Acceptability and feasibility of one-stop home-based genital self-sampling for Female Genital Schistosomiasis, Human Papilloma Virus and self- testing for Trichomonas and HIV: The Zipime Weka Schista Study in Zambia

Acceptability and feasibility of one-stop home-based genital self-sampling for Female Genital Schistosomiasis, Human Papilloma Virus and self- testing for Trichomonas and HIV: The Zipime Weka Schista Study in Zambia | 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 Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Acceptability and feasibility of one-stop home-based genital self-sampling for Female Genital Schistosomiasis, Human Papilloma Virus and self- testing for Trichomonas and HIV: The Zipime Weka Schista Study in Zambia Rhoda Ndubani, Olimpia Lamberti, Isaac Mshanga, Nkatya Kasese, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8278348/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Background Female genital schistosomiasis (FGS) is a neglected gynaecological disease that affects over 50 million girls and women in sub-Saharan Africa. It is caused by the waterborne parasite Schistosoma (S.) haematobium and has been associated with HIV infection, with human papillomavirus (HPV) and cervical precancer. FGS alters the normal sexual and reproductive health of girls and women. Diagnosis is bottlenecked, but previous studies have shown acceptability of genital self-sampling at home for individual diagnosis of FGS, HPV and selected STIs. Here, we aim to determine the acceptability and feasibility of home-based multi-pathogen self-sampling and testing. Methods The Zipime Weka Schista study is an ongoing longitudinal cohort integrating a one-stop home-based genital self-sampling for S. haematobium and HPV DNA detection with self-testing for HIV and Trichomonas vaginalis (Tv ) in three communities in Zambia. Sexually active women aged 15-50 years were randomly selected by community health workers and visited at home where they were invited to provide two cervicovaginal self-swabs and a urine sample, and to conduct self-tests for HIV and Tv . During the home visit, community health workers collected information on the acceptability and feasibility of the multi-pathogen genital self-sampling approach using a questionnaire. A follow-up visit was done in clinic. Results A total of 2,701 women were initially approached by community health workers and 2,532 were enrolled between January 2022 – March 2023. A total of 100% (2,532) women provided self-swabs, and 94.3% (2,389) and 55.4% (1,404) undertook Tv and HIV self-tests, respectively. Of these, 67% (1,694) were followed up in clinic. There was high acceptability 76.4% (1,934) on the procedures for home multi-genital self-sampling. Many participants 87.2% (2,208) preferred to be seen at home than in clinic. Some reasons stated were convenience 62.6% (1,585); privacy 47.9% (1,215); going to the clinic was not convenient 10.4% (264); lack of transport to go to the clinic 8.2% (208); unavailability due to work 4.6% (118) and availability of childcare 2.7% (69). Conclusion Home-based multi-pathogen self-sampling and testing is highly acceptable and feasible in three communities in Zambia. This has potential to increase access to diagnosis, treatment and care for different infections co-existing in women. Female genital schistosomiasis Schistosoma haematobium acceptability feasibility self-sampling women integration home clinic HPV Trichomonas HIV STI cervical cancer cervical precancer Figures Figure 1 Figure 2 Introduction Schistosomiasis is a parasitic disease acquired when people come into contact with larval forms of the trematode parasite of the Schistosoma (S.) genus, known as cercariae, which are released by freshwater snails acting as intermediate hosts ( 1 ). Contact occurs while wading, bathing or washing in contaminated water, when cercariae emerging from their host snails penetrate a person’s skin and develop into mature worms, which can live within the blood vessels of the human host for years, sometimes for decades ( 2 ). Human schistosomiasis affects approximately 200 million people worldwide and the majority of these infections (~ 165 million) occur in Sub-Saharan Africa ( 1 ). It is estimated that approximately 30% to 75% of women with S. haematobium infection may develop genital lesions attributable to this infection ( 3 ). The presence of Schistosoma ova in female reproductive organs is known as female genital schistosomiasis (FGS). The disease develops over a long period of time (months to years) from the time of infection, and most girls and women do not have access to treatment and care ( 4 ). FGS has been described as one of the most neglected sexual and reproductive health (SRH) diseases in sub-Saharan Africa (SSA), with an estimated 56 million women and girls affected ( 5 ). This adds to the global burden of other genital infections such as HPV leading to cervical cancer and HIV, which have the highest incidence and mortality rates in Africa, particularly among young women ( 6 ). Signs and symptoms associated with FGS include dyspareunia, bleeding after sex, vaginal discharge, abdominal and pelvic pain, sub-fertility and infertility and ectopic pregnancies which overlap with those seen in sexually transmitted infections (STI) ( 7 ). One of the methods for FGS diagnosis is visual examination of the genital tract by colposcopy, identifying classic lesions including grainy sandy patches, homogenous yellow patches abnormal blood vessels, and rubbery papules ( 8 ). However, this method is costly and requires specialised equipment and training and is not always available in health facilities in endemic communities ( 9 ). Further, there is a lack of awareness and recognition of FGS among health professionals as it is not part of standard medical training ( 10 – 12 ). Therefore, FGS remains underreported, misdiagnosed and largely untreated ( 12 – 14 ). FGS causes a high degree of inflammation in the genital tract which increases the risk of acquisition of STIs such as HIV ( 3 , 15 ). As a result, women and girls with FGS are up to three times more likely to acquire HIV ( 16 ). The inflammation and lesions can create an environment that is more susceptible to HPV infection ( 15 ). And the increased risk of HPV in women with FGS could potentially lead to higher risk of cervical cancer ( 12 ). Moreover, cervical cancer and S. haematobium eggs have been reported together in histopathology specimens of women with cervical precancer ( 15 ). Considering the association between FGS, HIV, HPV and cervical cancer, adopting an integrated approach with comprehensive screening and broader symptomatic and clinical management of sexual and reproductive health (SRH) programs for these infections, offers an opportunity to reach more girls and women ( 12 , 17 , 18 ) and provides an important first step for diagnosis, treatment and prevention of these infections. The World Health Organisation (WHO) neglected Tropical Diseases roadmap 2021–2030 also emphasizes the need for integration of disease interventions to strengthen the health systems and improve outcomes for affected populations ( 14 ). Accurate and effective diagnosis of FGS can prevent unnecessary cervical cancer treatments, reduce misdiagnosis of STIs, avert onward HIV transmission, and reduce repeated healthcare visits, ultimately reducing strain on the health system ( 19 ). Closer to the user and low-cost screening tools for multi-pathogen detection could be an effective intervention for service integration ( 14 ). Several studies have highlighted the importance of integrating disease or sector-specific interventions into broader health services to improve health coverage and efficiency ( 18 ). However, for these interventions to be deployable, their acceptability and feasibility need to be ascertained. Several studies have assessed the acceptability and feasibility of self-sampling for HPV and STIs and self-testing for HIV ( 20 – 24 ) and more recently for FGS ( 25 , 26 ). To date, no study has assessed the acceptability and a feasibility of a multi-pathogen genital self-sampling and testing done at a single visit at home. The aim of the Zipime Weka Schista study ( 27 ) was to develop a holistic approach for the community-based diagnosis of FGS through a comprehensive package for SRH screening including HPV, STIs & HIV. Here, we aim to determine the acceptability and feasibility of this approach in a large ongoing cohort in Zambia. Methods Study design and population The Zipime Weka Schista study is an ongoing (2021–2028) longitudinal cohort integrating home-based genital self-sampling for detection of FGS, high-risk Human Papillomavirus (HR-HPV), and self-testing for Trichomonas vaginalis ( Tv) and HIV in three communities in Zambia. Methods are described elsewhere ( 27 ). Briefly, sexually active girls and women aged 15–50 years and not pregnant, were randomly selected to take part in the study. Schista community workers (SCWs) recruited women during a home visit and obtained two cervicovaginal self-swabs and a urine sample and offered self-tests for HIV and Tv . Household demographic and symptom questionnaires were also administered ( 25 ). Women were referred to the clinic where a midwife collected genital samples and obtained images using hand-held colposcopy. Here, we present cross-sectional baseline data collected between January 2022 and March 2023. Sampling strategy Community-based cluster sampling was used to obtain a random sample of participants from the study communities. Communities and their households were mapped, and each community was subdivided into blocks of approximately 50 households and all eligible women aged 15–50 years invited to take part. Blocks were randomly selected using random number generation in Stata and were being visited sequentially in the order that they were randomly selected. Home Visit and questionnaire SCWs conducted home visits and study procedures were conducted in a private area of the house. Study information was given in a language of the participant’s choice, along with FGS education using a World Health Organization’s “Female Genital Schistosomiasis Pocket Atlas” ( 5 ). Study information and study procedures were also explained in detail. Participants were shown self-sampling procedures with the use of a three-dimensional model of a female anatomy and a test swab for illustration. Photos in the World Health Organization’s “Female Genital Schistosomiasis Pocket Atlas” were also displayed as a visual aid ( 5 ). Thereafter, participants were asked to self-sample with the two given swabs in a private room and later placed these swabs inside 2 ml tube of PrimeStore® MTM molecular transport media (donated by Longhorn Vaccines and Diagnostics LLC, Bethesda, MD). The two genital self-swabs were analysed for Sh by Polymerase Chain Reaction (PCR) and HPV by rDNA by GeneXpert. A genital self-swab for Trichomonas vaginalis (Tv) was also performed. Results were read by the SCW and given out immediately. If positive, the participant was referred to the clinic to meet with the study midwife and was given treatment. A 10- 30ml sample of urine was also collected. The urine test was analysed via microscopy for Sh ova detection and circulating anodic antigen (CAA). SCWs also offered one oral (saliva) for HIV self-test preceded by counselling ( 24 ). Instructions were read out to the participants before collecting the test. The participant proceeded with the oral swab in the presence of the SCW. If the results were positive, a confirmatory test was done immediately, if positive, the woman was referred to the local clinic for further management and linkage to care. Participants then completed a questionnaire, with responses captured on hand-held tablets. The questionnaire assessed basic demographics, information regarding genital symptoms, sexual behaviour and the participant’s assessment of the acceptability of self-sampling and testing, through their responses to 15 questions each measured on a five-point Likert scale ( 28 ). The SCW then asked the participant to complete further study procedure at the local clinic at their earliest convenience. A study identification card with the unique identifier number was placed in a badge and handed over to the participant to carry to the clinic where a midwife conducted the study visit. Ethics and informed consent SCWs obtained written consent from all eligible participants during the home visit. Participants who were unable to provide written informed consent were recruited in the presence of a witness with the participant placing their thumbprint on the consent form. All study staff underwent training in research ethics and confidentiality. The study was approved by the University of Zambia Biomedical Research Ethics Committee (reference number: 1858–2021), the Zambia National Health Research Authority (reference number: NHRA00012) and the London School of Hygiene and Tropical Medicine research ethics committee (reference number: 25258). Permission to conduct the study was further given by Ministry of Health, the Provincial and District Health offices. Identifiable data collected is stored securely and their confidentiality protected in accordance with the Data Protection Act 1998. Data management and statistical methods Participant data were entered using Open Data Kit (ODK) Collect on tablet devices ( 29 ). Acceptability was assessed by the following outcomes: the proportion of women who rated home based self-sampling and testing to be “easy” or “very easy” (for each of urine, vaginal, cervical self-sampling and oral self-test), the proportion who were willing to self-sample again “in the same setting” (for each of urine, vaginal, cervical self-sampling and oral self-test), and the proportion who would prefer to “sample at home” (versus sampling at the clinic). Proportion who found the instructions for genital (cervicovaginal) self-sampling to be “easy” or “very easy”.). Continuous variables were summarized by median and interquartile range (IQR), and categorical variables by frequency and percentage. The Mantel-Haenszel approach was used to obtain crude and age-adjusted odds ratios for the association of demographic variables with a participant’s preference for home-based versus clinic-based sampling. All field and clinic data were entered in the ODK system and uploaded to a secure server in Zambia. Results A total of 2,532 out of the 2,701 women contacted (93.7%) were eligible, enrolled and completed the initial home-based visit with the SCWs. Of the 6.3% of women (170/2,701) who were not enrolled into the study, 3.5% (6/170) were pregnant, 9.4% (16/170) were outside age criteria, 49.4% (84/170) reported that they were not interested in taking part in the study, 7.6% (13/170) had a family member who declined for them, 3.0% ( 5 ) were not well enough to participate,6.5% ( 11 ) had not had their sexual debut, 10.0% ( 17 ) were too busy and could not make time for study procedures, 6% (3.5%) had concerns about certain study components and 1.2% ( 2 ) were not informed prior to the visit by the research team (Fig. 1 ) . The medium age was 28 years (IQR 22–36). Approximately half of the participants 53.1% (1344/2532) had obtained some secondary school education. 79.5% (2012) were not in formal employment. Active schistosome infection was determined by detectable urine Circulating Anodic Antigen (CAA) 15.4%, or microscopy 5.3%, as shown in Table 1 . Of the 2532 participants completing the home-based visit, 1694 (67%), completed the clinic visit (Fig. 1 ) . Table 1 Baseline characteristics of 2,532 Zambian women living in Schistosoma haematobium endemic areas in Zambia. Comparison of community A, B and C Socio-behavioral Characteristics Category Overall n (2532) Community A n (1176) Community B n (1196) Community C n (160) P-value Age (years) Median (IQR) 32 ( 25 – 40 ) 31 ( 24 – 38 ) 33 ( 26 – 41 ) 29 ( 23 – 37 ) 0.021 Marital Status Single 931 (36.8) 408 (34.7) 500 (41.8) 23 (14.4) < 0.001 Married / living as married 1,410 (55.7) 665 (56.5) 624 (52.2) 121 (75.6) Divorced / Separated 130 (5.1) 59 (5.0) 58 (4.9) 13 (8.1) Widowed 60 (2.4) 44 (3.7) 13 (1.1) 3 (1.9) Education (Highest Level) No schooling 49 (1.9) 11 (0.9) 29 (2.4) 9 (5.6) < 0.001 Some/Completed primary 909 (35.9) 224 (19.0) 605 (50.6) 80 (50.0) Some/Completed secondary 1,344 (53.1) 787 (66.9) 491 (41.1) 66 (41.3) Some/Completed trade 229 (9.1) 154 (13.1) 70 (5.9) 5 (3.1) Employment Status Casual employment 151 (5.9) 75 (6.3) 66 (5.5) 10 (6.5) Formal wage employment 33 (1.3) 16 (1.4) 14 (1.2) 3 (1.9) Self-employed 287 (11.3) 143 (12.1) 114 (9.5) 30 (18.7) Not employed 2,061 (81.4) 942 (80.1) 1,002 (83.8) 117 (73.1) Current Water Status No 1,544 (61.0) 768 (65.3) 747 (62.4) 29 (18.1) < 0.001 Yes – more than once a week 987 (38.9) 389 (33.0) 448 (37.4) 131 (81.8) Childhood Water Contact No 1,057 (41.8) 612 (52.0) 402 (33.6) 43 (26.9) < 0.001 Yes 1,474 (58.2) 564 (47.9) 793 (66.3) 117 (73.1) Reason for Contact with Water Household chores 1,166 (46.0) 877 (74.6) 139 (11.6) 150 (93.8) < 0.001 Bathing self 257 (10.2) 20 (1.7) 234 (19.6) 3 (1.9) Bathing children 16 (0.6) 9 (0.8) 7 (0.6) 0 (0.0) Laundry 33 (1.3) 20 (1.7) 12 (1.0) 1 (0.6) Fetching water 208 (8.2) 149 (12.7) 53 (4.4) 6 (3.8) Play 183 (7.2) 101 (8.6) 82 (6.9) 0 (0.0) Missing / no contact reported 669 (26.4) 0 (0.0) 669 (55.9) 0 (0.0) History of schistosomiasis No 2,304 (91.0) 1,119 (95.1) 1,030 (86.1) 155 (96.9) < 0.001 Yes 193 (7.6) 50 (4.3) 138 (11.5) 5 (3.1) Maybe – I don’t know 34 (1.3) 7 (0.6) 27 (2.3) 0 (0.0) Treatment with praziquantel No 2,162 (85.4) 1,077 (91.6) 943 (78.8) 142 (88.8) < 0.001 Yes 280 (11.1) 80 (6.8) 184 (15.4) 16 (10.0) Maybe – I don’t know 89 (3.5) 19 (1.6) 68 (5.7) 2 (1.3) Acceptability and feasibility of procedures As shown in Table 2 and Fig. 2 a high proportion of women in the study indicated that self-collection of the genital specimen for FGS, HPV, and self-testing for Trichomonas vaginalis and for HIV was “very easy ” (13.8%) or “ easy ” (76.4%) on a 5-point Likert scale. Most participants indicated that they would be willing to self-sample and self-test in the same setting again (99.5%). Notably, only 4.7% and 0.2%, found it “ a little difficult” and “ very difficult” to self-collect the genital specimens. Overall, most women preferred to collect the specimens at home (87.2%, compared with clinic-based sampling (12.8%) ( Table 2 ). These results were consistent across communities, with women from all three communities reporting a preference to self-collect specimens from home (Community A: 80.9%, 951/1176; Community B: 95.7%, 1,144/1,196; Community C: 70.6%, 113/160) compared to attending the health facility. Some reasons for the preference stated were that it is more convenient 71.8% (1585) there was more privacy at home 1215 (55.0%); going to the clinic was not convenient 12.0% (264) lack of transport to go to the clinic 9.4% (208) unavailability due to work 5.3% (118) and lack of childcare, 3.1% (69). Further, there were differences between settings in terms of preferences. There was little evidence that age, marital status and employment status were associated with a participant’s preference. Given that the preference for self-sampling was universal across the groups examined in the crude analysis, multivariable analysis was not performed. Table 2. Acceptability of self-sampling and preference of screening. Category Overall N=2532) Community A n(1176) Community B n(1196) Community C n(160) P-value Ease of home-based vaginal self-sampling Very easy 349 (13.8) 186 (15.8) 149 (12.5) 14 (8.8) 0.002 Easy 1,934 (76.4) 819 (69.7) 985 (82.4) 130 (81.3) Neutral 123 (4.9) 86 (7.3) 27 (2.3) 10 (6.3) A little difficult 119 (4.7) 85 (7.2) 30 (2.5) 4 (2.5) Very difficult 6 (0.2) 0 (0.0) 4 (0.3) 2 (1.3) Preference for screening Clinic-based screening 323 (12.8) 225 (19.1) 51 (4.3) 47 (29.4) <0.001 Home-based self-sampling 2,208 (87.2) 951 (80.9) 1,144 (95.7) 113 (70.6) Discussion In this study, we found that self-sampling for the diagnosis of FGS, HPV and self-testing for HIV and Trichomonas Vaginalis has high acceptability and feasibility among women aged 15 to 50 years enrolled in the Zipime Weka Schista cohort study in Zambia. All women participating in the study provided all three self-collected specimens (oral, vaginal and cervical), and a high proportion found self-sampling “easy”. Our study is in agreement with other studies in which individual genital self-sampling for either FGS, HPV or STIs and self-test for HIV has been acceptable among young and older women of different ethnicity, educational and socio-economic status ( 6 , 21 , 24 , 25 ). A cross-sectional study conducted in Zambia also found high (86.6%) acceptability and feasibility of the genital self-sampling for the diagnosis of FGS in young women aged 18–36 years ( 25 ). Another study conducted in Zambia highlighted the high prevalence of FGS in adult women living in urban areas ( 30 ) which showed the importance of screening for FGS in Zambia. While there have been calls for integrated FGS in SRH programmes within the health systems ( 17 , 31 ), our study is the first to highlight the acceptability and feasibility of integrating screening of FGS with HPV, Tv and HIV at household level and in hard to reach areas. Genital self-sampling and self-testing as an alternative to clinician collected samples, has been validated in recent years for the diagnosis of different genital tract infections ( 26 , 32 ). This approach has shown to increase adherence among under-screened women, those who may not visit the health facility regularly and women who may be geographically isolated ( 33 , 34 ). In addition, self-sampling has been shown to be cost effective, highly acceptable in terms of ease to use, convenience, privacy, physical and emotional comfort and less embarrassing ( 35 – 37 ). Similarly, in this study, the home-based approach substantially reached women who were at risk of infection, had low awareness and were first -time testers. This has potential to reduce the burden and vulnerability for FGS, HIV, Tv , HPV and ultimately cervical cancer. Some studies have shown evidence on the reduction of disease controlling for others ( 17 , 38 ). The ease of self-sampling for the home-based procedures in this study was reported as easy (76.4%) by the majority of women recruited into the study (Table 2) . Some of the reasons given were the very clear instructions and the aid of the 3D model, which helped them visualize the technical instructions. Women found self-sampling and self-testing to be easy because the instructions were clear and understandable ( 39 ). However, some participants reported that they found the self-sampling a little difficult (4.7%) and (0.2%) very difficult (Table 2) . Despite this finding, most women indicated that they would be willing to self-sample in the same setting again. A qualitative study conducted at the cervical cancer screening clinic at ORCI in Dar es Salaam, showed that most participants liked self-sampling and still preferred it over provider-based sampling despite experiencing some difficulties with the procedure. They needed a health provider present when conducting the self-sampling ( 20 ). In other studies, health providers prepared the women prior to the self-sampling by providing health education, allowed the women to touch the swab and provided support through-out the process because some women were worried about the accuracy of the test. A cross-sectional study conducted in Hong Kong in women aged 25–35 and 45_> that explored the feasibility and acceptability of HPV self-sampling found high acceptability (80%) of self-sampling in under screened and never-screened women ( 40 ). Women from all three study communities preferred to self-collect specimens from home compared with clinic-based provider sampling. If adopted widely as a screening procedure, this preference may increase the uptake of screening for multiple infections. Further, women reported reassurance of having a community health worker who explained the procedures using the three Dimension model making it easy to follow the instructions and take the samples to a laboratory facility. The community health workers also provided knowledge on the different genital infections that were being screened for, this could have increased the acceptability levels. Community health workers can play a crucial role in raising awareness about the different infections, mostly in communities with low awareness for diseases like FGS and HPV and potentially increase screening ( 19 ). In this study, we also found that women preferred to self-sample at home because it was more convenient, there was more privacy. They further reported that going to the clinic was not convenient, there was lack of transport and difficulty reaching clinic due to work, and lack of childcare. Other studies have also highlighted stigma, travel time and waiting time at the clinic as further hurdles to this approach ( 33 ). As previously reported, high acceptability of the procedures was associated with higher education levels and those who live in distant areas ( 39 – 41 ). This may indicate that women with a higher education may be more confident with self-sampling than women with lower education and may have a better understanding for choice of screening methods ( 42 ). Another study found that religion significantly determined knowledge and prevention behaviour that influenced decision in the uptake of HPV self-sampling ( 40 ). Other factors that have shown to influence uptake of screening include age, household income, smoking, drinking and job status ( 43 ). The reasons for acceptability were not explored in detail. Therefore, more qualitative studies will need to be conducted to explore how these factors influence choice of screening methods. Conclusion Integrated self-sampling and testing procedures for multi-pathogen detection were highly acceptable and feasible in women aged 15–50 years in three communities in Zambia. Most women reported that self-sampling was “easy” with willingness to self-sample in the same setting again. Home-based procedures were preferred by most of the participants over clinic-based procedures. Our study provides new evidence on acceptability and feasibility on integration of a home-based multi-pathogen self-sampling and testing methods. This represents an evidence-based novel direction for national policy to increase access to diagnosis, treatment and care for different infections co-existing in women of childbearing age. Abbreviations FGS female genital schistosomiasis HPV human papillomavirus STI sexually transmitted infections HIV Human immunodeficiency viruses Tv trichomonas vaginalis SSA sub-saharan Africa SRH sexual reproductive health WHO world health organisation Declarations Ethics approval and consent to participate Informed consent was obtained from all study participants. This study was conducted in accordance with the Declaration of Helsinki, approved by the University of Zambia Biomedical Research Ethics Committee (reference number: 1858-2021), the Zambia National Health Research Authority (reference number: NHRA00012) and the London School of Hygiene and Tropical Medicine research ethics committee (reference number: 25258). Consent for publication Informed consent was obtained from all study participants for publication and dissemination of results. All authors gave consent for publication. Availability of data and materials Data are available upon reasonable request. Please contact the corresponding author if required. Competing interest statement The authors declare they have no competing interests. Funding statement This study is funded through a UKRI Future Leaders Fellowship (MR/T041900/1) awarded to Prof. AL Bustinduy. Funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Acknowledgements We would like to thank and acknowledge all the participants, and Schista! study fieldworkers and midwives in Kafue and Livingstone communities. We would like to thank our partners in Zambia including the Ministry of Health and District Health Management Teams; the administrative and support teams at Zambart and LSHTM. We thank the ODK forum for assistance with questionnaire construction and Chrissy Roberts (LSHTM) for his invaluable support with 3D printing of teaching models. We also want to thank Longhorn Vaccines and Diagnostics LLC, Bethesda, MD for the donations of the PrimeStore® MTM molecular transport media. Authors’ contributions AB originally conceived and designed the study with consultation with HA and HK. JC, RM, MC, MN, SP, GM collected the data with supervision from RN, KS and AB. JF contributed to the laboratory component of the study. EW and NK were responsible for data management. RN wrote the original draft of this manuscript. OL, NK and RN contributed to the analysis. IM, AB, KS, OL, EW reviewed and edited the article. KS and AB supervised and validated the article. References Ponzo E, Midiri A, Manno A, Pastorello M, Biondo C, Mancuso G. Insights into the epidemiology, pathogenesis, and differential diagnosis of schistosomiasis. Eur J Microbiol Immunol. 2024 May 14;14(2):86–96. Nour NM. Schistosomiasis: health effects on women. Rev Obstet Gynecol. 2010;3(1):28–32. Orish VN, Morhe EKS, Azanu W, Alhassan RK, Gyapong M. The parasitology of female genital schistosomiasis. Curr Res Parasitol Vector-Borne Dis. 2022;2:100093. Hegertun IEA, Sulheim Gundersen KM, Kleppa E, Zulu SG, Gundersen SG, Taylor M, et al. S. haematobium as a Common Cause of Genital Morbidity in Girls: A Cross-sectional Study of Children in South Africa. Downs JA, editor. PLoS Negl Trop Dis. 2013 Mar 21;7(3):e2104. Martinez SG, Mbabazi PS, Sebitloane MH, Vwalika B, Mocumbi S, Galaphaththi-Arachchige HN, et al. The WHO atlas for female-genital schistosomiasis: Co-design of a practicable diagnostic guide, digital support and training. Parray AA, editor. PLOS Glob Public Health. 2024 Mar 18;4(3):e0002249. Asangbeh-Kerman SL, Davidović M, Taghavi K, Kachingwe J, Rammipi KM, Muzingwani L, et al. Cervical cancer prevention in countries with the highest HIV prevalence: a review of policies. BMC Public Health. 2022 Aug 10;22(1):1530. Rossi B, Previtali L, Salvi M, Gerami R, Tomasoni LR, Quiros-Roldan E. Female Genital Schistosomiasis: A Neglected among the Neglected Tropical Diseases. Microorganisms. 2024 Feb 24;12(3):458. Kjetland EF, Ndhlovu PD, Mduluza T, Gomo E, Gwanzura L, Mason PR, et al. Simple clinical manifestations of genital Schistosoma haematobium infection in rural Zimbabwean women. Am J Trop Med Hyg. 2005 Mar;72(3):311–9. Lamberti O, Bozzani F, Kiyoshi K, Bustinduy AL. Time to bring female genital schistosomiasis out of neglect. Br Med Bull. 2024 Mar 13;149(1):45–59. Kukula VA, MacPherson EE, Tsey IH, Stothard JR, Theobald S, Gyapong M. A major hurdle in the elimination of urogenital schistosomiasis revealed: Identifying key gaps in knowledge and understanding of female genital schistosomiasis within communities and local health workers. Hsieh MH, editor. PLoS Negl Trop Dis. 2019 Mar 21;13(3):e0007207. Azanu WK, Osarfo J, Appiah G, Godonu YS, Ampofo GD, Orish V, et al. Knowledge of female genital schistosomiasis and urinary schistosomiasis among final-year midwifery students in the Volta Region of Ghana. Olorunlana A, editor. PLOS ONE. 2024 May 2;19(5):e0302554. An update on female and male genital schistosomiasis and a call to integrate efforts to escalate diagnosis, treatment and awareness in endemic and non-endemic settings: The time is now. In: Advances in Parasitology [Internet]. Elsevier; 2022 [cited 2025 Nov 3]. p. 1–44. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0065308X21000592 Pillay LN, Umbelino-Walker I, Schlosser D, Kalume C, Karuga R. Minimum Service Package for the integration of female genital schistosomiasis into sexual and reproductive health and rights interventions. Front Trop Dis. 2024 June 17;5:1321069. Umbelino-Walker I, Wong F, Cassolato M, Pantelias A, Jacobson J, Kalume C. Integration of female genital schistosomiasis into HIV/sexual and reproductive health and rights and neglected tropical diseases programmes and services: a scoping review. Sex Reprod Health Matters. 2023 Dec 31;31(1):2262882. Sturt A, Omar T, Hansingo I, Kamfwa P, Bustinduy A, Kelly H. Association of female genital schistosomiasis and human papillomavirus and cervical pre-cancer: a systematic review. BMC Womens Health. 2025 Jan 3;25(1):2. Kjetland EF, Ndhlovu PD, Gomo E, Mduluza T, Midzi N, Gwanzura L, et al. Association between genital schistosomiasis and HIV in rural Zimbabwean women. AIDS. 2006 Feb 28;20(4):593–600. Engels D, Hotez PJ, Ducker C, Gyapong M, Bustinduy AL, Secor WE, et al. Integration of prevention and control measures for female genital schistosomiasis, HIV and cervical cancer. Bull World Health Organ. 2020 Sept 1;98(9):615–24. Sutarsa IN, Campbell L, Dwi Ariawan IM, Kasim R, Marten R, Rajan D, et al. Multisectoral interventions and health system performance: a systematic review. Bull World Health Organ. 2024 July 1;102(07):521-532F. Hotez PJ, Harrison W, Fenwick A, Bustinduy AL, Ducker C, Sabina Mbabazi P, et al. Female genital schistosomiasis and HIV/AIDS: Reversing the neglect of girls and women. Hsieh MH, editor. PLoS Negl Trop Dis. 2019 Apr 4;13(4):e0007025. Bakiewicz A, Rasch V, Mwaiselage J, Linde DS. “The best thing is that you are doing it for yourself” – perspectives on acceptability and feasibility of HPV self-sampling among cervical cancer screening clients in Tanzania: a qualitative pilot study. BMC Womens Health. 2020 Dec;20(1):65. Paudyal P, Llewellyn C, Lau J, Mahmud M, Smith H. Obtaining Self-Samples to Diagnose Curable Sexually Transmitted Infections: A Systematic Review of Patients’ Experiences. Clark JL, editor. PLOS ONE. 2015 Apr 24;10(4):e0124310. Jones HE, Altini L, De Kock A, Young T, Van De Wijgert JHHM. Home-based versus clinic-based self-sampling and testing for sexually transmitted infections in Gugulethu, South Africa: randomised controlled trial. Sex Transm Infect. 2007 Dec 1;83(7):552–7. Camus C, Penaranda G, Khiri H, Camiade S, Molet L, Lebsir M, et al. Acceptability and efficacy of vaginal self-sampling for genital infection and bacterial vaginosis: A cross-sectional study. Mitchell C, editor. PLOS ONE. 2021 Nov 18;16(11):e0260021. Mkopi A, Korte JE, Lesslie V, diNapoli M, Mutiso F, Mwajubwa S, et al. Acceptability and uptake of oral HIV self-testing among rural community members in Tanzania: a pilot study. AIDS Care. 2023 Sept 2;35(9):1338–45. Rutty Phiri C, Sturt AS, Webb EL, Chola N, Hayes R, Shanaube K, et al. Acceptability and feasibility of genital self-sampling for the diagnosis of female genital schistosomiasis: a cross-sectional study in Zambia. Wellcome Open Res. 2020 Sept 2;5:61. Sturt AS, Webb EL, Phiri CR, Mweene T, Chola N, Van Dam GJ, et al. Genital self-sampling compared with cervicovaginal lavage for the diagnosis of female genital schistosomiasis in Zambian women: The BILHIV study. Cools P, editor. PLoS Negl Trop Dis. 2020 July 14;14(7):e0008337. Shanaube K, Ndubani R, Kelly H, Webb E, Mayaud P, Lamberti O, et al. Zipime-Weka-Schista study protocol: a longitudinal cohort study and economic evaluation of an integrated home-based approach for genital multipathogen screening in women, including female genital schistosomiasis, human papillomavirus, Trichomonas and HIV in Zambia. BMJ Open. 2024 June;14(6):e080395. Sullivan GM, Artino AR. Analyzing and Interpreting Data From Likert-Type Scales. J Grad Med Educ. 2013 Dec;5(4):541–2. Brunette W, Sudar S, Sundt M, Larson C, Beorse J, Anderson R. Open Data Kit 2.0: A Services-Based Application Framework for Disconnected Data Management. In: Proceedings of the 15th Annual International Conference on Mobile Systems, Applications, and Services [Internet]. Niagara Falls New York USA: ACM; 2017 [cited 2025 Oct 29]. p. 440–52. Available from: https://dl.acm.org/doi/10.1145/3081333.3081365 Rogers EQ, Mwangelwa S, Kabengele C, Kilembe W, Vwalika B, Inambao M, et al. Developing and validating a screening tool for female genital schistosomiasis in urban Zambia. Front Trop Dis. 2024 Feb 27;4:1308129. Mberu M, Zongo K, Leaning E, Makau-Barasa L, Kamara K, Jacobson J. Female genital schistosomiasis: Addressing diagnostic and programmatic gaps to advance elimination efforts. Int J Infect Dis. 2025 Mar;152:107798. Arbyn M, Smith SB, Temin S, Sultana F, Castle P. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ. 2018 Dec 5;k4823. Angotti N, Bula A, Gaydosh L, Kimchi EZ, Thornton RL, Yeatman SE. Increasing the acceptability of HIV counseling and testing with three C’s: Convenience, confidentiality and credibility. Soc Sci Med. 2009 June;68(12):2263–70. Krause J, Subklew-Sehume F, Kenyon C, Colebunders R. Acceptability of HIV self-testing: a systematic literature review. BMC Public Health. 2013 Dec;13(1):735. Pourette D, Cripps A, Guerrien M, Desprès C, Opigez E, Bardou M, et al. Assessing the Acceptability of Home-Based HPV Self-Sampling: A Qualitative Study on Cervical Cancer Screening Conducted in Reunion Island Prior to the RESISTE Trial. Cancers. 2022 Mar 8;14(6):1380. Meenan RT, Troja C, Buist DSM, Tiro JA, Lin J, Anderson ML, et al. Economic Evaluation of Mailed Home-Based Human Papillomavirus Self-sampling Kits for Cervical Cancer Screening. JAMA Netw Open. 2023 Mar 22;6(3):e234052. Hariprasad R, Bagepally BS, Kumar S, Pradhan S, Gurung D, Tamang H, et al. Cost-utility analysis of primary HPV testing through home-based self-sampling in comparison to visual inspection using acetic acid for cervical cancer screening in East district, Sikkim, India, 2023. Mahumud RA, editor. PLOS ONE. 2024 Aug 13;19(8):e0300556. Patel P, Rose CE, Kjetland EF, Downs JA, Mbabazi PS, Sabin K, et al. Association of schistosomiasis and HIV infections: A systematic review and meta-analysis. Int J Infect Dis. 2021 Jan;102:544–53. Kohler RE, Elliott T, Monare B, Moshashane N, Ramontshonyana K, Chatterjee P, et al. HPV self‐sampling acceptability and preferences among women living with HIV in Botswana. Int J Gynecol Obstet. 2019 Dec;147(3):332–8. Wong ELY, Cheung AWL, Wong AYK, Chan PKS. Acceptability and Feasibility of HPV Self-Sampling as an Alternative Primary Cervical Cancer Screening in Under-Screened Population Groups: A Cross-Sectional Study. Int J Environ Res Public Health. 2020 Aug 27;17(17):6245. Sechi I, Muresu N, Puci MV, Saderi L, Del Rio A, Cossu A, et al. Preliminary Results of Feasibility and Acceptability of Self-Collection for Cervical Screening in Italian Women. Pathogens. 2023 Sept 17;12(9):1169. Rafferty H, Sturt AS, Phiri CR, Webb EL, Mudenda M, Mapani J, et al. Association between cervical dysplasia and female genital schistosomiasis diagnosed by genital PCR in Zambian women. BMC Infect Dis. 2021 Dec;21(1):691. Chang HK, Myong JP, Byun SW, Lee SJ, Lee YS, Lee HN, et al. Factors associated with participation in cervical cancer screening among young Koreans: a nationwide cross-sectional study. BMJ Open. 2017 Apr;7(4):e013868. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 03 Feb, 2026 Reviews received at journal 25 Jan, 2026 Reviews received at journal 24 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviews received at journal 22 Jan, 2026 Reviews received at journal 21 Jan, 2026 Reviewers agreed at journal 16 Jan, 2026 Reviewers agreed at journal 16 Jan, 2026 Reviewers agreed at journal 10 Jan, 2026 Reviewers invited by journal 07 Jan, 2026 Editor assigned by journal 05 Jan, 2026 Editor invited by journal 18 Dec, 2025 Submission checks completed at journal 17 Dec, 2025 First submitted to journal 17 Dec, 2025 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 Advisory Board 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-8278348","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":572675920,"identity":"4af6dc21-db89-4133-8340-7bb5f30136d4","order_by":0,"name":"Rhoda Ndubani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYBAC+xkMDBIMFQwgkkhgcAOk+AxUywGitTC2kaTldvPBGz/n1cnrzm5+9vkDg02+vAP70w34tNjPOZZs2buNzXDbnWPGMw4wpFluBBI38Gmxk8gxk+DdxsO47UaCMdBhhw0MGxiO4dViDNQi+XeOhP22G+mfoVoY2/BqMZyRYybN22CQuO1GDsQWeQZmNrxaDG6kJVvLHEtI3nbnTDHDGYM0AwNmNkJakg/efFNTZ7vtdvtmhooKGwP59vZneLWgmwBEh0lQDwHyDSRrGQWjYBSMgmEOABGvTg+VgyQLAAAAAElFTkSuQmCC","orcid":"","institution":"Zambart","correspondingAuthor":true,"prefix":"","firstName":"Rhoda","middleName":"","lastName":"Ndubani","suffix":""},{"id":572675921,"identity":"a5e3d7f8-2505-4fb5-bf00-adffc98b9fbe","order_by":1,"name":"Olimpia Lamberti","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Olimpia","middleName":"","lastName":"Lamberti","suffix":""},{"id":572675922,"identity":"2c729cce-2e9b-4b9c-85aa-39df0fb6a8b9","order_by":2,"name":"Isaac Mshanga","email":"","orcid":"","institution":"Zambart","correspondingAuthor":false,"prefix":"","firstName":"Isaac","middleName":"","lastName":"Mshanga","suffix":""},{"id":572675923,"identity":"5e21c11a-4b8f-4e9c-8d57-0b4a819906eb","order_by":3,"name":"Nkatya Kasese","email":"","orcid":"","institution":"Zambart","correspondingAuthor":false,"prefix":"","firstName":"Nkatya","middleName":"","lastName":"Kasese","suffix":""},{"id":572675924,"identity":"b57b42b3-0d9c-4f14-8254-b7eca343f7b7","order_by":4,"name":"Helen Kelly","email":"","orcid":"","institution":"University College Dublin","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"","lastName":"Kelly","suffix":""},{"id":572675925,"identity":"5db1f50d-27e0-434b-acc2-e853588bccc2","order_by":5,"name":"Jennifer Fitzpatric","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Fitzpatric","suffix":""},{"id":572675926,"identity":"245ed15f-df7c-49ce-a224-0dbdbe11554e","order_by":6,"name":"Janet Chisaili","email":"","orcid":"","institution":"Zambart","correspondingAuthor":false,"prefix":"","firstName":"Janet","middleName":"","lastName":"Chisaili","suffix":""},{"id":572675927,"identity":"cb36c7bd-fd4e-40f0-a481-81bdd8d778dc","order_by":7,"name":"Ruth Mwanza","email":"","orcid":"","institution":"Zambart","correspondingAuthor":false,"prefix":"","firstName":"Ruth","middleName":"","lastName":"Mwanza","suffix":""},{"id":572675928,"identity":"590a0296-15c7-433a-9997-f9f846c2287b","order_by":8,"name":"Melisa Choongo","email":"","orcid":"","institution":"Zambart","correspondingAuthor":false,"prefix":"","firstName":"Melisa","middleName":"","lastName":"Choongo","suffix":""},{"id":572675929,"identity":"28863057-c671-48ec-912b-f930c4fb6944","order_by":9,"name":"Molen Ngoshe","email":"","orcid":"","institution":"Zambart","correspondingAuthor":false,"prefix":"","firstName":"Molen","middleName":"","lastName":"Ngoshe","suffix":""},{"id":572675931,"identity":"03669130-9685-4404-9ecd-f3774dc060d0","order_by":10,"name":"Sandra Phiri","email":"","orcid":"","institution":"Zambart","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"","lastName":"Phiri","suffix":""},{"id":572675932,"identity":"8bbe1cfd-7e57-4a74-b84d-4a7bca5b2863","order_by":11,"name":"Georgina Mukombwe","email":"","orcid":"","institution":"Zambart","correspondingAuthor":false,"prefix":"","firstName":"Georgina","middleName":"","lastName":"Mukombwe","suffix":""},{"id":572675933,"identity":"11154f9a-062f-4fe5-9b74-06633f692217","order_by":12,"name":"Emily L. Webb","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Emily","middleName":"L.","lastName":"Webb","suffix":""},{"id":572675934,"identity":"24b75c17-574e-42c6-ab1f-3965a3beeba1","order_by":13,"name":"Helen Ayles","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"","lastName":"Ayles","suffix":""},{"id":572675935,"identity":"5669f9cb-7f4b-4c0f-980b-fb747635d101","order_by":14,"name":"Kwame Shanaube","email":"","orcid":"","institution":"Zambart","correspondingAuthor":false,"prefix":"","firstName":"Kwame","middleName":"","lastName":"Shanaube","suffix":""},{"id":572675936,"identity":"b151909a-f420-424f-9f54-9345fe2927be","order_by":15,"name":"Amaya L. Bustinduy","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Amaya","middleName":"L.","lastName":"Bustinduy","suffix":""}],"badges":[],"createdAt":"2025-12-04 10:53:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8278348/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8278348/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100363009,"identity":"fee7f94f-85e3-4062-a4a4-fedf757c722f","added_by":"auto","created_at":"2026-01-16 07:48:34","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":128924,"visible":true,"origin":"","legend":"","description":"","filename":"AcceptabilityManuscriptDec25.docx","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/7426ffecd092a78edef6c4ce.docx"},{"id":100025489,"identity":"2115905d-8346-493a-a063-60cb662c62da","added_by":"auto","created_at":"2026-01-12 08:32:15","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":16848,"visible":true,"origin":"","legend":"","description":"","filename":"1e00c00cfdff4e9aa859e92903cdf4dc.json","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/ed41f229526aaf1a07f19124.json"},{"id":100362811,"identity":"2704b394-489b-446e-93b6-57440fcdbb50","added_by":"auto","created_at":"2026-01-16 07:48:07","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":127988,"visible":true,"origin":"","legend":"","description":"","filename":"1e00c00cfdff4e9aa859e92903cdf4dc1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/3511dbb1ec2093b38074663a.xml"},{"id":100362212,"identity":"d0120b94-0790-4194-885a-c575c79617b7","added_by":"auto","created_at":"2026-01-16 07:46:21","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":26303,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/9499c8fab556ca7c0ae11f60.png"},{"id":100025496,"identity":"448cd7ae-5263-4e34-ab69-7c0e8aa111cc","added_by":"auto","created_at":"2026-01-12 08:32:15","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":388618,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/f011c2e856a6e4057967b673.jpeg"},{"id":100362777,"identity":"369cd033-d4bc-4a6b-9f87-4cdf6dbf871f","added_by":"auto","created_at":"2026-01-16 07:48:04","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":13814,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/26d46e1583cfce25a0b540bd.png"},{"id":100361676,"identity":"6c5afa1a-0336-4917-8a84-a8fa42290529","added_by":"auto","created_at":"2026-01-16 07:45:30","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":12295,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/e30ad210e13b23c98f87d719.png"},{"id":100025492,"identity":"980c0593-566c-4f44-a03e-24161496aeb9","added_by":"auto","created_at":"2026-01-12 08:32:15","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":84175,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/bab6cfd833a1d5bed3a29f62.png"},{"id":100025498,"identity":"2029f5ac-5c1f-48bd-a464-ac61eb21212c","added_by":"auto","created_at":"2026-01-12 08:32:15","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9554,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/18a4a70a5520268a7f1ac8ef.png"},{"id":100362905,"identity":"a321ef91-a7bc-43c1-a371-ef0deea1a187","added_by":"auto","created_at":"2026-01-16 07:48:15","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":121907,"visible":true,"origin":"","legend":"","description":"","filename":"1e00c00cfdff4e9aa859e92903cdf4dc1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/d3a575ed72471f738d60596d.xml"},{"id":100025501,"identity":"73517d7b-0c00-4dc4-9c7d-998cda37ebf2","added_by":"auto","created_at":"2026-01-12 08:32:15","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":140433,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/b5f2ecd82c40c3871b93ce5c.html"},{"id":100025488,"identity":"d7d8e8d4-26a9-4b35-a350-e2c28657d1d6","added_by":"auto","created_at":"2026-01-12 08:32:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":128216,"visible":true,"origin":"","legend":"\u003cp\u003eZipime-Weka-Schista study flow diagram for the recruitment and enrolment of participants at baseline.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/86b98da4aeec0fe3e3568ca8.png"},{"id":100361770,"identity":"936c1660-c748-4f7e-bd9b-f4ffbb606172","added_by":"auto","created_at":"2026-01-16 07:45:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":70568,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEase of sampling.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResponses on Ease of self-sampling and testing of the 2,532 women at baseline.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/6beb8bb62ba502bb91f15bcc.png"},{"id":100381326,"identity":"39225459-168e-4e8e-848b-f21858dc4562","added_by":"auto","created_at":"2026-01-16 10:38:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1292976,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8278348/v1/112f77c2-13fd-4190-bd4f-eea4a4a9c1a4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Acceptability and feasibility of one-stop home-based genital self-sampling for Female Genital Schistosomiasis, Human Papilloma Virus and self- testing for Trichomonas and HIV: The Zipime Weka Schista Study in Zambia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSchistosomiasis is a parasitic disease acquired when people come into contact with larval forms of the trematode parasite of the \u003cem\u003eSchistosoma (S.)\u003c/em\u003e genus, known as cercariae, which are released by freshwater snails acting as intermediate hosts (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Contact occurs while wading, bathing or washing in contaminated water, when cercariae emerging from their host snails penetrate a person\u0026rsquo;s skin and develop into mature worms, which can live within the blood vessels of the human host for years, sometimes for decades (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Human schistosomiasis affects approximately 200\u0026nbsp;million people worldwide and the majority of these infections (~\u0026thinsp;165\u0026nbsp;million) occur in Sub-Saharan Africa (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It is estimated that approximately 30% to 75% of women with \u003cem\u003eS. haematobium\u003c/em\u003e infection may develop genital lesions attributable to this infection (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The presence of \u003cem\u003eSchistosoma\u003c/em\u003e ova in female reproductive organs is known as female genital schistosomiasis (FGS). The disease develops over a long period of time (months to years) from the time of infection, and most girls and women do not have access to treatment and care (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). FGS has been described as one of the most neglected sexual and reproductive health (SRH) diseases in sub-Saharan Africa (SSA), with an estimated 56\u0026nbsp;million women and girls affected (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This adds to the global burden of other genital infections such as HPV leading to cervical cancer and HIV, which have the highest incidence and mortality rates in Africa, particularly among young women (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSigns and symptoms associated with FGS include dyspareunia, bleeding after sex, vaginal discharge, abdominal and pelvic pain, sub-fertility and infertility and ectopic pregnancies which overlap with those seen in sexually transmitted infections (STI) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). One of the methods for FGS diagnosis is visual examination of the genital tract by colposcopy, identifying classic lesions including grainy sandy patches, homogenous yellow patches abnormal blood vessels, and rubbery papules (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, this method is costly and requires specialised equipment and training and is not always available in health facilities in endemic communities (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Further, there is a lack of awareness and recognition of FGS among health professionals as it is not part of standard medical training (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Therefore, FGS remains underreported, misdiagnosed and largely untreated (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFGS causes a high degree of inflammation in the genital tract which increases the risk of acquisition of STIs such as HIV (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). As a result, women and girls with FGS are up to three times more likely to acquire HIV (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The inflammation and lesions can create an environment that is more susceptible to HPV infection (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). And the increased risk of HPV in women with FGS could potentially lead to higher risk of cervical cancer (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Moreover, cervical cancer and \u003cem\u003eS. haematobium\u003c/em\u003e eggs have been reported together in histopathology specimens of women with cervical precancer (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsidering the association between FGS, HIV, HPV and cervical cancer, adopting an integrated approach with comprehensive screening and broader symptomatic and clinical management of sexual and reproductive health (SRH) programs for these infections, offers an opportunity to reach more girls and women (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and provides an important first step for diagnosis, treatment and prevention of these infections. The World Health Organisation (WHO) neglected Tropical Diseases roadmap 2021\u0026ndash;2030 also emphasizes the need for integration of disease interventions to strengthen the health systems and improve outcomes for affected populations (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Accurate and effective diagnosis of FGS can prevent unnecessary cervical cancer treatments, reduce misdiagnosis of STIs, avert onward HIV transmission, and reduce repeated healthcare visits, ultimately reducing strain on the health system (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCloser to the user and low-cost screening tools for multi-pathogen detection could be an effective intervention for service integration (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Several studies have highlighted the importance of integrating disease or sector-specific interventions into broader health services to improve health coverage and efficiency (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, for these interventions to be deployable, their acceptability and feasibility need to be ascertained.\u003c/p\u003e \u003cp\u003eSeveral studies have assessed the acceptability and feasibility of self-sampling for HPV and STIs and self-testing for HIV (\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and more recently for FGS (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). To date, no study has assessed the acceptability and a feasibility of a multi-pathogen genital self-sampling and testing done at a single visit at home. The aim of the Zipime Weka Schista study (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) was to develop a holistic approach for the community-based diagnosis of FGS through a comprehensive package for SRH screening including HPV, STIs \u0026amp; HIV. Here, we aim to determine the acceptability and feasibility of this approach in a large ongoing cohort in Zambia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and population\u003c/h2\u003e \u003cp\u003eThe Zipime Weka Schista study is an ongoing (2021\u0026ndash;2028) longitudinal cohort integrating home-based genital self-sampling for detection of FGS, high-risk Human Papillomavirus (HR-HPV), and self-testing for \u003cem\u003eTrichomonas vaginalis\u003c/em\u003e (\u003cem\u003eTv)\u003c/em\u003e and HIV in three communities in Zambia. Methods are described elsewhere (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Briefly, sexually active girls and women aged 15\u0026ndash;50 years and not pregnant, were randomly selected to take part in the study. Schista community workers (SCWs) recruited women during a home visit and obtained two cervicovaginal self-swabs and a urine sample and offered self-tests for HIV and \u003cem\u003eTv\u003c/em\u003e. Household demographic and symptom questionnaires were also administered (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Women were referred to the clinic where a midwife collected genital samples and obtained images using hand-held colposcopy. Here, we present cross-sectional baseline data collected between January 2022 and March 2023.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSampling strategy\u003c/h3\u003e\n\u003cp\u003eCommunity-based cluster sampling was used to obtain a random sample of participants from the study communities. Communities and their households were mapped, and each community was subdivided into blocks of approximately 50 households and all eligible women aged 15\u0026ndash;50 years invited to take part. Blocks were randomly selected using random number generation in Stata and were being visited sequentially in the order that they were randomly selected.\u003c/p\u003e\n\u003ch3\u003eHome Visit and questionnaire\u003c/h3\u003e\n\u003cp\u003eSCWs conducted home visits and study procedures were conducted in a private area of the house. Study information was given in a language of the participant\u0026rsquo;s choice, along with FGS education using a World Health Organization\u0026rsquo;s \u0026ldquo;Female Genital Schistosomiasis Pocket Atlas\u0026rdquo; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Study information and study procedures were also explained in detail.\u003c/p\u003e \u003cp\u003eParticipants were shown self-sampling procedures with the use of a three-dimensional model of a female anatomy and a test swab for illustration. Photos in the World Health Organization\u0026rsquo;s \u0026ldquo;Female Genital Schistosomiasis Pocket Atlas\u0026rdquo; were also displayed as a visual aid (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Thereafter, participants were asked to self-sample with the two given swabs in a private room and later placed these swabs inside 2 ml tube of PrimeStore\u0026reg; MTM molecular transport media (donated by Longhorn Vaccines and Diagnostics LLC, Bethesda, MD). The two genital self-swabs were analysed for \u003cem\u003eSh\u003c/em\u003e by Polymerase Chain Reaction (PCR) and HPV by rDNA by GeneXpert. A genital self-swab for \u003cem\u003eTrichomonas vaginalis (Tv)\u003c/em\u003e was also performed. Results were read by the SCW and given out immediately. If positive, the participant was referred to the clinic to meet with the study midwife and was given treatment. A 10- 30ml sample of urine was also collected. The urine test was analysed via microscopy for \u003cem\u003eSh\u003c/em\u003e ova detection and circulating anodic antigen (CAA).\u003c/p\u003e \u003cp\u003eSCWs also offered one oral (saliva) for HIV self-test preceded by counselling (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Instructions were read out to the participants before collecting the test. The participant proceeded with the oral swab in the presence of the SCW. If the results were positive, a confirmatory test was done immediately, if positive, the woman was referred to the local clinic for further management and linkage to care.\u003c/p\u003e \u003cp\u003eParticipants then completed a questionnaire, with responses captured on hand-held tablets. The questionnaire assessed basic demographics, information regarding genital symptoms, sexual behaviour and the participant\u0026rsquo;s assessment of the acceptability of self-sampling and testing, through their responses to 15 questions each measured on a five-point Likert scale (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The SCW then asked the participant to complete further study procedure at the local clinic at their earliest convenience. A study identification card with the unique identifier number was placed in a badge and handed over to the participant to carry to the clinic where a midwife conducted the study visit.\u003c/p\u003e\n\u003ch3\u003eEthics and informed consent\u003c/h3\u003e\n\u003cp\u003eSCWs obtained written consent from all eligible participants during the home visit. Participants who were unable to provide written informed consent were recruited in the presence of a witness with the participant placing their thumbprint on the consent form. All study staff underwent training in research ethics and confidentiality. The study was approved by the University of Zambia Biomedical Research Ethics Committee (reference number: 1858\u0026ndash;2021), the Zambia National Health Research Authority (reference number: NHRA00012) and the London School of Hygiene and Tropical Medicine research ethics committee (reference number: 25258). Permission to conduct the study was further given by Ministry of Health, the Provincial and District Health offices. Identifiable data collected is stored securely and their confidentiality protected in accordance with the Data Protection Act 1998.\u003c/p\u003e\n\u003ch3\u003eData management and statistical methods\u003c/h3\u003e\n\u003cp\u003eParticipant data were entered using Open Data Kit (ODK) Collect on tablet devices (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Acceptability was assessed by the following outcomes: the proportion of women who rated home based self-sampling and testing to be \u0026ldquo;easy\u0026rdquo; or \u0026ldquo;very easy\u0026rdquo; (for each of urine, vaginal, cervical self-sampling and oral self-test), the proportion who were willing to self-sample again \u0026ldquo;in the same setting\u0026rdquo; (for each of urine, vaginal, cervical self-sampling and oral self-test), and the proportion who would prefer to \u0026ldquo;sample at home\u0026rdquo; (versus sampling at the clinic). Proportion who found the instructions for genital (cervicovaginal) self-sampling to be \u0026ldquo;easy\u0026rdquo; or \u0026ldquo;very easy\u0026rdquo;.). Continuous variables were summarized by median and interquartile range (IQR), and categorical variables by frequency and percentage. The Mantel-Haenszel approach was used to obtain crude and age-adjusted odds ratios for the association of demographic variables with a participant\u0026rsquo;s preference for home-based versus clinic-based sampling. All field and clinic data were entered in the ODK system and uploaded to a secure server in Zambia.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 2,532 out of the 2,701 women contacted (93.7%) were eligible, enrolled and completed the initial home-based visit with the SCWs. Of the 6.3% of women (170/2,701) who were not enrolled into the study, 3.5% (6/170) were pregnant, 9.4% (16/170) were outside age criteria, 49.4% (84/170) reported that they were not interested in taking part in the study, 7.6% (13/170) had a family member who declined for them, 3.0% (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e) were not well enough to participate,6.5% (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e) had not had their sexual debut, 10.0% (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e) were too busy and could not make time for study procedures, 6% (3.5%) had concerns about certain study components and 1.2% (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) were not informed prior to the visit by the research team (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eThe medium age was 28 years (IQR 22\u0026ndash;36). Approximately half of the participants 53.1% (1344/2532) had obtained some secondary school education. 79.5% (2012) were not in formal employment. Active schistosome infection was determined by detectable urine Circulating Anodic Antigen (CAA) 15.4%, or microscopy 5.3%, as shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the 2532 participants completing the home-based visit, 1694 (67%), completed the clinic visit (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline characteristics of 2,532 Zambian women living in \u003cem\u003eSchistosoma haematobium\u003c/em\u003e endemic areas in Zambia. Comparison of community A, B and C\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"8\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003eSocio-behavioral Characteristics\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\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall n (2532)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity A n (1176)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity B n (1196)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity C n (160)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.021\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e931 (36.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e408 (34.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e500 (41.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eMarried / living as married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,410 (55.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e665 (56.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e624 (52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e121 (75.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eDivorced / Separated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e130 (5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation (Highest Level)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo schooling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eSome/Completed primary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e909 (35.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e224 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e605 (50.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eSome/Completed secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,344 (53.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e787 (66.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e491 (41.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (41.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eSome/Completed trade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e229 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e154 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCasual employment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e151 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eFormal wage employment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eSelf-employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e287 (11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e143 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e114 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eNot employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,061 (81.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e942 (80.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,002 (83.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117 (73.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent Water Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,544 (61.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e768 (65.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e747 (62.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (18.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eYes \u0026ndash; more than once a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e987 (38.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e389 (33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e448 (37.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131 (81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildhood Water Contact\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,057 (41.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e612 (52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e402 (33.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,474 (58.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e564 (47.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e793 (66.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117 (73.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eReason for Contact with Water\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousehold chores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,166 (46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e877 (74.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e139 (11.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e150 (93.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"7\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eBathing self\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e257 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e234 (19.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eBathing children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eLaundry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eFetching water\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e208 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e149 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003ePlay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e183 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101 (8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eMissing / no contact reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e669 (26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e669 (55.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of schistosomiasis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,304 (91.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,119 (95.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,030 (86.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e155 (96.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e193 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e138 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eMaybe \u0026ndash; I don\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment with praziquantel\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,162 (85.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,077 (91.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e943 (78.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e142 (88.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e280 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e184 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\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\u003eMaybe \u0026ndash; I don\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eAcceptability and feasibility of procedures\u003c/h3\u003e\n\u003cp\u003eAs shown in \u003cstrong\u003eTable\u0026nbsp;2 and\u003c/strong\u003e Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003ea high proportion of women in the study indicated that self-collection of the genital specimen for FGS, HPV, and self-testing for \u003cem\u003eTrichomonas vaginalis\u003c/em\u003e and for HIV was \u0026ldquo;very \u003cem\u003eeasy\u003c/em\u003e\u0026rdquo; (13.8%) or \u0026ldquo;\u003cem\u003eeasy\u003c/em\u003e\u0026rdquo; (76.4%) on a 5-point Likert scale. Most participants indicated that they would be willing to self-sample and self-test in the same setting again (99.5%). Notably, only 4.7% and 0.2%, found it \u0026ldquo;\u003cem\u003ea little difficult\u0026rdquo;\u003c/em\u003e and \u0026ldquo;\u003cem\u003every difficult\u0026rdquo;\u003c/em\u003e to self-collect the genital specimens. Overall, most women preferred to collect the specimens at home (87.2%, compared with clinic-based sampling (12.8%) (\u003cstrong\u003eTable\u0026nbsp;2\u003c/strong\u003e). These results were consistent across communities, with women from all three communities reporting a preference to self-collect specimens from home (Community A: 80.9%, 951/1176; Community B: 95.7%, 1,144/1,196; Community C: 70.6%, 113/160) compared to attending the health facility. Some reasons for the preference stated were that it is more convenient 71.8% (1585) there was more privacy at home 1215 (55.0%); going to the clinic was not convenient 12.0% (264) lack of transport to go to the clinic 9.4% (208) unavailability due to work 5.3% (118) and lack of childcare, 3.1% (69). Further, there were differences between settings in terms of preferences.\u003c/p\u003e\n\u003cp\u003eThere was little evidence that age, marital status and employment status were associated with a participant\u0026rsquo;s preference. Given that the preference for self-sampling was universal across the groups examined in the crude analysis, multivariable analysis was not performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Acceptability of self-sampling and preference of screening.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=2532)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity A n(1176)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity B n(1196)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity C n(160)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEase of home-based vaginal self-sampling\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eVery easy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e349 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e186 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e149 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e14 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eEasy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e1,934 (76.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e819 (69.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e985 (82.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e130 (81.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eNeutral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e123 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e86 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e27 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e10 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eA little difficult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e119 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e85 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e30 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eVery difficult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e6 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e2 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreference for screening\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eClinic-based screening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e323 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e225 (19.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e51 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e47 (29.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eHome-based self-sampling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2,208 (87.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e951 (80.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1,144 (95.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e113 (70.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we found that self-sampling for the diagnosis of FGS, HPV and self-testing for HIV and \u003cem\u003eTrichomonas Vaginalis\u003c/em\u003e has high acceptability and feasibility among women aged 15 to 50 years enrolled in the Zipime Weka Schista cohort study in Zambia. All women participating in the study provided all three self-collected specimens (oral, vaginal and cervical), and a high proportion found self-sampling \u0026ldquo;easy\u0026rdquo;.\u003c/p\u003e \u003cp\u003eOur study is in agreement with other studies in which individual genital self-sampling for either FGS, HPV or STIs and self-test for HIV has been acceptable among young and older women of different ethnicity, educational and socio-economic status (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). A cross-sectional study conducted in Zambia also found high (86.6%) acceptability and feasibility of the genital self-sampling for the diagnosis of FGS in young women aged 18\u0026ndash;36 years (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Another study conducted in Zambia highlighted the high prevalence of FGS in adult women living in urban areas (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) which showed the importance of screening for FGS in Zambia. While there have been calls for integrated FGS in SRH programmes within the health systems (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), our study is the first to highlight the acceptability and feasibility of integrating screening of FGS with HPV, \u003cem\u003eTv\u003c/em\u003e and HIV at household level and in hard to reach areas.\u003c/p\u003e \u003cp\u003eGenital self-sampling and self-testing as an alternative to clinician collected samples, has been validated in recent years for the diagnosis of different genital tract infections (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This approach has shown to increase adherence among under-screened women, those who may not visit the health facility regularly and women who may be geographically isolated (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). In addition, self-sampling has been shown to be cost effective, highly acceptable in terms of ease to use, convenience, privacy, physical and emotional comfort and less embarrassing (\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Similarly, in this study, the home-based approach substantially reached women who were at risk of infection, had low awareness and were first -time testers. This has potential to reduce the burden and vulnerability for FGS, HIV, \u003cem\u003eTv\u003c/em\u003e, HPV and ultimately cervical cancer. Some studies have shown evidence on the reduction of disease controlling for others (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe ease of self-sampling for the home-based procedures in this study was reported as easy (76.4%) by the majority of women recruited into the study \u003cb\u003e(Table\u0026nbsp;2)\u003c/b\u003e. Some of the reasons given were the very clear instructions and the aid of the 3D model, which helped them visualize the technical instructions. Women found self-sampling and self-testing to be easy because the instructions were clear and understandable (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). However, some participants reported that they found the self-sampling a little difficult (4.7%) and (0.2%) very difficult \u003cb\u003e(Table\u0026nbsp;2)\u003c/b\u003e. Despite this finding, most women indicated that they would be willing to self-sample in the same setting again. A qualitative study conducted at the cervical cancer screening clinic at ORCI in Dar es Salaam, showed that most participants liked self-sampling and still preferred it over provider-based sampling despite experiencing some difficulties with the procedure. They needed a health provider present when conducting the self-sampling (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In other studies, health providers prepared the women prior to the self-sampling by providing health education, allowed the women to touch the swab and provided support through-out the process because some women were worried about the accuracy of the test. A cross-sectional study conducted in Hong Kong in women aged 25\u0026ndash;35 and 45_\u0026gt; that explored the feasibility and acceptability of HPV self-sampling found high acceptability (80%) of self-sampling in under screened and never-screened women (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWomen from all three study communities preferred to self-collect specimens from home compared with clinic-based provider sampling. If adopted widely as a screening procedure, this preference may increase the uptake of screening for multiple infections. Further, women reported reassurance of having a community health worker who explained the procedures using the three Dimension model making it easy to follow the instructions and take the samples to a laboratory facility. The community health workers also provided knowledge on the different genital infections that were being screened for, this could have increased the acceptability levels. Community health workers can play a crucial role in raising awareness about the different infections, mostly in communities with low awareness for diseases like FGS and HPV and potentially increase screening (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In this study, we also found that women preferred to self-sample at home because it was more convenient, there was more privacy. They further reported that going to the clinic was not convenient, there was lack of transport and difficulty reaching clinic due to work, and lack of childcare. Other studies have also highlighted stigma, travel time and waiting time at the clinic as further hurdles to this approach (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs previously reported, high acceptability of the procedures was associated with higher education levels and those who live in distant areas (\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). This may indicate that women with a higher education may be more confident with self-sampling than women with lower education and may have a better understanding for choice of screening methods (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Another study found that religion significantly determined knowledge and prevention behaviour that influenced decision in the uptake of HPV self-sampling (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Other factors that have shown to influence uptake of screening include age, household income, smoking, drinking and job status (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The reasons for acceptability were not explored in detail. Therefore, more qualitative studies will need to be conducted to explore how these factors influence choice of screening methods.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIntegrated self-sampling and testing procedures for multi-pathogen detection were highly acceptable and feasible in women aged 15\u0026ndash;50 years in three communities in Zambia. Most women reported that self-sampling was \u0026ldquo;easy\u0026rdquo; with willingness to self-sample in the same setting again. Home-based procedures were preferred by most of the participants over clinic-based procedures. Our study provides new evidence on acceptability and feasibility on integration of a home-based multi-pathogen self-sampling and testing methods. This represents an evidence-based novel direction for national policy to increase access to diagnosis, treatment and care for different infections co-existing in women of childbearing age.\u003c/p\u003e"},{"header":"Abbreviations ","content":"\u003cp\u003eFGS\u0026nbsp; \u0026nbsp; \u0026nbsp;female genital schistosomiasis\u003c/p\u003e\n\u003cp\u003eHPV \u0026nbsp; \u0026nbsp;human papillomavirus\u003c/p\u003e\n\u003cp\u003eSTI \u0026nbsp; \u0026nbsp; \u0026nbsp;sexually transmitted infections\u003c/p\u003e\n\u003cp\u003eHIV \u0026nbsp; \u0026nbsp;\u0026nbsp;Human immunodeficiency viruses\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTv\u003c/em\u003e\u0026nbsp; trichomonas vaginalis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSSA \u0026nbsp; \u0026nbsp;\u0026nbsp;sub-saharan Africa\u003c/p\u003e\n\u003cp\u003eSRH \u0026nbsp; \u0026nbsp;sexual reproductive health\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; world health organisation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all study participants. This study was conducted in accordance with the Declaration of Helsinki, approved by the University of Zambia Biomedical Research Ethics Committee (reference number: 1858-2021), the Zambia National Health Research Authority (reference number: NHRA00012) and the London School of Hygiene and Tropical Medicine research ethics committee (reference number: 25258).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all study participants for publication and dissemination of results. All authors gave consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available upon reasonable request. Please contact the corresponding author if required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is funded through a UKRI Future Leaders Fellowship (MR/T041900/1) awarded to Prof. AL Bustinduy. Funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank and acknowledge all the participants, and Schista! study fieldworkers and midwives in Kafue and Livingstone communities. We would like to thank our partners in Zambia including the Ministry of Health and District Health Management Teams; the administrative and support teams at Zambart and LSHTM. We thank the ODK forum for assistance with questionnaire construction and Chrissy Roberts (LSHTM) for his invaluable support with 3D printing of teaching models. We also want to thank Longhorn Vaccines and Diagnostics LLC, Bethesda, MD for the donations of the PrimeStore® MTM molecular transport media.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAB originally conceived and designed the study with consultation with HA and HK. JC, RM, MC, MN, SP, GM collected the data with supervision from RN, KS and AB. JF contributed to the laboratory component of the study. EW and NK were responsible for data management. RN wrote the original draft of this manuscript. OL, NK and RN contributed to the analysis. IM, AB, KS, OL, EW reviewed and edited the article. KS and AB supervised and validated the article.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePonzo E, Midiri A, Manno A, Pastorello M, Biondo C, Mancuso G. Insights into the epidemiology, pathogenesis, and differential diagnosis of schistosomiasis. Eur J Microbiol Immunol. 2024 May 14;14(2):86\u0026ndash;96. \u003c/li\u003e\n\u003cli\u003eNour NM. Schistosomiasis: health effects on women. Rev Obstet Gynecol. 2010;3(1):28\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eOrish VN, Morhe EKS, Azanu W, Alhassan RK, Gyapong M. The parasitology of female genital schistosomiasis. Curr Res Parasitol Vector-Borne Dis. 2022;2:100093. \u003c/li\u003e\n\u003cli\u003eHegertun IEA, Sulheim Gundersen KM, Kleppa E, Zulu SG, Gundersen SG, Taylor M, et al. S. haematobium as a Common Cause of Genital Morbidity in Girls: A Cross-sectional Study of Children in South Africa. Downs JA, editor. PLoS Negl Trop Dis. 2013 Mar 21;7(3):e2104. \u003c/li\u003e\n\u003cli\u003eMartinez SG, Mbabazi PS, Sebitloane MH, Vwalika B, Mocumbi S, Galaphaththi-Arachchige HN, et al. The WHO atlas for female-genital schistosomiasis: Co-design of a practicable diagnostic guide, digital support and training. Parray AA, editor. PLOS Glob Public Health. 2024 Mar 18;4(3):e0002249. \u003c/li\u003e\n\u003cli\u003eAsangbeh-Kerman SL, Davidović M, Taghavi K, Kachingwe J, Rammipi KM, Muzingwani L, et al. Cervical cancer prevention in countries with the highest HIV prevalence: a review of policies. BMC Public Health. 2022 Aug 10;22(1):1530. \u003c/li\u003e\n\u003cli\u003eRossi B, Previtali L, Salvi M, Gerami R, Tomasoni LR, Quiros-Roldan E. Female Genital Schistosomiasis: A Neglected among the Neglected Tropical Diseases. Microorganisms. 2024 Feb 24;12(3):458. \u003c/li\u003e\n\u003cli\u003eKjetland EF, Ndhlovu PD, Mduluza T, Gomo E, Gwanzura L, Mason PR, et al. Simple clinical manifestations of genital Schistosoma haematobium infection in rural Zimbabwean women. Am J Trop Med Hyg. 2005 Mar;72(3):311\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eLamberti O, Bozzani F, Kiyoshi K, Bustinduy AL. Time to bring female genital schistosomiasis out of neglect. Br Med Bull. 2024 Mar 13;149(1):45\u0026ndash;59. \u003c/li\u003e\n\u003cli\u003eKukula VA, MacPherson EE, Tsey IH, Stothard JR, Theobald S, Gyapong M. A major hurdle in the elimination of urogenital schistosomiasis revealed: Identifying key gaps in knowledge and understanding of female genital schistosomiasis within communities and local health workers. Hsieh MH, editor. PLoS Negl Trop Dis. 2019 Mar 21;13(3):e0007207. \u003c/li\u003e\n\u003cli\u003eAzanu WK, Osarfo J, Appiah G, Godonu YS, Ampofo GD, Orish V, et al. Knowledge of female genital schistosomiasis and urinary schistosomiasis among final-year midwifery students in the Volta Region of Ghana. Olorunlana A, editor. PLOS ONE. 2024 May 2;19(5):e0302554. \u003c/li\u003e\n\u003cli\u003eAn update on female and male genital schistosomiasis and a call to integrate efforts to escalate diagnosis, treatment and awareness in endemic and non-endemic settings: The time is now. In: Advances in Parasitology [Internet]. Elsevier; 2022 [cited 2025 Nov 3]. p. 1\u0026ndash;44. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0065308X21000592\u003c/li\u003e\n\u003cli\u003ePillay LN, Umbelino-Walker I, Schlosser D, Kalume C, Karuga R. Minimum Service Package for the integration of female genital schistosomiasis into sexual and reproductive health and rights interventions. Front Trop Dis. 2024 June 17;5:1321069. \u003c/li\u003e\n\u003cli\u003eUmbelino-Walker I, Wong F, Cassolato M, Pantelias A, Jacobson J, Kalume C. Integration of female genital schistosomiasis into HIV/sexual and reproductive health and rights and neglected tropical diseases programmes and services: a scoping review. Sex Reprod Health Matters. 2023 Dec 31;31(1):2262882. \u003c/li\u003e\n\u003cli\u003eSturt A, Omar T, Hansingo I, Kamfwa P, Bustinduy A, Kelly H. Association of female genital schistosomiasis and human papillomavirus and cervical pre-cancer: a systematic review. BMC Womens Health. 2025 Jan 3;25(1):2. \u003c/li\u003e\n\u003cli\u003eKjetland EF, Ndhlovu PD, Gomo E, Mduluza T, Midzi N, Gwanzura L, et al. Association between genital schistosomiasis and HIV in rural Zimbabwean women. AIDS. 2006 Feb 28;20(4):593\u0026ndash;600. \u003c/li\u003e\n\u003cli\u003eEngels D, Hotez PJ, Ducker C, Gyapong M, Bustinduy AL, Secor WE, et al. Integration of prevention and control measures for female genital schistosomiasis, HIV and cervical cancer. Bull World Health Organ. 2020 Sept 1;98(9):615\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003eSutarsa IN, Campbell L, Dwi Ariawan IM, Kasim R, Marten R, Rajan D, et al. Multisectoral interventions and health system performance: a systematic review. Bull World Health Organ. 2024 July 1;102(07):521-532F. \u003c/li\u003e\n\u003cli\u003eHotez PJ, Harrison W, Fenwick A, Bustinduy AL, Ducker C, Sabina Mbabazi P, et al. Female genital schistosomiasis and HIV/AIDS: Reversing the neglect of girls and women. Hsieh MH, editor. PLoS Negl Trop Dis. 2019 Apr 4;13(4):e0007025. \u003c/li\u003e\n\u003cli\u003eBakiewicz A, Rasch V, Mwaiselage J, Linde DS. \u0026ldquo;The best thing is that you are doing it for yourself\u0026rdquo; \u0026ndash; perspectives on acceptability and feasibility of HPV self-sampling among cervical cancer screening clients in Tanzania: a qualitative pilot study. BMC Womens Health. 2020 Dec;20(1):65. \u003c/li\u003e\n\u003cli\u003ePaudyal P, Llewellyn C, Lau J, Mahmud M, Smith H. Obtaining Self-Samples to Diagnose Curable Sexually Transmitted Infections: A Systematic Review of Patients\u0026rsquo; Experiences. Clark JL, editor. PLOS ONE. 2015 Apr 24;10(4):e0124310. \u003c/li\u003e\n\u003cli\u003eJones HE, Altini L, De Kock A, Young T, Van De Wijgert JHHM. Home-based versus clinic-based self-sampling and testing for sexually transmitted infections in Gugulethu, South Africa: randomised controlled trial. Sex Transm Infect. 2007 Dec 1;83(7):552\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eCamus C, Penaranda G, Khiri H, Camiade S, Molet L, Lebsir M, et al. Acceptability and efficacy of vaginal self-sampling for genital infection and bacterial vaginosis: A cross-sectional study. Mitchell C, editor. PLOS ONE. 2021 Nov 18;16(11):e0260021. \u003c/li\u003e\n\u003cli\u003eMkopi A, Korte JE, Lesslie V, diNapoli M, Mutiso F, Mwajubwa S, et al. Acceptability and uptake of oral HIV self-testing among rural community members in Tanzania: a pilot study. AIDS Care. 2023 Sept 2;35(9):1338\u0026ndash;45. \u003c/li\u003e\n\u003cli\u003eRutty Phiri C, Sturt AS, Webb EL, Chola N, Hayes R, Shanaube K, et al. Acceptability and feasibility of genital self-sampling for the diagnosis of female genital schistosomiasis: a cross-sectional study in Zambia. Wellcome Open Res. 2020 Sept 2;5:61. \u003c/li\u003e\n\u003cli\u003eSturt AS, Webb EL, Phiri CR, Mweene T, Chola N, Van Dam GJ, et al. Genital self-sampling compared with cervicovaginal lavage for the diagnosis of female genital schistosomiasis in Zambian women: The BILHIV study. Cools P, editor. PLoS Negl Trop Dis. 2020 July 14;14(7):e0008337. \u003c/li\u003e\n\u003cli\u003eShanaube K, Ndubani R, Kelly H, Webb E, Mayaud P, Lamberti O, et al. Zipime-Weka-Schista study protocol: a longitudinal cohort study and economic evaluation of an integrated home-based approach for genital multipathogen screening in women, including female genital schistosomiasis, human papillomavirus, Trichomonas and HIV in Zambia. BMJ Open. 2024 June;14(6):e080395. \u003c/li\u003e\n\u003cli\u003eSullivan GM, Artino AR. Analyzing and Interpreting Data From Likert-Type Scales. J Grad Med Educ. 2013 Dec;5(4):541\u0026ndash;2. \u003c/li\u003e\n\u003cli\u003eBrunette W, Sudar S, Sundt M, Larson C, Beorse J, Anderson R. Open Data Kit 2.0: A Services-Based Application Framework for Disconnected Data Management. In: Proceedings of the 15th Annual International Conference on Mobile Systems, Applications, and Services [Internet]. Niagara Falls New York USA: ACM; 2017 [cited 2025 Oct 29]. p. 440\u0026ndash;52. Available from: https://dl.acm.org/doi/10.1145/3081333.3081365\u003c/li\u003e\n\u003cli\u003eRogers EQ, Mwangelwa S, Kabengele C, Kilembe W, Vwalika B, Inambao M, et al. Developing and validating a screening tool for female genital schistosomiasis in urban Zambia. Front Trop Dis. 2024 Feb 27;4:1308129. \u003c/li\u003e\n\u003cli\u003eMberu M, Zongo K, Leaning E, Makau-Barasa L, Kamara K, Jacobson J. Female genital schistosomiasis: Addressing diagnostic and programmatic gaps to advance elimination efforts. Int J Infect Dis. 2025 Mar;152:107798. \u003c/li\u003e\n\u003cli\u003eArbyn M, Smith SB, Temin S, Sultana F, Castle P. Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses. BMJ. 2018 Dec 5;k4823. \u003c/li\u003e\n\u003cli\u003eAngotti N, Bula A, Gaydosh L, Kimchi EZ, Thornton RL, Yeatman SE. Increasing the acceptability of HIV counseling and testing with three C\u0026rsquo;s: Convenience, confidentiality and credibility. Soc Sci Med. 2009 June;68(12):2263\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eKrause J, Subklew-Sehume F, Kenyon C, Colebunders R. Acceptability of HIV self-testing: a systematic literature review. BMC Public Health. 2013 Dec;13(1):735. \u003c/li\u003e\n\u003cli\u003ePourette D, Cripps A, Guerrien M, Despr\u0026egrave;s C, Opigez E, Bardou M, et al. Assessing the Acceptability of Home-Based HPV Self-Sampling: A Qualitative Study on Cervical Cancer Screening Conducted in Reunion Island Prior to the RESISTE Trial. Cancers. 2022 Mar 8;14(6):1380. \u003c/li\u003e\n\u003cli\u003eMeenan RT, Troja C, Buist DSM, Tiro JA, Lin J, Anderson ML, et al. Economic Evaluation of Mailed Home-Based Human Papillomavirus Self-sampling Kits for Cervical Cancer Screening. JAMA Netw Open. 2023 Mar 22;6(3):e234052. \u003c/li\u003e\n\u003cli\u003eHariprasad R, Bagepally BS, Kumar S, Pradhan S, Gurung D, Tamang H, et al. Cost-utility analysis of primary HPV testing through home-based self-sampling in comparison to visual inspection using acetic acid for cervical cancer screening in East district, Sikkim, India, 2023. Mahumud RA, editor. PLOS ONE. 2024 Aug 13;19(8):e0300556. \u003c/li\u003e\n\u003cli\u003ePatel P, Rose CE, Kjetland EF, Downs JA, Mbabazi PS, Sabin K, et al. Association of schistosomiasis and HIV infections: A systematic review and meta-analysis. Int J Infect Dis. 2021 Jan;102:544\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eKohler RE, Elliott T, Monare B, Moshashane N, Ramontshonyana K, Chatterjee P, et al. HPV self‐sampling acceptability and preferences among women living with HIV in Botswana. Int J Gynecol Obstet. 2019 Dec;147(3):332\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eWong ELY, Cheung AWL, Wong AYK, Chan PKS. Acceptability and Feasibility of HPV Self-Sampling as an Alternative Primary Cervical Cancer Screening in Under-Screened Population Groups: A Cross-Sectional Study. Int J Environ Res Public Health. 2020 Aug 27;17(17):6245. \u003c/li\u003e\n\u003cli\u003eSechi I, Muresu N, Puci MV, Saderi L, Del Rio A, Cossu A, et al. Preliminary Results of Feasibility and Acceptability of Self-Collection for Cervical Screening in Italian Women. Pathogens. 2023 Sept 17;12(9):1169. \u003c/li\u003e\n\u003cli\u003eRafferty H, Sturt AS, Phiri CR, Webb EL, Mudenda M, Mapani J, et al. Association between cervical dysplasia and female genital schistosomiasis diagnosed by genital PCR in Zambian women. BMC Infect Dis. 2021 Dec;21(1):691. \u003c/li\u003e\n\u003cli\u003eChang HK, Myong JP, Byun SW, Lee SJ, Lee YS, Lee HN, et al. Factors associated with participation in cervical cancer screening among young Koreans: a nationwide cross-sectional study. BMJ Open. 2017 Apr;7(4):e013868. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Female genital schistosomiasis, Schistosoma haematobium, acceptability, feasibility, self-sampling, women, integration, home, clinic, HPV, Trichomonas, HIV, STI, cervical cancer, cervical precancer","lastPublishedDoi":"10.21203/rs.3.rs-8278348/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8278348/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale genital schistosomiasis (FGS) is a neglected gynaecological disease that affects over 50 million girls and women in sub-Saharan Africa. It is caused by the waterborne parasite \u003cem\u003eSchistosoma (S.) haematobium\u003c/em\u003e and has been associated with HIV infection, with human papillomavirus (HPV) and cervical precancer. FGS alters the normal sexual and reproductive health of girls and women. Diagnosis is bottlenecked, but previous studies have shown acceptability of genital self-sampling at home for individual diagnosis of FGS, HPV and selected STIs. Here, we aim to determine the acceptability and feasibility of home-based multi-pathogen self-sampling and testing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Zipime Weka Schista study is an ongoing longitudinal cohort integrating a one-stop home-based genital self-sampling for \u003cem\u003eS. haematobium\u003c/em\u003e and HPV DNA detection with self-testing for HIV and \u003cem\u003eTrichomonas vaginalis (Tv\u003c/em\u003e) in three communities in Zambia. Sexually active women aged 15-50 years were randomly selected by community health workers and visited at home where they were invited to provide two cervicovaginal self-swabs and a urine sample, and to conduct self-tests for HIV and \u003cem\u003eTv\u003c/em\u003e. During the home visit, community health workers collected information on the acceptability and feasibility of the multi-pathogen genital self-sampling approach using a questionnaire. A follow-up visit was done in clinic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 2,701 women were initially approached by community health workers and 2,532 were enrolled between January 2022 – March 2023. A total of 100% (2,532) women provided self-swabs, and 94.3% (2,389) and 55.4% (1,404) undertook \u003cem\u003eTv\u003c/em\u003e and HIV self-tests, respectively. Of these, 67% (1,694) were followed up in clinic. There was high acceptability 76.4% (1,934) on the procedures for home multi-genital self-sampling. Many participants 87.2% (2,208) preferred to be seen at home than in clinic. Some reasons stated were convenience 62.6% (1,585); privacy 47.9% (1,215); going to the clinic was not convenient 10.4% (264); lack of transport to go to the clinic 8.2% (208); unavailability due to work 4.6% (118) and availability of childcare 2.7% (69).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHome-based multi-pathogen self-sampling and testing is highly acceptable and feasible in three communities in Zambia. This has potential to increase access to diagnosis, treatment and care for different infections co-existing in women.\u003c/p\u003e","manuscriptTitle":"Acceptability and feasibility of one-stop home-based genital self-sampling for Female Genital Schistosomiasis, Human Papilloma Virus and self- testing for Trichomonas and HIV: The Zipime Weka Schista Study in Zambia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 08:32:10","doi":"10.21203/rs.3.rs-8278348/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-04T00:21:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-25T12:51:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-24T09:12:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250449219674031419479012913536938064847","date":"2026-01-23T08:23:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-22T10:45:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-21T09:12:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45318634893700054379214901233446952206","date":"2026-01-16T18:49:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120418535730620305516226392516004875337","date":"2026-01-16T12:14:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54726257399246523142549123280471275258","date":"2026-01-10T11:48:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T18:21:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-05T12:33:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-18T11:00:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-17T09:37:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-12-17T09:25:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"31997d91-c946-4ebe-9e0e-93391e36c75f","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T07:25:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 08:32:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8278348","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8278348","identity":"rs-8278348","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}