. Long term risk of invasive cancer after treatment for cervical intraepithelial neoplasia grade 3: population based cohort study. Bmj. 2007;335(7629):1077.\u003c/li\u003e\n\u003cli\u003eM\u0026apos;imunya JM, Kredo T, Volmink J. Patient education and counselling for promoting adherence to treatment for tuberculosis. Cochrane database of systematic reviews. 2012(5).\u003c/li\u003e\n\u003cli\u003eChigbu CO, Onwudiwe EN, Onyebuchi AK. Thermo‐coagulation versus cryotherapy for treatment of cervical precancers: a prospective analytical study in a low‐resource African setting. Journal of Obstetrics and Gynaecology Research. 2020;46(1):147-52.\u003c/li\u003e\n\u003cli\u003eDuan L, Du H, Belinson JL, Liu Z, Xiao A, Liu S, et al. Thermocoagulation versus cryotherapy for the treatment of cervical precancers. Journal of Obstetrics and Gynaecology Research. 2021;47(1):279-86.\u003c/li\u003e\n\u003cli\u003eRandall TC, Sauvaget C, Muwonge R, Trimble EL, Jeronimo J. Worthy of further consideration: an updated meta-analysis to address the feasibility, acceptability, safety and efficacy of thermal ablation in the treatment of cervical cancer precursor lesions. Preventive medicine. 2019;118:81-91.\u003c/li\u003e\n\u003cli\u003eCastle PE, Murokora D, Perez C, Alvarez M, Quek SC, Campbell C. Treatment of cervical intraepithelial lesions. International Journal of Gynecology \u0026amp; Obstetrics. 2017;138:20-5.\u003c/li\u003e\n\u003cli\u003eChapola J, Lee F, Bula A, Mapanje C, Phiri BR, Kamtuwange N, et al. Barriers to follow-up after an abnormal cervical cancer screening result and the role of male partners: a qualitative study. BMJ open. 2021;11(9):e049901.\u003c/li\u003e\n\u003cli\u003eMichielutte R, Diseker RA, Young LD, May WJ. Noncompliance in screening follow-up among family planning clinic patients with cervical dysplasia. Preventive Medicine. 1985;14(2):248-58.\u003c/li\u003e\n\u003cli\u003eKurewa N, Munjoma M, Chirenje Z, Rusakaniko S, Hussain A, Stray-Pedersen B. Compliance and loss to follow up of HIV negative and positive mothers recruited from a PMTCT programme in Zimbabwe. The Central African journal of medicine. 2007;53(5-8):25-30.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Premalignant cervical lesions, loss, follow-up, adherence, south-western Uganda","lastPublishedDoi":"10.21203/rs.3.rs-2881926/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2881926/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFor a cervical cancer control program to be effective in reducing incidence of the disease, there should be a high compliance to treatment and follow-up of the women diagnosed with precursor lesions. Screening programs in low-resource countries like Uganda are challenged by poor adherence to follow-up following treatment for premalignant cervical lesions. This study sought to describe the burden and factors associated with loss to follow-up among women undergoing treatment for premalignant cervical lesions at a tertiary hospital in south-western Uganda\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis was a retrospective cohort study. We reviewed the registers at the Mbarara Regional Referral Hospital cervical cancer clinic for a period of four years from January 2017 to December 2020. Data was collected on; age, district of residence, diagnosis, date of diagnosis, date and type of initial treatment as well as date of follow up visit. We also captured data on whether patients returned on the scheduled follow up date or within three months after the scheduled follow up date. We defined loss to follow-up as failure to return for follow up either on the scheduled date or within three months after the scheduled date.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOut of the 298 patients who underwent treatment for premalignant cervical lesions in the study period, 227(76.2%) did not return for follow-up at one year. At bivariate analysis, failure to attend the review visit at 6weeks predicted the loss to follow up at one year following treatment for premalignant lesions almost perfectly (RR\u0026thinsp;=\u0026thinsp;2.84, 95% CI: 2.18\u0026ndash;3.71, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Negative HIV serostatus and receiving thermocoagulation, slightly increased the risk of getting lost to follow-up while being more than 45years old reduced the odds. At multi-variate analysis, treatment with thermocoagulation (ARR\u0026thinsp;=\u0026thinsp;1.21, 95% CI:1.07,1.36, p-value-0.03) was associated with loss to follow-up at one year.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe proportion of women who don\u0026rsquo;t return for follow-up at one year following treatment for premalignant cervical lesions at Mbarara regional referral hospital is very high. There is need to implement strategies that prompt patients to return for follow-up following treatment for premalignant cervical lesions.\u003c/p\u003e","manuscriptTitle":"High rate of loss to follow-up among patients undergoing treatment for premalignant cervical lesions at Mbarara Regional Referral Hospital, South Western Uganda; a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-05-10 16:42:00","doi":"10.21203/rs.3.rs-2881926/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0df966ee-b426-4e56-8445-514863153b3a","owner":[],"postedDate":"May 10th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-08-23T04:59:20+00:00","versionOfRecord":[],"versionCreatedAt":"2023-05-10 16:42:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2881926","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2881926","identity":"rs-2881926","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}