Predictors of delay in the cervical cancer care cascade in Kampala, Uganda

Predictors of delay in the cervical cancer care cascade in Kampala, Uganda | 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 Predictors of delay in the cervical cancer care cascade in Kampala, Uganda Megan Swanson, Alison El Ayadi, Miriam Nakalembe, Jane Namugga, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5467551/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Feb, 2026 Read the published version in BMC Women's Health → Version 1 posted 11 You are reading this latest preprint version Abstract Background Cervical cancer is the fourth most common cancer among women with significant global disparities in disease burden. In lower-resource settings, where routine screening is uncommon, delays in diagnosis and treatment contribute to morbidity and mortality. Understanding care delays may inform strategies to decrease time to treatment, improving patient outcomes. Methods We collected sociodemographic, reproductive health and care journey data from 268 Ugandan women newly diagnosed with cervical cancer. We explored the influence of patient, health provider, system, and disease factors on time to presentation (patient interval), diagnosis (diagnostic interval) and treatment (treatment interval) using survival analysis. Results Median patient, diagnostic and treatment intervals were 74 days (IQR 26–238), 83 days (IQR 34–229), and 34 days (IQR 18–58), respectively. Patient interval was delayed by belief that symptoms would resolve (aHR 0.37, 95% CI 0.24–0.57), confusion about where to seek care (aHR 0.64, 95% CI 0.47–0.88), and utilization of traditional care (aHR 0.70, 95% CI 0.51–0.96). Patient interval facilitators included perceiving symptoms as serious (aHR 2.14, 95% CI 1.43–3.19) and suspecting cancer (aHR 1.82, 95% CI 1.12–2.97). Diagnostic interval delays included symptomatic bleeding (aHR 055, 95% CI 0.35–0.85) and visiting > 2 clinics (aHR 0.69, 95% CI 0.49–0.97); facilitators included early-stage disease (aHR 1.41, 95% CI 1.03–1.95) and direct tertiary care presentation (aHR 2.13, 95% CI 1.20–3.79). Treatment interval delays included anticipating long waits (aHR 0.68, 95% CI 0.46–1.02) and requiring blood transfusions (aHR 0.63, 95% CI 0.37–1.07); no facilitators were identified. Conclusions We identified potentially modifiable barriers and facilitators along the cervical cancer care cascade. Interventions targeting these factors may improve care timeliness but are unlikely to significantly improve morbidity or mortality. Expanding cervical cancer screening and vaccination are of utmost importance. cervical cancer delay treatment access Figures Figure 1 Background Cervical cancer is the fourth most common cancer among women worldwide, but there is great disparity in disease distribution globally [ 1 , 2 ]. In Uganda, like many countries in East Africa, cervical cancer is the most common malignancy and is responsible for the greatest cancer-related mortality among women [ 3 ]. Most women present with advanced-stage disease and 5-year overall survival in Uganda is estimated to be just 18% [ 4 , 5 ]. While surgery, chemotherapy and radiation are all services offered at the national public tertiary care facilities, namely Mulago National Referral Hospital (MNRH) and the Uganda Cancer Institute (UCI), multisystem obstacles challenge access to the various treatment modalities [ 6 , 7 ]. Screening can detect asymptomatic cervical precancerous lesions as well as cancer, allowing for effective preventative treatments or diagnosis at an early stage, respectively. Women with invasive cancer may present with symptoms such as bleeding, foul smelling discharge or pain. Symptoms are more common in advanced disease. In low- and middle-income countries (LMICs), cervical cancer is rarely diagnosed when asymptomatic as routine effective screening is not readily accessible. Many women with cervical cancer around the world experience some delay in presentation to care as well as in accurate diagnosis with staging and initiating appropriate treatment [ 8 – 13 ]. Younger age [ 8 , 9 , 13 ] and rural residence [ 8 , 9 ] are commonly associated with delay in accessing cervical cancer care. However, no single accepted definition of “delay” exists, and women may experience a subjective or objective delay in initial presentation to a clinician, obtaining diagnostic tests, receiving a diagnosis, and/or in initiating treatment (curative or palliative). The United States Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) has set a quality standard of ≤ 90 days from abnormal screening to final diagnosis [ 14 ], though this standard may not apply outside of high-income countries with ready access to screening, diagnostic and treatment modalities.. There is a paucity of data evaluating the impact of delayed definitive treatment for cervical cancer on survival, especially in advanced disease, particularly in LMICs [ 15 ]. However, data from high-income countries suggest that an interval greater than three months from diagnosis to treatment initiation may increase morbidity and impair survival from cervical cancer, even when controlling for stage, age and co-morbidities [ 16 , 17 ]. “Delay” is not necessarily synonymous with advanced disease. Patients with cervical cancer at any stage may experience delay in accessing care, obtaining a diagnosis and/or initiating treatment. In fact, studies in Uganda and Brazil found that a diagnosis to treatment interval greater than or equal to three months was common overall (55 to 93%, respectively), and that women with advanced cervical cancer were not significantly more likely than those with earlier-stage disease to experience such delay [ 18 , 19 ]. Reasons for delay in accessing cervical cancer care are speculative and likely vary across the care cascade. Awareness of cervical cancer is generally high; however, misattribution of symptoms and misconceptions regarding etiology are common in Uganda [ 20 – 22 ], and could theoretically contribute to patient delays in seeking medical care. Once care is established, fees associated with labs, imaging and pathology studies can be cost-prohibitive for many families and could result in a delay in obtaining a diagnosis. For instance, one CT scan costs at least as much as the average monthly income nationally (300,000 Ugandan Shillings, about $ 80 USD). While most medical care, including some basic diagnostic testing has been offered free of charge at public facilities in Uganda since 2001, nearly half of the country’s healthcare financing continues to come from out-of-pocket expenditures [ 23 ]. Once a diagnosis has been made, lack of available subspecialists [ 24 ], anesthesiologists [ 25 , 26 ], cross-matched blood [ 27 ], and equipment [ 28 ] may limit the availability of cancer surgery. Radiation availability has been dynamic in the past decade, but even prior to 2016, when Uganda’s one intermittently functional external beam machine was working 20 + hours per day, it was only meeting 2.6% of the nation’s indicated radiation treatments [ 29 , 30 ]. A new cobalt 60 radiotherapy machine was inaugurated in January 2018. Studies are needed to characterize the intervals in the process of obtaining care for cervical cancer as well as to investigate of predictors of delay at each of these intervals in order to identify modifiable barriers and facilitators along the cascade [ 18 , 22 ]. The purpose of this study was to describe the cascade of cervical cancer care among women ultimately accessing specialty care at government supported tertiary care centers in Kampala, Uganda and to identify barriers and facilitators to timely care across each interval in the care cascade. Understanding which factors contribute to more relative delay during these intervals may help identify ways to reduce overall time to treatment initiation and potentially improve outcomes for women with cervical cancer. Methods The current analysis is part of a larger mixed-methods study which seeks to characterize barriers to cervical cancer care among Ugandan women to inform strategies to minimize delay and improve access to care. Study setting, participant recruitment and data collection activities have been described previously in detail [31]. Women aged 18 or above presenting to care at MNRH and/or UCI with primary cervical cancer were enrolled in the study from May 3, 2017 – September 17, 2018. Data on sociodemographic and reproductive characteristics and participants’ care journeys were collected through interviewer-administered survey at care enrollment. Data on treatment initiation was captured via phone one to three months later. Medical record abstraction was used to supplement self-reported data. Study Setting Mulago National Referral Hospital and UCI are part of the Mulago Hospital Complex, located in Kampala, Uganda, associated with Makerere University College of Health Sciences. They provide comprehensive specialist services for the entire nation. Ninety-nine per cent of the national population seeks care through the public sector and would access specialty cancer care exclusively at these institutions [32]. Patients without private insurance may present to MNRH through emergency gynecologic triage and may access gynecologic oncology diagnostic and surgical care there. Patients may present directly to UCI’s screening clinic or may be referred for diagnostics, surgery, chemotherapy and/or radiotherapy from the gynecology division of MNRH or from surrounding facilities. Gynecologic oncology specialists and fellowship trainees care for patients at MNRH and UCI through a Memorandum of Understanding between the institutions. Between March, 2016 and January, 2018, no external beam radiotherapy was available in Uganda; during this time, the Ministry of Health partially subsidized radiation at a private hospital in Nairobi, Kenya, though it is unclear how many patients benefitted from this program. In response to the challenges obtaining radiotherapy 2016-2018, providers at UCI and MNRH developed a protocol for treating locally and regionally-advanced cervical cancer with neoadjuvant chemotherapy followed by possible radical hysterectomy, an evidence-based strategy supported by the American Society of Clinical Oncology (ASCO) Resource-stratified Treatment Guidelines [33-36]. A new cobalt 60 radiotherapy machine became operational at UCI in January, 2018. Brachytherapy was available throughout the study period and may have been recommended for treatment or palliation in conjunction with other therapies. In Uganda, radiotherapy is only available at UCI. There are nominal fees associated with surgery and radiation at MNRH and UCI. The UCI provides chemotherapy free of charge, but drug inventory fluctuates, and stock-outs are common. Theoretical Orientation Our research was oriented by the Model of Pathways to Care [37, 38], a theoretical model adapted from the Andersen’s Model of Total Patient Delay [39], for understanding the process of seeking and obtaining diagnosis and treatment for cancer. Intervals defined by this model include: patient appraisal and health seeking intervals, characterizing detection of bodily change to perceiving a need to discuss symptoms with a health care provider to first consultation; diagnostic interval, time between first health care consultation to formal diagnosis; and treatment interval, time between diagnosis to treatment initiation. Various contributing factors at multiple levels including the patient, provider, health care system and disease are considered to influence the processes operating within these intervals. The three main levels of factors within this model are ‘patient factors’, representing the individual within their particular social and cultural context (e.g., demographics, previous experience, co‐morbidities, cognitions, and emotions), ‘health care provider and system factors’, representing health care services aspects which can impact patient and provider decisions and behavior (e.g., access to generalist and/or specialist health care including diagnostic procedures and treatment), and ‘disease factors’, the clinical and physiological aspects of the condition (e.g., symptoms and prognosis). Utilizing the intervals specified in this model allows for a standardized, uniform way to report about delay in a patient’s journey to obtaining cancer diagnoses and treatment. Greater precision and transparency in defining this process should, in turn, facilitate the effective design and implementation of interventions to minimize delay. See our conceptual framework (Fig 1). Measures From patient-reported data on timing of events in their care journey, we calculated three major time intervals in the cervical cancer cascade of care: patient interval, diagnostic interval, and treatment interval. Patient interval represents the time (in days) between first noticing symptoms and first presenting to a health care provider, including the process of making the decision to seek care. Diagnostic interval represents the time (in days) between first presenting to any health care provider and the consultation with a specialist when diagnosis was confirmed, stage assigned, and treatment recommendations made. Treatment interval represented the time (in days) between specialist consultation and initiation of treatment (surgery, chemotherapy, external beam radiation therapy (EBRT) inclusive of radio-sensitizing chemotherapy, or palliative care/hospice). While patients may ultimately receive multi-modal therapy (like chemotherapy followed by hysterectomy or EBRT followed by brachytherapy), the treatment interval ends when the first treatment modality started. While brachytherapy was available throughout the study period, this was never the first recommended and/or initiated therapy; patients may have accessed brachytherapy later in their care journey, though these data not captured in this study. Of note, systemic chemotherapy may have been recommended for distant metastatic disease or for non-operable local- or regionally-advanced disease during the time when EBRT was not available in-country. The survey used in this study was adapted from a validated instrument to measure time intervals and factors correlated with delay in accessing breast cancer care [40]. Where specific dates were unable to be recalled, participants were asked to estimate according to a validated protocol: if participants could not recall exact day, they were asked if the event occurred in the beginning (coded as 5 th ), middle (coded as 15 th ) or end (coded as 25 th ) of the month; if participants could not recall the month exactly, they estimated beginning (coded as February), middle (coded as June) or end (coded at November) or the year [40]. If no estimation could be made, the date was treated as missing. Patient factors captured included variables representing sociodemographic characteristics, awareness, perceived symptom severity, and perspectives on care access timeline. Sociodemographic characteristics captured included age at enrollment (<40 versus ≥40), educational attainment (none, primary, secondary, and other), occupation (farming/domestic work versus industry/business), relationship status (married or partnered versus not). Residence was characterized as rural versus urban (as defined by the Uganda Bureau of Statistics) and distance to specialized care site (MNRH or UCI) calculated (<15 km, 16-50 km, 51-150 km, ≥151 km). Reproductive history included parity, HIV status (positive, negative, never been tested, tested but don’t know result), prior cervical cancer screening (yes versus no), current contraceptive use (yes versus no). Awareness of cervical cancer was captured through asking whether participants had ever heard of cervical cancer before coming to the doctor (yes versus no), whether they had any friends or family members who had cervical cancer (yes versus no). Perceived symptom severity was assessed through asking participants how serious they felt their initial symptom was (not serious, a little serious, moderately serious, serious, very serious), what their level of concern was around this initial symptom (no concern, a little concern, moderate concern, very concerned), and what they initially thought was causing the symptom (cancer, menstrual irregularities, pregnancy, contraception, STI/HIV or other infection, bewitching, other). Patients were also asked to reflect on their own care access timeline, reporting on their impressions of how long it took to decide to seek care, to initially present for care, to see the specialist, and to ultimately start treatment (response options: immediate, quick, a little delayed, and very delayed). Women who reported a little delayed or very delayed were then asked for reasons that contributed to subjective delay (thought symptoms would resolve, didn’t know where to go, scared, embarrassed, sought alternative treatments herbal and/or spiritual in nature, perceived long waits, lack of trust in medical system, and financial constraints). Health care provider and health systems factors of interest included characteristics of the first clinical encounter: facility type (public versus private), facility level (referral/tertiary, regional versus district/village), provider type (physician, medical officer, nurse or midwife), pelvic exam with speculum to visualize cervix (yes versus no), biopsy (yes versus no); radiation available (yes versus no), number of biopsies done (≥2 biopsies, one versus none), cost of biopsy (>100,000 Ugandan Shillings,~$27 USD, versus less), location of biopsy (referral hospital versus elsewhere), number of clinics attended prior to MNRH/UCI (≥2 clinics versus one or none), and initial treatment recommendation (chemotherapy, surgery, EBRT, or palliative care). Disease factors captured included symptomatic (yes versus no), initial symptom (e.g., bleeding, vaginal discharge, pain, other), other symptoms present prior to healthcare presentation (intermenstrual/post-menopausal bleeding, bleeding with sex, vaginal discharge, pain with sex, abdominal/pelvic pain, fatigue). Clinical cancer stage was captured and confirmed by chart abstraction and ultimately classified as early-stage (IA to IIA) versus late-stage (IIB to IVB). Histology (squamous versus adenocarcinoma or adenosquamous) was also abstracted from chart. Statistical analyses Patient characteristics were described with medians with interquartile ranges and proportions. Due to some missing participant self-report data on the exact timing of certain steps in the care cascade (but timing data having been captured on a variety of steps), we implemented an interval censoring approach to our survival analysis [41, 42]. Such an approach accommodates situations where an event of interest is not exactly observed but is known to have occurred within a particular time window. For each interval, we characterized the interval length and estimated a series of proportional hazards regression models using the Weibull survival distribution to explore the impacts of patient, provider and health systems factors, as well as disease characteristics, on interval length. Factors theorized to be associated with the outcomes or those found to be significantly associated in bivariate analysis were considered for multivariate analysis, after ensuring lack of collinearity. In most applications of survival analysis, a longer time to event is preferable due to its interpretation as greater length of time event-free. However, for our characterization of care cascade intervals, a shorter time to event is preferable as our outcomes represent time to completing particular care steps. Hazard ratios (HR) can be interpreted as velocity: the higher the HR, the faster the time to the end of the step. Thus, HRs 1 indicate faster times to completing a step. Model goodness of fit was established using Akaike’s Information Criteria. All data were analyzed using Stata version 16.0 (Stata Corporation, College Station, TX). P values less than 0.05 were considered statistically significant. Ethics approval The study protocol was reviewed and approved by institutional review boards at MNRH (Mulago Research and Ethics Committee, MREC), UCI and the University of California San Francisco (UCSF). Uganda’s national review board, the Uganda National Council for Science and Technology (UNCST), also reviewed and approved the research. All participants provided written informed consent. Results During the study period, there were 268 women ranging in age from 20 to 81 years, with median age 49 (IQR 41-58; Table 1) who sought treatment for cervical cancer at MNRH or the UCI. Over half had primary or higher education (56.3%) and 65.3% worked in farming or domestic work. About one-third (32.1%) lived within 15 km of MNRH or UCI. Most participants had sought care based on symptoms (86.9%) while 13.1% were asymptomatic with cancer detected on screening. Over three-quarters had late-stage cancer on diagnosis (76.1%). The most recommended treatment was chemotherapy (61.2%), followed by EBRT (25.4%), surgery (12.7%), and palliative care (0.8%). Table 1 . Sociodemographic and clinical characteristics of women presenting for specialist care for primary cervical cancer, Uganda (n=268) All participants n=268 n % Sociodemographic characteristics Age group 20-29 7 2.6 30-39 47 17.5 40-49 79 29.5 50-59 69 25.7 60-69 39 14.6 ≥70 16 6.0 Missing 11 4.1 Educational attainment None 111 41.4 Primary 100 37.3 Secondary 51 19.0 Other 6 2.2 Occupation Farming/domestic work 175 65.3 Industry/business 93 34.7 Marital Status Married 121 45.1 Not married 147 54.9 Distance to MNRH or UCI <15 km 86 32.1 16-50 km 37 13.8 51-150 km 76 28.4 ≥151 km 69 25.7 Residence Rural 126 47.0 Urban 142 53.0 HIV Status Positive 83 31.7 Negative 179 68.3 Clinical/disease characteristics Prior cervical cancer screening Yes 68 25.4 No 200 74.6 Symptomatic Yes 233 86.9 No 35 13.1 Stage IA1 3 1.1 IA2 6 2.2 IB1 26 9.7 IB2 12 4.5 IIA 17 6.3 IIB 96 35.8 IIIA 4 1.5 IIIB 90 33.6 IVA 8 3.0 IVB 6 2.2 Recommended treatment Surgery 34 12.7 Chemotherapy 164 61.2 EBRT 68 25.4 Palliative care 2 0.7 Notes: MNRH : Mulago National Referral Hospital ; UCI: Uganda Cancer Institute ; EBRT : external beam radiation therapy. Among the 233 (87%) women who were symptomatic prior to diagnosis, the first symptom noticed for most women was bleeding (65.2%) or abnormal discharge (29.6%; Table 2). A variety of presumed causes of initial symptom were endorsed, most commonly infection (36.5%), abnormal menstruation or menopause (30.5%), versus cancer (10.3%). Over half of women perceived their initial symptoms to be not serious (45.9%) or a little serious (14.6%), and most had no concern (30.9%) or only a little concern (33.9%). Over half of women reported deciding to seek care due to persistent symptoms (53.9%) followed by worsening symptoms (39.7%). Table 2 . Initial symptom experiences and interpretation among Ugandan women with symptomatic primary cervical cancer seeking care at tertiary public facilities (n=233) n % Initial symptom identification Initial symptom noticed Bleeding 152 65.2 Discharge 69 29.6 Other a 12 5.2 Initial symptom interpretation Presumed cause of initial symptom Infection 85 36.5 Abnormal menstruation/menopause 71 30.5 Cancer 24 10.3 Contraceptive side effect 19 8.2 Pregnancy 8 3.4 Other b 26 11.2 Perceived seriousness of the problem Not serious 107 45.9 A little serious 34 14.6 Moderate 22 9.4 Serious 49 21.0 Very serious 21 9.0 Level of concern about the problem at first No concern 72 30.9 A little concern 79 33.9 Moderate 33 14.2 Very concerned 49 21.0 Symptoms present prior to presentation at any healthcare setting Abnormal bleeding c 163 70.0 Post-coital bleeding 122 52.4 Vaginal discharge 188 80.7 Dyspareunia 51 21.9 Abdominal or pelvic pain 161 69.1 Fatigue 89 38.2 a Other symptoms included pain (n=11) and fatigue (n=1). b Other presumed causes included bewitched (n=6), heavy work (n=3), fibroids (n=2), and other medical (n=7). c Intermenstrual or postmenopausal. Patient interval Median patient interval was 74 days (IQR 26-238 days). In unadjusted models of patient sociodemographic characteristics (Table 3), no factors were significantly associated with length of patient interval. In multivariate analysis (Table 4), completion of the patient interval was significantly slower those who believed that their symptoms would resolve (aHR 0.37, 95% CI 0.24-0.57), those who reported not knowing where to access care (aHR 0.64, 95% CI 0.47-0.88), as well as those who first sought alternative treatments (including herbal medicine, spiritual healing or other such practices) (aHR 0.70, 95% CI 0.51-0.96). Patient interval completion was significantly faster for those who reported thinking that their initial symptom was serious or very serious (HR 2.14, 95% CI 1.43-3.19), those who were moderately or very concerned about their symptom (HR 2.06, 95% CI 1.45-2.93), and those who believed their first symptom was cancer (HR 1.82, 95% CI 1.12-2.97). Table 3. Sociodemographic Factors Influencing Time to Cervical Cancer Care Cascade Intervals Patient interval Diagnostic interval Treatment interval n=233 n=268 n=268 HR 95% CI P HR 95% CI P HR 95% CI P Sociodemographic characteristics Age < 40 0.82 0.55-1.20 0.305 1.11 0.81-1.54 0.519 1.27 0.88-1.84 0.205 Primary education or higher 1.14 0.84-1.55 0.395 0.78 0.60-1.02 0.070 0.94 0.69-1.28 0.701 Occupation 1.09 0.80-1.48 0.604 1.22 0.93-1.59 0.148 0.77 0.56-1.07 0.117 Married 1.04 0.77-1.41 0.791 1.41 1.09-1.83 0.009 1.40 1.02-1.91 0.032 Parity 1.13 0.83-1.55 0.428 0.97 0.75-1.27 0.842 1.16 0.85-1.58 0.350 Distance to facility ≤ 15km 1.01 0.73-1.41 0.943 1.89 1.43-2.50 <0.001 1.47 1.06-2.03 0.020 Urban 0.88 0.65-1.19 0.418 1.11 0.86-1.44 0.424 1.34 0.98-1.82 0.066 HIV positive 0.79 0.57-1.08 0.143 0.98 0.74-1.29 0.865 1.10 0.79-1.52 0.579 Table 4. Factors Influencing Time to Cervical Cancer Care Cascade Intervals, Adjusted Models Patient interval Diagnostic interval Treatment interval n=233 n=268 n=268 HR 95% CI P HR 95% CI P HR 95% CI P Patient factors Cancer-related knowledge and experience Prior screening 0.99 0.67-1.46 0.943 1.27 0.93-1.74 0.136 1.12 0.75-1.65 0.582 Heard of cervical cancer 0.96 0.64-1.44 0.847 0.75 0.53-1.06 0.100 1.04 0.71-1.64 0.825 Know friend w cervical cancer 0.95 0.63-1.43 0.799 0.84 0.60-1.19 0.335 0.79 0.52-1.22 0.292 Symptom perception Thought symptom was serious or very serious 2.14 1.43-3.19 <0.001 Very concerned about symptom 2.06 1.45-2.93 <0.001 Thought 1st symptom cancer 1.82 1.12-2.97 0.017 Thought 1st symptom menstrual 0.83 0.60-1.18 0.315 Thought symptom would resolve 0.37 0.24-0.57 <0.001 Emotional barriers Scared 1.20 0.75-1.90 0.443 0.98 0.72-1.33 0.890 0.54 0.23-1.23 0.143 Embarrassed 0.88 0.45-1.71 0.702 0.99 0.67-1.45 0.943 Doubted provider/recommendation 0.95 0.61-1.47 0.804 NE - - Logistical barriers Didn't know where to go 0.64 0.47-0.88 0.007 1.06 0.81-1.38 0.684 1.53 0.89-2.60 0.121 Financial barriers 1.46 0.69-3.06 0.320 0.86 0.63-1.18 0.354 0.93 0.66-1.29 0.650 Anticipated long wait 0.99 0.62-1.59 0.978 0.78 0.57-1.06 0.108 0.68 0.46-1.02 0.062 Needed blood for treatment 0.63 0.37-1.07 0.085 Personal barriers Family responsibilities 1.44 0.87-2.37 0.153 1.70 1.17-2.46 0.005 1.30 0.52-3.27 0.578 Difficult to miss work 1.23 0.71-2.14 0.467 1.61 0.98-2.66 0.061 NE - - Pursuing alternative treatment 0.70 0.51-0.96 0.033 0.83 0.63-1.09 0.185 0.69 0.41-1.17 0.168 Disease factors Symptoms and clinical characteristics Stage IA-IIA (early) 1.17 0.79-1.73 0.427 1.41 1.03-1.95 0.034 1.13 0.77-1.64 0.529 Symptom: bleeding 0.65 0.40-1.04 0.072 0.55 0.35-0.85 0.007 0.75 0.45-1.23 0.248 Symptom: pain 0.77 0.53-1.12 0.171 0.89 0.63-1.26 0.508 1.03 0.68-1.57 0.888 Provider and health systems factors First presentation characteristics Public 1.27 0.95-1.70 0.104 MNRH/UCI 2.13 1.20-3.79 0.010 Physician 0.90 0.59-1.37 0.618 Speculum 1.07 0.80-1.43 0.657 Biopsy done 1.23 0.87-1.73 0.244 Provider suspected cancer 1.13 0.851.51 0.397 Biopsy characteristics ≥2 biopsies 0.72 0.44-1.18 0.193 Cost > 100,000 Ug Shillings 1.02 0.73-1.44 0.897 Biopsy done at MNRH/UCI 1.22 0.92-1.61 0.162 Clinics attended prior to MNRH/UCI ≥2 Clinics 0.69 0.49-0.97 0.031 Radiation availability Radiation machine operational 0.98 0.70-1.36 0.886 Treatment recommendation Chemo REF - - Surgery 1.23 0.76-1.98 0.394 EBRT 0.89 0.60-1.32 0.566 Palliative care 0.39 0.05-2.85 0.352 Note: all models adjusted for age, education, marital status, parity, and distance to facility. NE: not estimable. MNRH: Mulago National Referral Hospital. UCI: Uganda Cancer Institute Participants with symptoms reflected on the time they took to present for care (Table 5); 27.5% reported accessing care was a little delayed and 28.3% very delayed. Main reasons participants reported for not having sought medical care earlier included thinking symptoms would resolve (83.7%), not knowing where to go (57.8%), and seeking alternative treatment (46.4%). Table 5. Patient perspectives on care timeline and reasons for delay along the cervical cancer care cascade Patient interval Diagnostic interval Treatment interval n=233 n=268 n=268 n % n % n % Patient impression of time interval Immediate 41 17.6 14 5.2 29 17.4 Quick 62 26.6 56 20.9 65 38.9 A little delayed 64 27.5 83 31.0 45 26.9 Very delayed 66 28.3 115 42.9 28 16.8 Reasons cited for delay Thought symptoms would resolve 195 83.7 Didn't know where to go 133 57.8 145 54.3 24 10.1 Scared a 41 17.6 70 26.3 17 7.3 Embarassed 28 12.0 43 16.2 Seeking alternative treatment 108 46.4 112 42.3 32 13.4 Financial constraints 9 3.9 187 70.0 153 64.8 Needed blood transfusion for treatment 32 13.4 Too difficult to miss work 31 13.5 30 13.2 1 0.4 Had to care for family 44 19.0 52 19.5 8 3.4 Didn't believe provider/trust tx rec 34 12.7 7 2.9 Long wait 51 22.2 88 33.0 54 22.8 Notes: a For treatment interval, scared of side effects Diagnostic interval Median diagnostic interval was 83 days (IQR 34-229 days). In unadjusted analysis (Table 3), time to diagnostic interval completion was significantly faster for married individuals (HR 1.41, 95% CI 1.09-1.83) and for those living within 15 kilometers of a health facility (HR 1.89, 95% CI 1.43-2.50). Time to diagnostic interval completion was marginally slower for individuals with primary-level education or higher (HR 0.78, 95% CI 0.60-1.02). Among the subset of women under age 40, using family planning was associated with significantly faster time to diagnostic interval completion (HR 3.21, 95% CI 1.13, 9.14; not shown). In multivariate analysis (Table 4), time to diagnostic interval completion was significantly longer for those who had attended multiple clinics prior to seeking care at MNRH or UCI (aHR 0.69, 95% CI 0.49-0.97), as well as for those who reported symptomatic bleeding (aHR 0.55, 95% CI 0.35-0.85). Time to diagnostic interval completion was paradoxically less for women reporting personal barriers like family responsibilities (aHR 1.70, 95% CI 1.17-2.46). Women whose cancer was early stage (HR 1.41, 95% CI 1.03-1.95) and those who attended MRNH or UCI directly (HR 2.13, 95% CI 1.20-3.79) also had significantly faster diagnostic intervals. Participants reflected on the time it took from first presenting for any care to receiving their diagnosis and treatment recommendations (Table 5); 31% reported receiving diagnosis was a little delayed and 42.9% very delayed. Most common reasons cited for delay included financial constraints (70%), not knowing where to go (54.3%), and seeking alternative therapies (42.3%). Treatment interval Median treatment interval was 34 days (IQR 18-58 days). In unadjusted modeling (Table 3), time to treatment interval completion was significantly faster for married individuals (HR 1.40, 95% CI 1.02-1.91) and those living within 15 kilometers of a health facility (HR 1.47, 95% CI 1.06-2.03), with a marginal finding for urban residents (HR 1.32, 95% CI 0.98-1.82). In multivariate analysis, no specific patient, disease or health systems factors were significantly associated with a relatively faster or slower interval completion (Table 4). Notably, no particular treatment modality was associated with a longer or shorter treatment interval. Participants who anticipated a long wait for treatment (HR 0.68, 95% CI 0.46-1.02) and those who required a blood transfusion prior to treatment (HR 0.63, 95% CI 0.37-1.07) experienced marginally longer time to complete the interval. Participants reflected on the time it took from receiving their diagnosis to initiating treatment (Table 5); 26.9% reported starting treatment was a little delayed and 16.8% very delayed. Main reasons cited for delay were financial constraints (64.8%), long wait time (22.8%), seeking alternative treatment (13.4%) and the need for a blood transfusion prior to starting treatment (13.4%). Discussion We found that, despite a subjective impression of delay, especially during the patient and diagnostic intervals, overall, women with cervical cancer in Uganda were able to present for care, obtain diagnosis and start treatment in a relatively timely fashion. Our conceptual framework allowed us to consider how patient, health system and disease factors either inhibited or facilitated timely completion of different intervals along the cascade to care for women with a new diagnosis of cervical cancer at public tertiary care facilities in Uganda. While we did identify some potentially modifiable barriers in the patient interval (misattribution of symptoms and utilization of traditional care in place of Western medicine), it’s unlikely that interventions to diminish or remove these barriers would significantly impact morbidity or mortality from cervical cancer, given the median duration of the patient interval was less than three months and most patients had experienced hallmark symptoms of advanced disease before even attempting to seek care. Similar to 20 year-old estimates from the Kampala Cancer Registry [ 4 ], as well as to regional estimates [ 18 , 43 – 48 ], approximately three-fourths of participants in our study had late-stage disease at diagnosis. The lack of change, while disappointing, is not surprising as there has been little expansion of screening and/or vaccination services nationwide during the last few decades. Vaccination and screening are the strongest strategies to decrease incidence, morbidity and mortality of cervical cancer [ 49 – 52 ]. Immediate rapid scale-up of primary and secondary prevention programs (80–100% global vaccine coverage and 70% HPV-based screening coverage) would be required to meet the WHO Director-General’s global call for action to eliminate cervical cancer in the next century [ 53 ]. In this study, the patient interval, median duration 74 days, was delayed among participants incorrectly thinking symptoms would resolve. Misattribution of symptoms was also common; nearly 90% of participants did not suspect cancer. Similarly, qualitative studies from Northern Uganda have showed that incorrect attribution and minimization of symptoms were common and were hypothesized to delay presentation to care [ 20 – 22 ]. Our findings suggest that engaging in alternative therapies also significantly prolonged the patient interval and, while not significantly associated with relatively slower completion of diagnostic or treatment intervals, participants did cite “seeking alternative treatment” as a common qualitative reason for delay during these intervals. Qualitative data from Northern Uganda suggests that traditional medicines are commonly used for treatment of cervical cancer and often thought to be superior to Western medical therapies. This same study reported community perceptions of cervical cancer care in hospitals to be congested, confusing and disrespectful, contributing to a distrust of Western medical treatments for cervical cancer [ 54 ]. During the diagnostic interval, we found that early-stage disease was associated with a faster journey through the health system to obtain a diagnosis, whereas a study from Northern Uganda, a more rural setting, did not find a significant association between stage and delay (defined as > three months from symptom perception to diagnosis) [ 18 ]. We also found that direct presentation to tertiary care center (first presentation) was associated with a faster diagnostic interval. There are likely several unmeasured factors that contribute to presenting earlier in the disease course and directly to an urban tertiary care center. Overall, it is notable that the median diagnostic interval in our study, 83 days, is below that NBCCEDP quality standard of ≤ 90 days for diagnostic interval [ 14 ]. Our absolute median duration of the treatment interval, 39 days from diagnosis to starting treatment, was similar to a reported duration at a specialty center in Botswana [ 55 ]. Whereas other studies from the region have reported median duration > 100 days [ 46 , 56 ], substantially longer than our reported treatment interval (though our reported treatment interval is likely a conservative estimate). Both the specialty center in Botswana and MNRH/UCI have regular multidisciplinary Tumor Board discussions, perhaps improving communication between the various subspecialties providing care for these patients. Disappointingly, neither early-stage disease (better chance of survival/cure with appropriate treatment) nor a recommendation for curative hysterectomy was associated with a shorter treatment interval. As discussed previously, data from high income countries, where cervical cancer is more likely be diagnosed at an earlier/highly curable stage, has associated treatment interval delay to worse outcomes [ 16 , 17 ]; however, the median duration of the treatment interval in our study, 39 days, is well-below the 3-month threshold defining delay in these studies, again calling into question whether there is room for improvement. Strengths and Limitations This is the first study to examine relative barriers and facilitators to care at specific intervals in the cervical cancer care cascade in Uganda. Our conceptual framework (Fig. 1) is based on the Model of Pathways to Treatment [ 37 ], a theoretical approach that informs measurement and description of delay in accessing cancer care in a generalizable way across cancer sites, potentially allowing for greater consistency in reporting delay and allowing for better comparison of delay across studies in order to advance existing knowledge and effectively design interventions. Because the process of obtaining care for cancer is heterogeneous, the granular interval-specific data allow us to consider the role for specific interventions to address delay at various points on the care cascade. A major limitation of this study is that recall bias could have affected the precision of measurement of intervals and other variables. We have tried to limit recall bias by using validated measures with demonstrated reliability for estimation of these intervals [ 40 ], and through the interval-censoring analytic approach. Another limitation is limited generalization of our findings given that the study population was a convenience sample of women who were able to access specialized cancer care at national referral centers. Three-fourths of women in this study, who were able to navigate to a public tertiary care facility, had advanced disease. While this is possibly an underestimate of proportion at large with late-stage disease, it is also possible that women with very early-stage disease were treated locally with simple hysterectomy. The particular delays experienced by women in this study may not be generalizable to the national population of women with cervical cancer, especially those experiencing such significant delay that they never made it to diagnosis or treatment. Meaningful implications Our findings suggest that interventions that aimed at improving identification of cervical cancer symptoms, perhaps undertaken in conjunction with traditional healers, may expedite the patient interval and, thus, presentation to care. Misattribution of symptoms was common and was associated with delay in presenting for care. While most women in the present study reported general awareness of cervical cancer [ 31 ], perhaps there is a role for education efforts specifically regarding signs and symptoms of cervical cancer, especially as those women who did suspect their symptoms were serious and/or due to cancer had a relatively faster patient interval. A similar vulnerability (knowledge) has been associated with delay among women with endometrial cancer in the United States and highlighted as a potential area for evidence-based intervention [ 57 , 58 ]. Acknowledging that many participants are not only using alternative therapies including traditional medicine and spiritual healing, but citing utilization as a reason for delay, perhaps re-framing these modalities as complementary, rather than alternative, with engagement and buy-in from traditional practitioners, could facilitate earlier and potentially more streamlined referral to Western medical care for cervical cancer. In Uganda, traditional healers are highly respected authoritative figures and commonly consulted, especially by women, often prior to or instead of engagement with allopathic clinics. There is an estimated one traditional healer for every 200–400 people [ 59 ], while a level II health center (providing basic outpatient medical services, staffed by nurses) serves a catchment area of 5000 and just 71% of Ugandans live within a one-hour walk of such a facility [ 60 ]. There are examples of effective collaborations among traditional allopathic medicine in Uganda, especially in the realm of HIV and family planning care [ 61 ]; but there is likely a potential for greater collaboration as evidence suggests mutual mistrust and competition between traditional healers and Western medical practitioners [ 62 ]. Interventions designed to streamline referrals to national referral centers (MNRH and UCI, the only public facilities able to provide cancer care) may hasten the diagnostic interval. We did find that patients who went to two or more clinics prior to MNRH or UCI experienced longer diagnostic intervals, while those who presented directly to the national referral centers completed this interval quicker. However, a practical solution to streamline timely referrals is challenging. The health system in Uganda operates on a decentralized referral system with government-trained Village Health Team (VHT) as intended first point of contact with subsequent referral based on health needs, but great disparities exist between rural and urban populations with the most vulnerable poor rural Ugandans facing disproportionately worse access to even basic health centers [ 60 , 63 ]. Given an under-funded health sector with inequitable distribution [ 32 ], an effective intervention would likely require significant restructuring of the health sector. Alternatively, disseminating specialty cancer care beyond the urban national referral centers, a model undertaken by the Rwandan Ministry of Health in their creation of the Butaro Cancer Center of Excellence (BCCOE) [ 44 ], may improve timeliness to diagnosis and potentially treatment. The anticipated long wait times, which seemed to lengthen the treatment interval, implies an unmet need for treatment, be it a radical hysterectomy, primary radiation and/or chemotherapy. Worldwide, the burden of cancer morbidity and mortality disproportionately affects LMICs (78% of global years of life lost and 77% of disability-adjusted life years due to cancer), yet less-developed countries account for just 6% of total resources spent on cancer care globally [ 64 , 65 ]. Amidst the global COVID-19 pandemic, now more than ever before, the international community, must recognize the inter-connected nature of our health systems and re-calibrate it’s response to widespread inequity to enable sufficient funding for capacity building and treatment. Part of the WHO Director-General’s call for global elimination of cervical cancer is for 90% of women with invasive cancer to access effective treatment, a target not achieved in this cohort [ 31 ]. Unanswered questions While our findings suggest interval-specific barriers and facilitators to timely completion of the cervical cancer care cascade, given that most participants had symptoms motivating presentation to care (87%) and that most were advanced stage at diagnosis (76%), interventions aimed at decreasing the median duration of intervals, may not result in substantial reduction in morbidity or mortality from cervical cancer. Again, vaccination and screening are the most effective strategies to decrease morbidity and mortality from cervical cancer and must a primary and immediate focus for intervention [ 52 ]. Expanding access to screening may result in increasing the proportion of cervical cancer diagnosed at an early stage, when curative hysterectomy is possible. World-wide, early-stage cervical cancer is often asymptomatic and incidentally diagnosed during routine screening. Cure rates are highest for early-stage cervical cancer. While timely access to treatment is certainly important for palliation of advanced symptoms, like pain and bleeding, hastening treatment for advanced disease by a matter of days to even weeks will not likely decrease morbidity or mortality. A cohort study in the United States recently found that while median time to initiate definitive chemoradiation for locoregionally advanced cervical cancer increased from 36 to 44 days between 2004–2014, survival was not impacted [ 66 ]. Efforts to expand primary and secondary prevention are of utmost importance for women in Uganda as well as world-wide. On the other side of the spectrum, hospice and palliative care, though widely available in Uganda and subsidized, seem to be poorly utilized. Given the proportion of women with late-stage, less-likely curable cervical cancer, coupled with the significant portion of participants who had not yet accessed treatment during the study period, future research is needed to understand the specific barriers among patients and providers to uptake and referral to palliative care and hospice. Conclusions We identified potentially modifiable barriers along the cervical cancer care cascade including: misattribution of symptoms, preferential use of local healers, lack of streamlined referral and anticipated long wait times. Interventions targeting these factors may improve care timeliness but are unlikely to significantly improve morbidity or mortality given the average stage at symptomatic presentation. While expanding cervical cancer screening and vaccination are the most effective strategies to improve morbidity and/or mortality, timely care is important for palliation of symptoms of advanced disease. Abbreviations IQR interquartile range HR hazard ratio aHR adjusted hazard ratio CI confidence interval MNRH Mulago National Referral Hospital UCI Uganda Cancer Institute LMICs low- and middle-income countries NBCCEDP National Breast and Cervical Cancer Early Detection Program EBRT external beam radiation therapy STI sexually transmitted infection HIV human immunodeficiency virus MREC Mulago Research and Ethics Committee UCSF University of California San Francisco UNCST Uganda National Council for Science and Technology Declarations Ethics approval and consent to participate The study protocol was reviewed and approved by institutional review boards at MNRH (MREC Protocol 1058), UCI (ER-007) and UCSF (16-21306). Uganda’s national review board, UNCST, also reviewed and approved the research (HS29Es). All participants provided written informed consent. Consent for publication Not applicable Availability of data and materials The datasets generated by the survey research during and/or analyzed during the current study are available in the Dryad repository (doi:10.5061/dryad.dv41ns24m): https://datadryad.org/stash/share/upLAOiCWeBLV8Bu4Zdee67d8Df5rfQmF9pdeqAgCLvw. Competing interests The authors declare that they have no competing interests. Funding This research was supported by the Fogarty International Center at the U.S. National Institutes of Health (Grant: R25TW009343) through the University of California Global Health Institute Program for Fellows and Scholars. The funder had no role in study design, implementation, analysis, interpretation, or decision to submit the manuscript for publication. Authors contributions MS, MN, and MH conceptualized the study. MS planned and supervised all aspects of the study. MN, JN and CN provided site-specific supervision. MS and AEA interpreted and analyzed the data and drafted the manuscript. AEA and MH substantially revised the manuscript. All authors revised and approved the final manuscript. Acknowledgements We greatly appreciate our research participants for sharing their experiences and time with the research team, and our data collection and patient advisory team: Najjemba Irene, Najjemba Beatrice, Nakadu Laurant, and Nankya Esther. We would also like to thank Corinne Rocca, Katrina Kimport and the participants in the Bixby Center Works in Progress seminar for their feedback on this manuscript, and John Neuhaus for his guidance on implementing the interval-censored survival analyses. References Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A: Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries . CA: a cancer journal for clinicians 2018, 68 (6):394-424. Singh D, Vignat J, Lorenzoni V, Eslahi M, Ginsburg O, Lauby-Secretan B, Arbyn M, Basu P, Bray F, Vaccarella S: Global estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO Global Cervical Cancer Elimination Initiative . Lancet Glob Health 2023, 11 (2):e197-e206. Bruni L B-RL, Albero G, Aldea M, Serrano B, Valencia S, Brotons M, Mena M, Cosano R, Muñoz J, Bosch FX, de Sanjosé S, Castellsagué X: Human Papillomavirus and Related Diseases in Uganda. Summary Report 2016- 02-26 . In . : ICO Information Centre on HPV and Cancer (HPV Information Centre); 2016. Wabinga H, Ramanakumar AV, Banura C, Luwaga A, Nambooze S, Parkin DM: Survival of cervix cancer patients in Kampala, Uganda: 1995-1997 . British journal of cancer 2003, 89 (1):65-69. Gondos A, Brenner H, Wabinga H, Parkin DM: Cancer survival in Kampala, Uganda . British journal of cancer 2005, 92 (9):1808-1812. Swanson M, Ueda S, Chen L-m, Huchko MJ, Nakisige C, Namugga J: Evidence-based improvisation: Facing the challenges of cervical cancer care in Uganda . Gynecologic Oncology Reports 2018, 24 :30-35. Sullivan R, Alatise OI, Anderson BO, Audisio R, Autier P, Aggarwal A, Balch C, Brennan MF, Dare A, D'Cruz A et al : Global cancer surgery: delivering safe, affordable, and timely cancer surgery . The Lancet Oncology 2015, 16 (11):1193-1224. Robinson KM, Christensen KB, Ottesen B, Krasnik A: Socio-demographic factors, comorbidity and diagnostic delay among women diagnosed with cervical, endometrial or ovarian cancer . European journal of cancer care 2011, 20 (5):653-661. Berraho M, Obtel M, Bendahhou K, Zidouh A, Errihani H, Benider A, Nejjari C: Sociodemographic factors and delay in the diagnosis of cervical cancer in Morocco . The Pan African medical journal 2012, 12 :14. Tadesse SK: Socio-economic and cultural vulnerabilities to cervical cancer and challenges faced by patients attending care at Tikur Anbessa Hospital: a cross sectional and qualitative study . BMC women's health 2015, 15 :75. Marlow LA, McGregor LM, Nazroo JY, Wardle J: Facilitators and barriers to help-seeking for breast and cervical cancer symptoms: a qualitative study with an ethnically diverse sample in London . Psycho-oncology 2014, 23 (7):749-757. Anorlu RI, Orakwue CO, Oyeneyin L, Abudu OO: Late presentation of patients with cervical cancer to a tertiary hospital in Lagos: what is responsible? European journal of gynaecological oncology 2004, 25 (6):729-732. Lim AW, Ramirez AJ, Hamilton W, Sasieni P, Patnick J, Forbes LJ: Delays in diagnosis of young females with symptomatic cervical cancer in England: an interview-based study . The British journal of general practice : the journal of the Royal College of General Practitioners 2014, 64 (627):e602-610. Miller JW, Hanson V, Johnson GD, Royalty JE, Richardson LC: From cancer screening to treatment: service delivery and referral in the National Breast and Cervical Cancer Early Detection Program . Cancer 2014, 120 Suppl 16 (0 16):2549-2556. Hanna TP, King WD, Thibodeau S, Jalink M, Paulin GA, Harvey-Jones E, O'Sullivan DE, Booth CM, Sullivan R, Aggarwal A: Mortality due to cancer treatment delay: systematic review and meta-analysis . Bmj 2020, 371 :m4087. Shen SC, Hung YC, Kung PT, Yang WH, Wang YH, Tsai WC: Factors involved in the delay of treatment initiation for cervical cancer patients: A nationwide population-based study . Medicine 2016, 95 (33):e4568. Chen CP, Kung PT, Wang YH, Tsai WC: Effect of time interval from diagnosis to treatment for cervical cancer on survival: A nationwide cohort study . PLoS One 2019, 14 (9):e0221946. Mwaka AD, Garimoi CO, Were EM, Roland M, Wabinga H, Lyratzopoulos G: Social, demographic and healthcare factors associated with stage at diagnosis of cervical cancer: cross-sectional study in a tertiary hospital in Northern Uganda . BMJ open 2016, 6 (1):e007690. Ferreira da Silva I, Ferreira da Silva I, Koifman RJ: Cervical Cancer Treatment Delays and Associated Factors in a Cohort of Women From a Developing Country . J Glob Oncol 2019, 5 :1-11. Mwaka AD, Orach CG, Were EM, Lyratzopoulos G, Wabinga H, Roland M: Awareness of cervical cancer risk factors and symptoms: cross-sectional community survey in post-conflict northern Uganda . Health Expect 2015. Mwaka AD, Okello ES, Kiguli J, Rutebemberwa E: Understanding cervical cancer: an exploration of lay perceptions, beliefs and knowledge about cervical cancer among the Acholi in northern Uganda . BMC Womens Health 2014, 14 :84. Mwaka AD, Okello ES, Wabinga H, Walter FM: Symptomatic presentation with cervical cancer in Uganda: a qualitative study assessing the pathways to diagnosis in a low-income country . BMC women's health 2015, 15 :15. Orem JN, Zikusooka CM: Health financing reform in Uganda: How equitable is the proposed National Health Insurance scheme? International journal for equity in health 2010, 9 :23. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J et al : Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development . International journal of obstetric anesthesia 2016, 25 :75-78. Dubowitz G, Detlefs S, McQueen KA: Global anesthesia workforce crisis: a preliminary survey revealing shortages contributing to undesirable outcomes and unsafe practices . World journal of surgery 2010, 34 (3):438-444. Epiu I, Tindimwebwa JV, Mijumbi C, Chokwe TM, Lugazia E, Ndarugirire F, Twagirumugabe T, Dubowitz G: Challenges of Anesthesia in Low- and Middle-Income Countries: A Cross-Sectional Survey of Access to Safe Obstetric Anesthesia in East Africa . Anesthesia and analgesia 2017, 124 (1):290-299. Lund TC, Hume H, Allain JP, McCullough J, Dzik W: The blood supply in Sub-Saharan Africa: needs, challenges, and solutions . Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis 2013, 49 (3):416-421. LeBrun DG, Chackungal S, Chao TE, Knowlton LM, Linden AF, Notrica MR, Solis CV, McQueen KA: Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries . Surgery 2014, 155 (3):365-373. Abdel-Wahab M, Bourque JM, Pynda Y, Izewska J, Van der Merwe D, Zubizarreta E, Rosenblatt E: Status of radiotherapy resources in Africa: an International Atomic Energy Agency analysis . The Lancet Oncology 2013, 14 (4):e168-175. Datta NR, Samiei M, Bodis S: Radiation therapy infrastructure and human resources in low- and middle-income countries: present status and projections for 2020 . International journal of radiation oncology, biology, physics 2014, 89 (3):448-457. Swanson M, Nakalembe M, Chen LM, Ueda S, Namugga J, Nakisige C, Huchko MJ: Surgical candidacy and treatment initiation among women with cervical cancer at public referral hospitals in Kampala, Uganda: a descriptive cohort study . BMJ Open 2020, 10 (12):e039946. Zikusooka CM, Kyomuhang R, Orem JN, Tumwine M: Is health care financing in Uganda equitable? Afr Health Sci 2009, 9 Suppl 2 (Suppl 2):S52-58. Chuang LT, Feldman S, Nakisige C, Temin S, Berek JS: Management and Care of Women With Invasive Cervical Cancer: ASCO Resource-Stratified Clinical Practice Guideline . J Clin Oncol 2016, 34 (27):3354-3355. Benedetti-Panici P, Greggi S, Colombo A, Amoroso M, Smaniotto D, Giannarelli D, Amunni G, Raspagliesi F, Zola P, Mangioni C et al : Neoadjuvant chemotherapy and radical surgery versus exclusive radiotherapy in locally advanced squamous cell cervical cancer: results from the Italian multicenter randomized study . J Clin Oncol 2002, 20 (1):179-188. Chang TC, Lai CH, Hong JH, Hsueh S, Huang KG, Chou HH, Tseng CJ, Tsai CS, Chang JT, Lin CT et al : Randomized trial of neoadjuvant cisplatin, vincristine, bleomycin, and radical hysterectomy versus radiation therapy for bulky stage IB and IIA cervical cancer . J Clin Oncol 2000, 18 (8):1740-1747. Kokka F, Bryant A, Brockbank E, Powell M, Oram D: Hysterectomy with radiotherapy or chemotherapy or both for women with locally advanced cervical cancer . Cochrane Database Syst Rev 2015(4):Cd010260. Walter F, Webster A, Scott S, Emery J: The Andersen Model of Total Patient Delay: a systematic review of its application in cancer diagnosis . Journal of health services research & policy 2012, 17 (2):110-118. Scott SE, Walter FM, Webster A, Sutton S, Emery J: The model of pathways to treatment: conceptualization and integration with existing theory . British journal of health psychology 2013, 18 (1):45-65. Andersen BL, Cacioppo JT: Delay in seeking a cancer diagnosis: delay stages and psychophysiological comparison processes . The British journal of social psychology 1995, 34 ( Pt 1) :33-52. Unger-Saldana K, Pelaez-Ballestas I, Infante-Castaneda C: Development and validation of a questionnaire to assess delay in treatment for breast cancer . BMC Cancer 2012, 12 :626. Ahn S, Lim J, Paik MC, Sacco RL, Elkind MS: Cox model with interval-censored covariate in cohort studies . Biom J 2018, 60 (4):797-814. Zhang Z, Sun J: Interval censoring . Stat Methods Med Res 2010, 19 (1):53-70. Dunyo P, Effah K, Udofia EA: Factors associated with late presentation of cervical cancer cases at a district hospital: a retrospective study . BMC Public Health 2018, 18 (1):1156. Park PH, Davey S, Fehr AE, Butonzi J, Shyirambere C, Hategekimana V, Bigirimana JB, Borg R, Uwizeye R, Tapela N et al : Patient Characteristics, Early Outcomes, and Implementation Lessons of Cervical Cancer Treatment Services in Rural Rwanda . J Glob Oncol 2018, 4 :1-11. DeBoer RJ, Umutoni V, Bazzett-Matabele L, Katznelson E, Nguyen C, Umwizerwa A, Bigirimana JB, Paciorek A, Nsabimana N, Ruhangaza D et al : Cervical cancer treatment in Rwanda: Resource-driven adaptations, quality indicators, and patient outcomes . Gynecol Oncol 2022, 164 (2):370-378. Dereje N, Addissie A, Worku A, Gebremariam A, Kantelhardt EJ, Assefa M, Jemal A: Association between waiting time for radiotherapy initiation and disease progression among women with cervical cancer in Addis Ababa, Ethiopia . Int J Cancer 2021, 149 (6):1284-1289. Mumba JM, Kasonka L, Owiti OB, Andrew J, Lubeya MK, Lukama L, Kasempa C, Msadabwe SC, Kalinda C: Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia . Gynecol Oncol Rep 2021, 37 :100784. Kantelhardt EJ, Moelle U, Begoihn M, Addissie A, Trocchi P, Yonas B, Hezkiel P, Stang A, Thomssen C, Vordermark D et al : Cervical cancer in Ethiopia: survival of 1,059 patients who received oncologic therapy . Oncologist 2014, 19 (7):727-734. Levi F, Lucchini F, Negri E, Franceschi S, la Vecchia C: Cervical cancer mortality in young women in Europe: patterns and trends . Eur J Cancer 2000, 36 (17):2266-2271. Drolet M, Bénard É, Pérez N, Brisson M: Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis . Lancet 2019, 394 (10197):497-509. Brisson M, Kim JJ, Canfell K, Drolet M, Gingras G, Burger EA, Martin D, Simms KT, Bénard É, Boily MC et al : Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries . Lancet 2020, 395 (10224):575-590. Canfell K, Kim JJ, Brisson M, Keane A, Simms KT, Caruana M, Burger EA, Martin D, Nguyen DTN, Bénard É et al : Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries . Lancet 2020, 395 (10224):591-603. Simms KT, Steinberg J, Caruana M, Smith MA, Lew JB, Soerjomataram I, Castle PE, Bray F, Canfell K: Impact of scaled up human papillomavirus vaccination and cervical screening and the potential for global elimination of cervical cancer in 181 countries, 2020-99: a modelling study . Lancet Oncol 2019, 20 (3):394-407. Mwaka AD, Okello ES, Orach CG: Barriers to biomedical care and use of traditional medicines for treatment of cervical cancer: an exploratory qualitative study in northern Uganda . Eur J Cancer Care (Engl) 2015, 24 (4):503-513. Grover S, Chiyapo SP, Puri P, Narasimhamurthy M, Gaolebale BE, Tapela N, Ramogola-Masire D, Kayembe MKA, Moloi T, Gaolebale PA: Multidisciplinary Gynecologic Oncology Clinic in Botswana: A Model for Multidisciplinary Oncology Care in Low- and Middle-Income Settings . J Glob Oncol 2017, 3 (5):666-670. Tumba N, Adewuyi SA, Eguzo K, Adenipekun A, Oyesegun R: Radiotherapy waiting time in Northern Nigeria: experience from a resource-limited setting . Ecancermedicalscience 2020, 14 :1097. Doll KM, Hempstead B, Alson J, Sage L, Lavallee D: Assessment of Prediagnostic Experiences of Black Women With Endometrial Cancer in the United States . JAMA Netw Open 2020, 3 (5):e204954. Doll KM, Nguyen A, Alson JG: A conceptual model of vulnerability to care delay among women at risk for endometrial cancer . Gynecol Oncol 2022, 164 (2):318-324. Bodeker G, Kabatesi D, King R, Homsy J: A regional task force on traditional medicine and AIDS . Lancet 2000, 355 (9211):1284. Dowhaniuk N: Exploring country-wide equitable government health care facility access in Uganda . Int J Equity Health 2021, 20 (1):38. Ssali A, Butler LM, Kabatesi D, King R, Namugenyi A, Kamya MR, Mandel J, Chen SY, McFarland W: Traditional healers for HIV/AIDS prevention and family planning, Kiboga District, Uganda: evaluation of a program to improve practices . AIDS Behav 2005, 9 (4):485-493. Akol A, Moland KM, Babirye JN, Engebretsen IMS: "We are like co-wives": Traditional healers' views on collaborating with the formal Child and Adolescent Mental Health System in Uganda . BMC Health Serv Res 2018, 18 (1):258. Kiwanuka SN, Ekirapa EK, Peterson S, Okui O, Rahman MH, Peters D, Pariyo GW: Access to and utilisation of health services for the poor in Uganda: a systematic review of available evidence . Trans R Soc Trop Med Hyg 2008, 102 (11):1067-1074. Beaulieu N BD, Bloom R, Stein R: Breakaway: the global burden of cancer - challenges and opportunities. A report from the Economist Inteligence Unit . In . ; 2009. Institute of Medicine Committee on Cancer Control in L, Middle-Income C: The National Academies Collection: Reports funded by National Institutes of Health . In: Cancer Control Opportunities in Low- and Middle-Income Countries. edn. Edited by Sloan FA, Gelband H. Washington (DC): National Academies Press (US) National Academy of Sciences.; 2007. Ramey SJ, Asher D, Kwon D, Ahmed AA, Wolfson AH, Yechieli R, Portelance L: Delays in definitive cervical cancer treatment: An analysis of disparities and overall survival impact . Gynecol Oncol 2018, 149 (1):53-62. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Feb, 2026 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Revision requested 13 Mar, 2025 Reviews received at journal 20 Feb, 2025 Reviewers agreed at journal 19 Feb, 2025 Reviewers agreed at journal 16 Feb, 2025 Reviews received at journal 11 Feb, 2025 Reviewers agreed at journal 10 Feb, 2025 Reviewers invited by journal 10 Feb, 2025 Editor invited by journal 18 Nov, 2024 Editor assigned by journal 18 Nov, 2024 Submission checks completed at journal 18 Nov, 2024 First submitted to journal 16 Nov, 2024 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-5467551","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":381063070,"identity":"71cb52d8-32e0-4444-af1d-707e18403c6b","order_by":0,"name":"Megan Swanson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYPCDCiBmPsDAwEO8ljNAzJZAihbGNiK06La3X/xcwFCX2D+7/eHjwnmH5eXbGBgfvG3DrcXszJli6RkMhxNn3DljbDxz22HDDccYmA3n4tNyIydBmofhQG7DjRw2ad5thxMM5BuADHxa7r9J/s3DUJc7/0b6M2neOYcTgA5j/41Xyw32Y0BbmHM33Egwk+ZtOJzAcIyBjRmvljM5bNY8BofrN97IMTbmOZYO9Atjs+Scc3i0HD/++DZPRZ2x3I30h495aqyBIcZ88MObMtxagFFgwMBggCLC2IBPPRCwPyCgYBSMglEwCkY8AACFcVAmBYwxhwAAAABJRU5ErkJggg==","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Megan","middleName":"","lastName":"Swanson","suffix":""},{"id":381063071,"identity":"3a4fe10b-9cb3-4fef-ab67-b2b0b4904438","order_by":1,"name":"Alison El Ayadi","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alison","middleName":"El","lastName":"Ayadi","suffix":""},{"id":381063072,"identity":"1663c560-b351-4e6b-b543-ddb99b333cb7","order_by":2,"name":"Miriam Nakalembe","email":"","orcid":"","institution":"Makerere University College for Health Sciences School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Miriam","middleName":"","lastName":"Nakalembe","suffix":""},{"id":381063073,"identity":"7d46a8a4-7122-464e-b2fa-e8eedf782525","order_by":3,"name":"Jane Namugga","email":"","orcid":"","institution":"Mulago Specialised Women and Neonatal Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jane","middleName":"","lastName":"Namugga","suffix":""},{"id":381063074,"identity":"46bf0da0-ef0b-4e78-8352-eaf5beed6156","order_by":4,"name":"Carol Nakisige","email":"","orcid":"","institution":"Uganda Cancer Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Carol","middleName":"","lastName":"Nakisige","suffix":""},{"id":381063075,"identity":"85ecfecb-59e7-41fb-8f02-2624bd734b05","order_by":5,"name":"Lee-may Chen","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lee-may","middleName":"","lastName":"Chen","suffix":""},{"id":381063076,"identity":"b17480a7-7a2b-491a-a9e1-d1a266300b5e","order_by":6,"name":"Megan J Huchko","email":"","orcid":"","institution":"Duke University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Megan","middleName":"J","lastName":"Huchko","suffix":""}],"badges":[],"createdAt":"2024-11-16 21:38:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5467551/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5467551/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12905-026-04292-7","type":"published","date":"2026-02-13T15:58:45+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71808401,"identity":"3acfc33f-3559-4f62-9db6-63d243e8efca","added_by":"auto","created_at":"2024-12-18 17:56:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70212,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdapted Model of Pathways to Care - Conceptual Framework for Cervical Cancer Cascade Intervals\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Swansonfigure1ConceptualFramework.png","url":"https://assets-eu.researchsquare.com/files/rs-5467551/v1/7a2f0e680189808beb442798.png"},{"id":102786728,"identity":"80b6c016-73ff-44b8-9c0e-c3470aed50a2","added_by":"auto","created_at":"2026-02-16 16:14:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4965810,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5467551/v1/04373a03-4b54-49db-b2ee-e093b60f935a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Predictors of delay in the cervical cancer care cascade in Kampala, Uganda","fulltext":[{"header":"Background","content":"\u003cp\u003eCervical cancer is the fourth most common cancer among women worldwide, but there is great disparity in disease distribution globally [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In Uganda, like many countries in East Africa, cervical cancer is the most common malignancy and is responsible for the greatest cancer-related mortality among women [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Most women present with advanced-stage disease and 5-year overall survival in Uganda is estimated to be just 18% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While surgery, chemotherapy and radiation are all services offered at the national public tertiary care facilities, namely Mulago National Referral Hospital (MNRH) and the Uganda Cancer Institute (UCI), multisystem obstacles challenge access to the various treatment modalities [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eScreening can detect asymptomatic cervical precancerous lesions as well as cancer, allowing for effective preventative treatments or diagnosis at an early stage, respectively. Women with invasive cancer may present with symptoms such as bleeding, foul smelling discharge or pain. Symptoms are more common in advanced disease. In low- and middle-income countries (LMICs), cervical cancer is rarely diagnosed when asymptomatic as routine effective screening is not readily accessible.\u003c/p\u003e \u003cp\u003eMany women with cervical cancer around the world experience some delay in presentation to care as well as in accurate diagnosis with staging and initiating appropriate treatment [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Younger age [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and rural residence [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] are commonly associated with delay in accessing cervical cancer care. However, no single accepted definition of \u0026ldquo;delay\u0026rdquo; exists, and women may experience a subjective or objective delay in initial presentation to a clinician, obtaining diagnostic tests, receiving a diagnosis, and/or in initiating treatment (curative or palliative). The United States Centers for Disease Control and Prevention\u0026rsquo;s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) has set a quality standard of \u0026le;\u0026thinsp;90 days from abnormal screening to final diagnosis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], though this standard may not apply outside of high-income countries with ready access to screening, diagnostic and treatment modalities.. There is a paucity of data evaluating the impact of delayed definitive treatment for cervical cancer on survival, especially in advanced disease, particularly in LMICs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, data from high-income countries suggest that an interval greater than three months from diagnosis to treatment initiation may increase morbidity and impair survival from cervical cancer, even when controlling for stage, age and co-morbidities [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e\u0026ldquo;Delay\u0026rdquo; is not necessarily synonymous with advanced disease. Patients with cervical cancer at any stage may experience delay in accessing care, obtaining a diagnosis and/or initiating treatment. In fact, studies in Uganda and Brazil found that a diagnosis to treatment interval greater than or equal to three months was common overall (55 to 93%, respectively), and that women with advanced cervical cancer were not significantly more likely than those with earlier-stage disease to experience such delay [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eReasons for delay in accessing cervical cancer care are speculative and likely vary across the care cascade. Awareness of cervical cancer is generally high; however, misattribution of symptoms and misconceptions regarding etiology are common in Uganda [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and could theoretically contribute to patient delays in seeking medical care. Once care is established, fees associated with labs, imaging and pathology studies can be cost-prohibitive for many families and could result in a delay in obtaining a diagnosis. For instance, one CT scan costs at least as much as the average monthly income nationally (300,000 Ugandan Shillings, about \u003cspan\u003e$\u003c/span\u003e80 USD). While most medical care, including some basic diagnostic testing has been offered free of charge at public facilities in Uganda since 2001, nearly half of the country\u0026rsquo;s healthcare financing continues to come from out-of-pocket expenditures [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Once a diagnosis has been made, lack of available subspecialists [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], anesthesiologists [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], cross-matched blood [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], and equipment [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] may limit the availability of cancer surgery. Radiation availability has been dynamic in the past decade, but even prior to 2016, when Uganda\u0026rsquo;s one intermittently functional external beam machine was working 20\u0026thinsp;+\u0026thinsp;hours per day, it was only meeting 2.6% of the nation\u0026rsquo;s indicated radiation treatments [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A new cobalt 60 radiotherapy machine was inaugurated in January 2018.\u003c/p\u003e \u003cp\u003eStudies are needed to characterize the intervals in the process of obtaining care for cervical cancer as well as to investigate of predictors of delay at each of these intervals in order to identify modifiable barriers and facilitators along the cascade [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The purpose of this study was to describe the cascade of cervical cancer care among women ultimately accessing specialty care at government supported tertiary care centers in Kampala, Uganda and to identify barriers and facilitators to timely care across each interval in the care cascade. Understanding which factors contribute to more relative delay during these intervals may help identify ways to reduce overall time to treatment initiation and potentially improve outcomes for women with cervical cancer.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u0026nbsp;The current analysis is part of a larger mixed-methods study which seeks to characterize barriers to cervical cancer care among Ugandan women to inform strategies to minimize delay and improve access to care. Study setting, participant recruitment and data collection activities have been described previously in detail [31]. Women aged 18 or above presenting to care at MNRH and/or UCI with primary cervical cancer were enrolled in the study from May 3, 2017 \u0026ndash; September 17, 2018. Data on sociodemographic and reproductive characteristics and participants\u0026rsquo; care journeys were collected through interviewer-administered survey at care enrollment. Data on treatment initiation was captured via phone one to three months later. Medical record abstraction was used to supplement self-reported data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMulago National Referral Hospital and UCI are part of the Mulago Hospital Complex, located in Kampala, Uganda, associated with Makerere University College of Health Sciences. They provide comprehensive specialist services for the entire nation. Ninety-nine per cent of the national population seeks care through the public sector and would access specialty cancer care exclusively at these institutions [32]. Patients without private insurance may present to MNRH through emergency gynecologic triage and may access gynecologic oncology diagnostic and surgical care there. Patients may present directly to UCI\u0026rsquo;s screening clinic or may be referred for diagnostics, surgery, chemotherapy and/or radiotherapy from the gynecology division of MNRH or from surrounding facilities. Gynecologic oncology specialists and fellowship trainees care for patients at MNRH and UCI through a Memorandum of Understanding between the institutions.\u003c/p\u003e\n\u003cp\u003eBetween March, 2016 and January, 2018, no external beam radiotherapy was available in Uganda; during this time, the Ministry of Health partially subsidized radiation at a private hospital in Nairobi, Kenya, though it is unclear how many patients benefitted from this program. In response to the challenges obtaining radiotherapy 2016-2018, providers at UCI and MNRH developed a protocol for treating locally and regionally-advanced cervical cancer with neoadjuvant chemotherapy followed by possible radical hysterectomy, an evidence-based strategy supported by the American Society of Clinical Oncology (ASCO) Resource-stratified Treatment Guidelines [33-36]. A new cobalt 60 radiotherapy machine became operational at UCI in January, 2018. Brachytherapy was available throughout the study period and may have been recommended for treatment or palliation in conjunction with other therapies. In Uganda, radiotherapy is only available at UCI. There are nominal fees associated with surgery and radiation at MNRH and UCI. The UCI provides chemotherapy free of charge, but drug inventory fluctuates, and stock-outs are common.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheoretical Orientation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur research was oriented by the Model of Pathways to Care [37, 38], a theoretical model adapted from the Andersen\u0026rsquo;s Model of Total Patient Delay [39], for understanding the process of seeking and obtaining diagnosis and treatment for cancer. Intervals defined by this model include: patient appraisal and health seeking intervals, characterizing detection of bodily change to perceiving a need to discuss symptoms with a health care provider to first consultation; diagnostic interval, time between first health care consultation to formal diagnosis; and treatment interval, time between diagnosis to treatment initiation. Various contributing factors at multiple levels including the patient, provider, health care system and disease are considered to influence the processes operating within these intervals. The three main levels of factors within this model are \u0026lsquo;patient factors\u0026rsquo;, representing the individual within their particular social and cultural context (e.g., demographics, previous experience, co‐morbidities, cognitions, and emotions), \u0026lsquo;health care provider and system factors\u0026rsquo;, representing health care services aspects which can impact patient and provider decisions and behavior (e.g., access to generalist and/or specialist health care including diagnostic procedures and treatment), and \u0026lsquo;disease factors\u0026rsquo;, the clinical and physiological aspects of the condition (e.g., symptoms and prognosis). Utilizing the intervals specified in this model allows for a standardized, uniform way to report about delay in a patient\u0026rsquo;s journey to obtaining cancer diagnoses and treatment. Greater precision and transparency in defining this process should, in turn, facilitate the effective design and implementation of interventions to minimize delay. See our conceptual framework (Fig 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom patient-reported data on timing of events in their care journey, we calculated three major time intervals in the cervical cancer cascade of care: patient interval, diagnostic interval, and treatment interval. \u003cem\u003ePatient interval\u003c/em\u003e represents the time (in days) between first noticing symptoms and first presenting to a health care provider, including the process of making the decision to seek care. \u003cem\u003eDiagnostic interval\u0026nbsp;\u003c/em\u003erepresents the time (in days) between first presenting to any health care provider and the consultation with a specialist when diagnosis was confirmed, stage assigned, and treatment recommendations made. \u003cem\u003eTreatment interval\u0026nbsp;\u003c/em\u003erepresented the time (in days) between specialist consultation and initiation of treatment (surgery, chemotherapy, external beam radiation therapy (EBRT) inclusive of radio-sensitizing chemotherapy, or palliative care/hospice). While patients may ultimately receive multi-modal therapy (like chemotherapy followed by hysterectomy or EBRT followed by brachytherapy), the \u003cem\u003etreatment interval\u0026nbsp;\u003c/em\u003eends when the first treatment modality started. While brachytherapy was available throughout the study period, this was never the \u003cem\u003efirst\u0026nbsp;\u003c/em\u003erecommended and/or initiated therapy; patients may have accessed brachytherapy later in their care journey, though these data not captured in this study. Of note, systemic chemotherapy may have been recommended for distant metastatic disease or for non-operable local- or regionally-advanced disease during the time when EBRT was not available in-country.\u003c/p\u003e\n\u003cp\u003eThe survey used in this study was adapted from a validated instrument to measure time intervals and factors correlated with delay in accessing breast cancer care [40]. Where specific dates were unable to be recalled, participants were asked to estimate according to a validated protocol: if participants could not recall exact day, they were asked if the event occurred in the beginning (coded as 5\u003csup\u003eth\u003c/sup\u003e), middle (coded as 15\u003csup\u003eth\u003c/sup\u003e) or end (coded as 25\u003csup\u003eth\u003c/sup\u003e) of the month; if participants could not recall the month exactly, they estimated beginning (coded as February), middle (coded as June) or end (coded at November) or the year [40]. If no estimation could be made, the date was treated as missing.\u003c/p\u003e\n\u003cp\u003ePatient factors captured included variables representing sociodemographic characteristics, awareness, perceived symptom severity, and perspectives on care access timeline. \u003cem\u003eSociodemographic characteristics\u003c/em\u003e captured included age at enrollment (\u0026lt;40 versus \u0026ge;40), educational attainment (none, primary, secondary, and other), occupation (farming/domestic work versus industry/business), relationship status (married or partnered versus not). Residence was characterized as rural versus urban (as defined by the Uganda Bureau of Statistics) and distance to specialized care site (MNRH or UCI) calculated (\u0026lt;15 km, 16-50 km, 51-150 km, \u0026ge;151 km). \u003cem\u003eReproductive history\u0026nbsp;\u003c/em\u003eincluded parity, HIV status (positive, negative, never been tested, tested but don\u0026rsquo;t know result), prior cervical cancer screening (yes versus no), current contraceptive use (yes versus no). \u003cem\u003eAwareness of cervical cancer\u003c/em\u003e was captured through asking whether participants had ever heard of cervical cancer before coming to the doctor (yes versus no), whether they had any friends or family members who had cervical cancer (yes versus no). \u003cem\u003ePerceived symptom severity\u003c/em\u003e was assessed through asking participants how serious they felt their initial symptom was (not serious, a little serious, moderately serious, serious, very serious), what their level of concern was around this initial symptom (no concern, a little concern, moderate concern, very concerned), and what they initially thought was causing the symptom (cancer, menstrual irregularities, pregnancy, contraception, STI/HIV or other infection, bewitching, other). Patients were also asked to reflect on their own care access timeline, reporting on their impressions of how long it took to decide to seek care, to initially present for care, to see the specialist, and to ultimately start treatment (response options: immediate, quick, a little delayed, and very delayed). Women who reported a little delayed or very delayed were then asked for reasons that contributed to subjective delay (thought symptoms would resolve, didn\u0026rsquo;t know where to go, scared, embarrassed, sought alternative treatments herbal and/or spiritual in nature, perceived long waits, lack of trust in medical system, and financial constraints).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHealth care provider and health systems factors of interest included characteristics of the first clinical encounter: facility type (public versus private), facility level (referral/tertiary, regional versus district/village), provider type (physician, medical officer, nurse or midwife), pelvic exam with speculum to visualize cervix (yes versus no), biopsy (yes versus no); radiation available (yes versus no), number of biopsies done (\u0026ge;2 biopsies, one versus none), cost of biopsy (\u0026gt;100,000 Ugandan Shillings,~$27 USD, versus less), location of biopsy (referral hospital versus elsewhere), number of clinics attended prior to MNRH/UCI (\u0026ge;2 clinics versus one or none), and initial treatment recommendation (chemotherapy, surgery, EBRT, or palliative care).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDisease factors captured included symptomatic (yes versus no), initial symptom (e.g., bleeding, vaginal discharge, pain, other), other symptoms present prior to healthcare presentation (intermenstrual/post-menopausal bleeding, bleeding with sex, vaginal discharge, pain with sex, abdominal/pelvic pain, fatigue). Clinical cancer stage was captured and confirmed by chart abstraction and ultimately classified as early-stage (IA to IIA) versus late-stage (IIB to IVB). Histology (squamous versus adenocarcinoma or adenosquamous) was also abstracted from chart.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient characteristics were described with medians with interquartile ranges and proportions. Due to some missing participant self-report data on the exact timing of certain steps in the care cascade (but timing data having been captured on a variety of steps), we implemented an interval censoring approach to our survival analysis [41, 42]. Such an approach accommodates situations where an event of interest is not exactly observed but is known to have occurred within a particular time window. For each interval, we characterized the interval length and estimated a series of proportional hazards regression models using the Weibull survival distribution to explore the impacts of patient, provider and health systems factors, as well as disease characteristics, on interval length. Factors theorized to be associated with the outcomes or those found to be significantly associated in bivariate analysis were considered for multivariate analysis, after ensuring lack of collinearity. In most applications of survival analysis, a longer time to event is preferable due to its interpretation as greater length of time event-free. However, for our characterization of care cascade intervals, a shorter time to event is preferable as our outcomes represent time to completing particular care steps. Hazard ratios (HR) can be interpreted as velocity: the higher the HR, the faster the time to the end of the step. Thus, HRs \u0026lt;1 indicate slower times to completing a step whereas HRs \u0026gt; 1 indicate faster times to completing a step. Model goodness of fit was established using Akaike\u0026rsquo;s Information Criteria. All data were analyzed using Stata version 16.0 (Stata Corporation, College Station, TX). P values less than 0.05 were considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by institutional review boards at MNRH (Mulago Research and Ethics Committee, MREC), UCI and the University of California San Francisco (UCSF). Uganda\u0026rsquo;s national review board, the Uganda National Council for Science and Technology (UNCST), also reviewed and approved the research. All participants provided written informed consent.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study period, there were 268 women ranging in age from 20 to 81 years, with median age 49 (IQR 41-58; Table 1) who sought treatment for cervical cancer at MNRH or the UCI. Over half had primary or higher education (56.3%) and 65.3% worked in farming or domestic work. About one-third (32.1%) lived within 15 km of MNRH or UCI. Most participants had sought care based on symptoms (86.9%) while 13.1% were asymptomatic with cancer detected on screening. Over three-quarters had late-stage cancer on diagnosis (76.1%). The most recommended treatment was chemotherapy (61.2%), followed by EBRT (25.4%), surgery (12.7%), and palliative care (0.8%). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e. Sociodemographic and clinical characteristics of women presenting for specialist care for primary cervical cancer, Uganda (n=268)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"352\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eAll participants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003en=268\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSociodemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eAge group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e20-29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e30-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e40-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e29.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e50-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e25.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e60-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026ge;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eEducational attainment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e41.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e37.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e19.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eFarming/domestic work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e65.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eIndustry/business\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e34.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e45.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eNot married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e54.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eDistance to MNRH or UCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026lt;15 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e32.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e16-50 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e51-150 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e28.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u0026ge;151 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e25.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e47.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e53.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eHIV Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e31.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e68.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical/disease characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003ePrior cervical cancer screening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e25.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e74.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eSymptomatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e233\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e86.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eStage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eIA1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eIA2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eIB1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eIB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eIIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e35.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eIIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eIIIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e33.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eIVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eIVB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eRecommended treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eSurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e61.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003eEBRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e25.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 224px;\"\u003e\n \u003cp\u003ePalliative care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNotes: MNRH : Mulago National Referral Hospital ; UCI: Uganda Cancer Institute ; EBRT : external beam radiation therapy.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 233 (87%) women who were symptomatic prior to diagnosis, the first symptom noticed for most women was bleeding (65.2%) or abnormal discharge (29.6%; Table 2). A variety of presumed causes of initial symptom were endorsed, most commonly infection (36.5%), abnormal menstruation or menopause (30.5%), versus cancer (10.3%). Over half of women perceived their initial symptoms to be not serious (45.9%) or a little serious (14.6%), and most had no concern (30.9%) or only a little concern (33.9%). Over half of women reported deciding to seek care due to persistent symptoms (53.9%) followed by worsening symptoms (39.7%). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e. Initial symptom experiences and interpretation among Ugandan women with symptomatic primary cervical cancer seeking care at tertiary public facilities (n=233)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"395\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003eInitial symptom identification\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003eInitial symptom noticed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 125px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003eBleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e65.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003eDischarge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e29.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003eOther\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003eInitial symptom interpretation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003ePresumed cause of initial symptom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 125px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e36.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003eAbnormal menstruation/menopause\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e30.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003eContraceptive side effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003ePregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eOther\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003ePerceived seriousness of the problem \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 125px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Not serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e45.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;A little serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Moderate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Very serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eLevel of concern about the problem at first\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 125px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No concern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e30.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;A little concern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e33.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Moderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Very concerned\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 395px;\"\u003e\n \u003cp\u003eSymptoms present prior to presentation at any healthcare setting\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eAbnormal bleeding\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e70.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003ePost-coital bleeding\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e52.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eVaginal discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e80.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eDyspareunia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e21.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eAbdominal or pelvic pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e161\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e69.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eFatigue\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e38.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/em\u003e\u003cem\u003eOther symptoms included pain (n=11) and fatigue (n=1). \u003csup\u003eb\u003c/sup\u003eOther presumed causes included bewitched (n=6), heavy work (n=3), fibroids (n=2), and other medical (n=7). \u003csup\u003ec\u003c/sup\u003eIntermenstrual or postmenopausal.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient interval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedian patient interval was 74 days (IQR 26-238 days). In unadjusted models of patient sociodemographic characteristics (Table 3), no factors were significantly associated with length of patient interval. In multivariate analysis (Table 4), completion of the patient interval was significantly slower those who believed that their symptoms would resolve (aHR 0.37, 95% CI 0.24-0.57), those who reported not knowing where to access care (aHR 0.64, 95% CI 0.47-0.88), as well as those who first sought alternative treatments (including herbal medicine, spiritual healing or other such practices) (aHR 0.70, 95% CI 0.51-0.96). Patient interval completion was significantly faster for those who reported thinking that their initial symptom was serious or very serious (HR 2.14, 95% CI 1.43-3.19), those who were moderately or very concerned about their symptom (HR 2.06, 95% CI 1.45-2.93), and those who believed their first symptom was cancer (HR 1.82, 95% CI 1.12-2.97). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Sociodemographic Factors Influencing Time to Cervical Cancer Care Cascade Intervals\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"858\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 294px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnostic interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 294px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=233\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=268\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=268\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 294px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 294px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSociodemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 294px;\"\u003e\n \u003cp\u003eAge \u0026lt; 40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.55-1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.305\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.81-1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.519\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.88-1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.205\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 294px;\"\u003e\n \u003cp\u003ePrimary education or higher\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.84-1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.395\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.60-1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.69-1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.701\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 294px;\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.80-1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.604\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.93-1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.56-1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.117\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 294px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.77-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.791\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.09-1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.02-1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 294px;\"\u003e\n \u003cp\u003eParity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.83-1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.428\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.75-1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.842\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.85-1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.350\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eDistance to facility \u0026le; 15km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.73-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.43-2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.06-2.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.65-1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.86-1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.424\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.98-1.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eHIV positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.57-1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.74-1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.865\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.79-1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Factors Influencing Time to Cervical Cancer Care Cascade Intervals, Adjusted Models\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"847\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnostic interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=233\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=268\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=268\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient factors\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCancer-related knowledge and experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003ePrior screening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.67-1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.93-1.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.75-1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.582\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003eHeard of cervical cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.64-1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.847\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.53-1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.71-1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.825\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003eKnow friend w cervical cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.63-1.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.799\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.60-1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.335\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.52-1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.292\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptom perception\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eThought symptom was serious or very serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.43-3.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eVery concerned about symptom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.45-2.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003eThought 1st symptom cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e1.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.12-2.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003eThought 1st symptom menstrual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.60-1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eThought symptom would resolve\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.24-0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmotional barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eScared\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.75-1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.72-1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.23-1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eEmbarrassed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.45-1.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.702\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.67-1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eDoubted provider/recommendation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.61-1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.804\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003eNE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLogistical barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eDidn\u0026apos;t know where to go\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.47-0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.81-1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.684\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e1.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.89-2.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.121\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eFinancial barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.69-3.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.63-1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.66-1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.650\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eAnticipated long wait\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.62-1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.978\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.57-1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.46-1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eNeeded blood for treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.37-1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonal barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eFamily responsibilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.87-2.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.17-2.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e1.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.52-3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.578\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eDifficult to miss work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.71-2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.467\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.98-2.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003eNE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003ePursuing alternative treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.51-0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.63-1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.185\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.41-1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.168\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease factors\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptoms and clinical characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eStage IA-IIA (early)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.79-1.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.427\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.03-1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.77-1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.529\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eSymptom: bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.40-1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.35-0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.45-1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eSymptom: pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.53-1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.171\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.63-1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.508\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.68-1.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.888\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProvider and health systems factors\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFirst presentation characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.95-1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eMNRH/UCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1.20-3.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003ePhysician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.59-1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.618\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eSpeculum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.80-1.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.657\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eBiopsy done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.87-1.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.244\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eProvider suspected cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.851.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.397\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBiopsy characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026ge;2 biopsies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.44-1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eCost \u0026gt; 100,000 Ug Shillings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.73-1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.897\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eBiopsy done at MNRH/UCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.92-1.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinics attended prior to MNRH/UCI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026ge;2 Clinics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.49-0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadiation availability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\n \u003cp\u003eRadiation machine operational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.70-1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.886\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment recommendation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eChemo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003eREF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eSurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.76-1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.394\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eEBRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.60-1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.566\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003ePalliative care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 26px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e0.05-2.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.352\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 279px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 26px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote: all models adjusted for age, education, marital status, parity, and distance to facility. NE: not estimable. MNRH: Mulago National Referral Hospital. UCI: Uganda Cancer Institute\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants with symptoms reflected on the time they took to present for care (Table 5); 27.5% reported accessing care was a little delayed and 28.3% very delayed. Main reasons participants reported for not having sought medical care earlier included thinking symptoms would resolve (83.7%), not knowing where to go (57.8%), and seeking alternative treatment (46.4%). \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Patient perspectives on care timeline and reasons for delay along the cervical cancer care cascade\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"645\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnostic interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=233\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=268\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=268\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003ePatient impression of time interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eImmediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e17.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e17.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eQuick\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e26.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e20.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e38.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eA little delayed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e31.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eVery delayed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e42.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eReasons cited for delay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eThought symptoms would resolve\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e83.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eDidn\u0026apos;t know where to go\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e57.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e54.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e10.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eScared\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e17.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e26.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eEmbarassed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e16.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eSeeking alternative treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e46.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e42.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eFinancial constraints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e70.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e64.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eNeeded blood transfusion for treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eToo difficult to miss work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eHad to care for family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e19.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eDidn\u0026apos;t believe provider/trust tx rec\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eLong wait\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e33.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e22.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNotes: \u003csup\u003ea\u003c/sup\u003eFor treatment interval, scared of side effects\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic interval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedian diagnostic interval was 83 days (IQR 34-229 days). In unadjusted analysis (Table 3), time to diagnostic interval completion was significantly faster for married individuals (HR 1.41, 95% CI 1.09-1.83) and for those living within 15 kilometers of a health facility (HR 1.89, 95% CI 1.43-2.50). Time to diagnostic interval completion was marginally slower for individuals with primary-level education or higher (HR 0.78, 95% CI 0.60-1.02). Among the subset of women under age 40, using family planning was associated with significantly faster time to diagnostic interval completion (HR 3.21, 95% CI 1.13, 9.14; not shown).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn multivariate analysis (Table 4), time to diagnostic interval completion was significantly longer for those who had attended multiple clinics prior to seeking care at MNRH or UCI (aHR 0.69, 95% CI 0.49-0.97), as well as for those who reported symptomatic bleeding (aHR 0.55, 95% CI 0.35-0.85). Time to diagnostic interval completion was paradoxically less for women reporting personal barriers like family responsibilities (aHR 1.70, 95% CI 1.17-2.46). Women whose cancer was early stage (HR 1.41, 95% CI 1.03-1.95) and those who attended MRNH or UCI directly (HR 2.13, 95% CI 1.20-3.79) also had significantly faster diagnostic intervals. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants reflected on the time it took from first presenting for any care to receiving their diagnosis and treatment recommendations (Table 5); 31% reported receiving diagnosis was a little delayed and 42.9% very delayed. Most common reasons cited for delay included financial constraints (70%), not knowing where to go (54.3%), and seeking alternative therapies (42.3%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment interval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedian treatment interval was 34 days (IQR 18-58 days). In unadjusted modeling (Table 3), time to treatment interval completion was significantly faster for married individuals (HR 1.40, 95% CI 1.02-1.91) and those living within 15 kilometers of a health facility (HR 1.47, 95% CI 1.06-2.03), with a marginal finding for urban residents (HR 1.32, 95% CI 0.98-1.82).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn multivariate analysis, no specific patient, disease or health systems factors were significantly associated with a relatively faster or slower interval completion (Table 4). Notably, no particular treatment modality was associated with a longer or shorter treatment interval. Participants who anticipated a long wait for treatment (HR 0.68, 95% CI 0.46-1.02) and those who required a blood transfusion prior to treatment (HR 0.63, 95% CI 0.37-1.07) experienced marginally longer time to complete the interval.\u003c/p\u003e\n\u003cp\u003eParticipants reflected on the time it took from receiving their diagnosis to initiating treatment (Table 5); 26.9% reported starting treatment was a little delayed and 16.8% very delayed. Main reasons cited for delay were financial constraints (64.8%), long wait time (22.8%), seeking alternative treatment (13.4%) and the need for a blood transfusion prior to starting treatment (13.4%).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe found that, despite a subjective impression of delay, especially during the patient and diagnostic intervals, overall, women with cervical cancer in Uganda were able to present for care, obtain diagnosis and start treatment in a relatively timely fashion. Our conceptual framework allowed us to consider how patient, health system and disease factors either inhibited or facilitated timely completion of different intervals along the cascade to care for women with a new diagnosis of cervical cancer at public tertiary care facilities in Uganda. While we did identify some potentially modifiable barriers in the patient interval (misattribution of symptoms and utilization of traditional care in place of Western medicine), it\u0026rsquo;s unlikely that interventions to diminish or remove these barriers would significantly impact morbidity or mortality from cervical cancer, given the median duration of the patient interval was less than three months and most patients had experienced hallmark symptoms of advanced disease before even attempting to seek care.\u003c/p\u003e \u003cp\u003eSimilar to 20 year-old estimates from the Kampala Cancer Registry [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], as well as to regional estimates [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR44 CR45 CR46 CR47\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], approximately three-fourths of participants in our study had late-stage disease at diagnosis. The lack of change, while disappointing, is not surprising as there has been little expansion of screening and/or vaccination services nationwide during the last few decades. Vaccination and screening are the strongest strategies to decrease incidence, morbidity and mortality of cervical cancer [\u003cspan additionalcitationids=\"CR50 CR51\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Immediate rapid scale-up of primary and secondary prevention programs (80\u0026ndash;100% global vaccine coverage and 70% HPV-based screening coverage) would be required to meet the WHO Director-General\u0026rsquo;s global call for action to eliminate cervical cancer in the next century [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the patient interval, median duration 74 days, was delayed among participants incorrectly thinking symptoms would resolve. Misattribution of symptoms was also common; nearly 90% of participants did not suspect cancer. Similarly, qualitative studies from Northern Uganda have showed that incorrect attribution and minimization of symptoms were common and were hypothesized to delay presentation to care [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings suggest that engaging in alternative therapies also significantly prolonged the patient interval and, while not significantly associated with relatively slower completion of diagnostic or treatment intervals, participants did cite \u0026ldquo;seeking alternative treatment\u0026rdquo; as a common qualitative reason for delay during these intervals. Qualitative data from Northern Uganda suggests that traditional medicines are commonly used for treatment of cervical cancer and often thought to be superior to Western medical therapies. This same study reported community perceptions of cervical cancer care in hospitals to be congested, confusing and disrespectful, contributing to a distrust of Western medical treatments for cervical cancer [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDuring the diagnostic interval, we found that early-stage disease was associated with a faster journey through the health system to obtain a diagnosis, whereas a study from Northern Uganda, a more rural setting, did not find a significant association between stage and delay (defined as \u0026gt;\u0026thinsp;three months from symptom perception to diagnosis) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. We also found that direct presentation to tertiary care center (first presentation) was associated with a faster diagnostic interval. There are likely several unmeasured factors that contribute to presenting earlier in the disease course and directly to an urban tertiary care center. Overall, it is notable that the median diagnostic interval in our study, 83 days, is below that NBCCEDP quality standard of \u0026le;\u0026thinsp;90 days for diagnostic interval [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur absolute median duration of the treatment interval, 39 days from diagnosis to starting treatment, was similar to a reported duration at a specialty center in Botswana [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Whereas other studies from the region have reported median duration\u0026thinsp;\u0026gt;\u0026thinsp;100 days [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], substantially longer than our reported treatment interval (though our reported treatment interval is likely a conservative estimate). Both the specialty center in Botswana and MNRH/UCI have regular multidisciplinary Tumor Board discussions, perhaps improving communication between the various subspecialties providing care for these patients. Disappointingly, neither early-stage disease (better chance of survival/cure with appropriate treatment) nor a recommendation for curative hysterectomy was associated with a shorter treatment interval. As discussed previously, data from high income countries, where cervical cancer is more likely be diagnosed at an earlier/highly curable stage, has associated treatment interval delay to worse outcomes [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]; however, the median duration of the treatment interval in our study, 39 days, is well-below the 3-month threshold defining delay in these studies, again calling into question whether there is room for improvement.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis is the first study to examine relative barriers and facilitators to care at specific intervals in the cervical cancer care cascade in Uganda. Our conceptual framework (Fig.\u0026nbsp;1) is based on the Model of Pathways to Treatment [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], a theoretical approach that informs measurement and description of delay in accessing cancer care in a generalizable way across cancer sites, potentially allowing for greater consistency in reporting delay and allowing for better comparison of delay across studies in order to advance existing knowledge and effectively design interventions. Because the process of obtaining care for cancer is heterogeneous, the granular interval-specific data allow us to consider the role for specific interventions to address delay at various points on the care cascade.\u003c/p\u003e \u003cp\u003eA major limitation of this study is that recall bias could have affected the precision of measurement of intervals and other variables. We have tried to limit recall bias by using validated measures with demonstrated reliability for estimation of these intervals [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], and through the interval-censoring analytic approach. Another limitation is limited generalization of our findings given that the study population was a convenience sample of women who were able to access specialized cancer care at national referral centers. Three-fourths of women in this study, who were able to navigate to a public tertiary care facility, had advanced disease. While this is possibly an underestimate of proportion at large with late-stage disease, it is also possible that women with very early-stage disease were treated locally with simple hysterectomy. The particular delays experienced by women in this study may not be generalizable to the national population of women with cervical cancer, especially those experiencing such significant delay that they never made it to diagnosis or treatment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMeaningful implications\u003c/h2\u003e \u003cp\u003eOur findings suggest that interventions that aimed at improving identification of cervical cancer symptoms, perhaps undertaken in conjunction with traditional healers, may expedite the patient interval and, thus, presentation to care. Misattribution of symptoms was common and was associated with delay in presenting for care. While most women in the present study reported general awareness of cervical cancer [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], perhaps there is a role for education efforts specifically regarding signs and symptoms of cervical cancer, especially as those women who did suspect their symptoms were serious and/or due to cancer had a relatively faster patient interval. A similar vulnerability (knowledge) has been associated with delay among women with endometrial cancer in the United States and highlighted as a potential area for evidence-based intervention [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAcknowledging that many participants are not only using alternative therapies including traditional medicine and spiritual healing, but citing utilization as a reason for delay, perhaps re-framing these modalities as complementary, rather than alternative, with engagement and buy-in from traditional practitioners, could facilitate earlier and potentially more streamlined referral to Western medical care for cervical cancer. In Uganda, traditional healers are highly respected authoritative figures and commonly consulted, especially by women, often prior to or instead of engagement with allopathic clinics. There is an estimated one traditional healer for every 200\u0026ndash;400 people [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e], while a level II health center (providing basic outpatient medical services, staffed by nurses) serves a catchment area of 5000 and just 71% of Ugandans live within a one-hour walk of such a facility [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. There are examples of effective collaborations among traditional allopathic medicine in Uganda, especially in the realm of HIV and family planning care [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]; but there is likely a potential for greater collaboration as evidence suggests mutual mistrust and competition between traditional healers and Western medical practitioners [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterventions designed to streamline referrals to national referral centers (MNRH and UCI, the only public facilities able to provide cancer care) may hasten the diagnostic interval. We did find that patients who went to two or more clinics prior to MNRH or UCI experienced longer diagnostic intervals, while those who presented directly to the national referral centers completed this interval quicker. However, a practical solution to streamline timely referrals is challenging. The health system in Uganda operates on a decentralized referral system with government-trained Village Health Team (VHT) as intended first point of contact with subsequent referral based on health needs, but great disparities exist between rural and urban populations with the most vulnerable poor rural Ugandans facing disproportionately worse access to even basic health centers [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Given an under-funded health sector with inequitable distribution [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], an effective intervention would likely require significant restructuring of the health sector. Alternatively, disseminating specialty cancer care beyond the urban national referral centers, a model undertaken by the Rwandan Ministry of Health in their creation of the Butaro Cancer Center of Excellence (BCCOE) [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], may improve timeliness to diagnosis and potentially treatment.\u003c/p\u003e \u003cp\u003eThe anticipated long wait times, which seemed to lengthen the treatment interval, implies an unmet need for treatment, be it a radical hysterectomy, primary radiation and/or chemotherapy. Worldwide, the burden of cancer morbidity and mortality disproportionately affects LMICs (78% of global years of life lost and 77% of disability-adjusted life years due to cancer), yet less-developed countries account for just 6% of total resources spent on cancer care globally [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Amidst the global COVID-19 pandemic, now more than ever before, the international community, must recognize the inter-connected nature of our health systems and re-calibrate it\u0026rsquo;s response to widespread inequity to enable sufficient funding for capacity building and treatment. Part of the WHO Director-General\u0026rsquo;s call for global elimination of cervical cancer is for 90% of women with invasive cancer to access effective treatment, a target not achieved in this cohort [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eUnanswered questions\u003c/h2\u003e \u003cp\u003eWhile our findings suggest interval-specific barriers and facilitators to timely completion of the cervical cancer care cascade, given that most participants had symptoms motivating presentation to care (87%) and that most were advanced stage at diagnosis (76%), interventions aimed at decreasing the median duration of intervals, may not result in substantial reduction in morbidity or mortality from cervical cancer. Again, vaccination and screening are the most effective strategies to decrease morbidity and mortality from cervical cancer and must a primary and immediate focus for intervention [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExpanding access to screening may result in increasing the proportion of cervical cancer diagnosed at an early stage, when curative hysterectomy is possible. World-wide, early-stage cervical cancer is often asymptomatic and incidentally diagnosed during routine screening. Cure rates are highest for early-stage cervical cancer. While timely access to treatment is certainly important for palliation of advanced symptoms, like pain and bleeding, hastening treatment for advanced disease by a matter of days to even weeks will not likely decrease morbidity or mortality. A cohort study in the United States recently found that while median time to initiate definitive chemoradiation for locoregionally advanced cervical cancer increased from 36 to 44 days between 2004\u0026ndash;2014, survival was not impacted [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEfforts to expand primary and secondary prevention are of utmost importance for women in Uganda as well as world-wide. On the other side of the spectrum, hospice and palliative care, though widely available in Uganda and subsidized, seem to be poorly utilized. Given the proportion of women with late-stage, less-likely curable cervical cancer, coupled with the significant portion of participants who had not yet accessed treatment during the study period, future research is needed to understand the specific barriers among patients and providers to uptake and referral to palliative care and hospice.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe identified potentially modifiable barriers along the cervical cancer care cascade including: misattribution of symptoms, preferential use of local healers, lack of streamlined referral and anticipated long wait times. Interventions targeting these factors may improve care timeliness but are unlikely to significantly improve morbidity or mortality given the average stage at symptomatic presentation. While expanding cervical cancer screening and vaccination are the most effective strategies to improve morbidity and/or mortality, timely care is important for palliation of symptoms of advanced disease.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eIQR interquartile range\u003c/p\u003e\n\u003cp\u003eHR hazard ratio\u003c/p\u003e\n\u003cp\u003eaHR adjusted hazard ratio\u003c/p\u003e\n\u003cp\u003eCI confidence interval\u003c/p\u003e\n\u003cp\u003eMNRH Mulago National Referral Hospital\u003c/p\u003e\n\u003cp\u003eUCI Uganda Cancer Institute\u003c/p\u003e\n\u003cp\u003eLMICs low- and middle-income countries\u003c/p\u003e\n\u003cp\u003eNBCCEDP National Breast and Cervical Cancer Early Detection Program\u003c/p\u003e\n\u003cp\u003eEBRT external beam radiation therapy\u003c/p\u003e\n\u003cp\u003eSTI sexually transmitted infection\u003c/p\u003e\n\u003cp\u003eHIV human immunodeficiency virus\u003c/p\u003e\n\u003cp\u003eMREC Mulago Research and Ethics Committee\u003c/p\u003e\n\u003cp\u003eUCSF University of California San Francisco\u003c/p\u003e\n\u003cp\u003eUNCST Uganda National Council for Science and Technology\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by institutional review boards at MNRH (MREC Protocol 1058), UCI (ER-007) and UCSF (16-21306). Uganda\u0026rsquo;s national review board, UNCST, also reviewed and approved the research (HS29Es). All participants provided written informed consent.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated by the survey research during and/or \u0026nbsp;analyzed during the current study are available in the Dryad repository (doi:10.5061/dryad.dv41ns24m): \u0026nbsp;https://datadryad.org/stash/share/upLAOiCWeBLV8Bu4Zdee67d8Df5rfQmF9pdeqAgCLvw.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Fogarty International Center at the U.S. National Institutes of Health (Grant: R25TW009343) through the University of California Global Health Institute Program for Fellows and Scholars. The funder had no role in study design, implementation, analysis, interpretation, or decision to submit the manuscript for publication. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMS, MN, and MH conceptualized the study. \u0026nbsp;MS planned and supervised all aspects of the study. \u0026nbsp; MN, JN and CN provided site-specific supervision. \u0026nbsp;MS and AEA interpreted and analyzed the data and drafted the manuscript. \u0026nbsp;AEA and MH substantially revised the manuscript. \u0026nbsp; All authors revised and approved the final manuscript. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe greatly appreciate our research participants for sharing their experiences and time with the research team, and our data collection and patient advisory team: Najjemba Irene, Najjemba Beatrice, Nakadu Laurant, and Nankya Esther. We would also like to thank Corinne Rocca, Katrina Kimport and the participants in the Bixby Center Works in Progress seminar for their feedback on this manuscript, and John Neuhaus for his guidance on implementing the interval-censored survival analyses.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A: \u003cstrong\u003eGlobal cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries\u003c/strong\u003e. \u003cem\u003eCA: a cancer journal for clinicians \u003c/em\u003e2018, \u003cstrong\u003e68\u003c/strong\u003e(6):394-424.\u003c/li\u003e\n\u003cli\u003eSingh D, Vignat J, Lorenzoni V, Eslahi M, Ginsburg O, Lauby-Secretan B, Arbyn M, Basu P, Bray F, Vaccarella S: \u003cstrong\u003eGlobal estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO Global Cervical Cancer Elimination Initiative\u003c/strong\u003e. \u003cem\u003eLancet Glob Health \u003c/em\u003e2023, \u003cstrong\u003e11\u003c/strong\u003e(2):e197-e206.\u003c/li\u003e\n\u003cli\u003eBruni L B-RL, Albero G, Aldea M, Serrano B, Valencia S, Brotons M, Mena M, Cosano R, Mu\u0026ntilde;oz J, Bosch FX, de Sanjos\u0026eacute; S, Castellsagu\u0026eacute; X: \u003cstrong\u003eHuman Papillomavirus and Related Diseases in Uganda. Summary Report 2016-\u003cstrong\u003e02-26\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e: ICO Information Centre on HPV and Cancer (HPV Information Centre); 2016.\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003eWabinga H, Ramanakumar AV, Banura C, Luwaga A, Nambooze S, Parkin DM: \u003cstrong\u003eSurvival of cervix cancer patients in Kampala, Uganda: 1995-1997\u003c/strong\u003e. \u003cem\u003eBritish journal of cancer \u003c/em\u003e2003, \u003cstrong\u003e89\u003c/strong\u003e(1):65-69.\u003c/li\u003e\n\u003cli\u003eGondos A, Brenner H, Wabinga H, Parkin DM: \u003cstrong\u003eCancer survival in Kampala, Uganda\u003c/strong\u003e. \u003cem\u003eBritish journal of cancer \u003c/em\u003e2005, \u003cstrong\u003e92\u003c/strong\u003e(9):1808-1812.\u003c/li\u003e\n\u003cli\u003eSwanson M, Ueda S, Chen L-m, Huchko MJ, Nakisige C, Namugga J: \u003cstrong\u003eEvidence-based improvisation: Facing the challenges of cervical cancer care in Uganda\u003c/strong\u003e. \u003cem\u003eGynecologic Oncology Reports \u003c/em\u003e2018, \u003cstrong\u003e24\u003c/strong\u003e:30-35.\u003c/li\u003e\n\u003cli\u003eSullivan R, Alatise OI, Anderson BO, Audisio R, Autier P, Aggarwal A, Balch C, Brennan MF, Dare A, D\u0026apos;Cruz A\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eGlobal cancer surgery: delivering safe, affordable, and timely cancer surgery\u003c/strong\u003e. \u003cem\u003eThe Lancet Oncology \u003c/em\u003e2015, \u003cstrong\u003e16\u003c/strong\u003e(11):1193-1224.\u003c/li\u003e\n\u003cli\u003eRobinson KM, Christensen KB, Ottesen B, Krasnik A: \u003cstrong\u003eSocio-demographic factors, comorbidity and diagnostic delay among women diagnosed with cervical, endometrial or ovarian cancer\u003c/strong\u003e. \u003cem\u003eEuropean journal of cancer care \u003c/em\u003e2011, \u003cstrong\u003e20\u003c/strong\u003e(5):653-661.\u003c/li\u003e\n\u003cli\u003eBerraho M, Obtel M, Bendahhou K, Zidouh A, Errihani H, Benider A, Nejjari C: \u003cstrong\u003eSociodemographic factors and delay in the diagnosis of cervical cancer in Morocco\u003c/strong\u003e. \u003cem\u003eThe Pan African medical journal \u003c/em\u003e2012, \u003cstrong\u003e12\u003c/strong\u003e:14.\u003c/li\u003e\n\u003cli\u003eTadesse SK: \u003cstrong\u003eSocio-economic and cultural vulnerabilities to cervical cancer and challenges faced by patients attending care at Tikur Anbessa Hospital: a cross sectional and qualitative study\u003c/strong\u003e. \u003cem\u003eBMC women\u0026apos;s health \u003c/em\u003e2015, \u003cstrong\u003e15\u003c/strong\u003e:75.\u003c/li\u003e\n\u003cli\u003eMarlow LA, McGregor LM, Nazroo JY, Wardle J: \u003cstrong\u003eFacilitators and barriers to help-seeking for breast and cervical cancer symptoms: a qualitative study with an ethnically diverse sample in London\u003c/strong\u003e. \u003cem\u003ePsycho-oncology \u003c/em\u003e2014, \u003cstrong\u003e23\u003c/strong\u003e(7):749-757.\u003c/li\u003e\n\u003cli\u003eAnorlu RI, Orakwue CO, Oyeneyin L, Abudu OO: \u003cstrong\u003eLate presentation of patients with cervical cancer to a tertiary hospital in Lagos: what is responsible?\u003c/strong\u003e \u003cem\u003eEuropean journal of gynaecological oncology \u003c/em\u003e2004, \u003cstrong\u003e25\u003c/strong\u003e(6):729-732.\u003c/li\u003e\n\u003cli\u003eLim AW, Ramirez AJ, Hamilton W, Sasieni P, Patnick J, Forbes LJ: \u003cstrong\u003eDelays in diagnosis of young females with symptomatic cervical cancer in England: an interview-based study\u003c/strong\u003e. \u003cem\u003eThe British journal of general practice : the journal of the Royal College of General Practitioners \u003c/em\u003e2014, \u003cstrong\u003e64\u003c/strong\u003e(627):e602-610.\u003c/li\u003e\n\u003cli\u003eMiller JW, Hanson V, Johnson GD, Royalty JE, Richardson LC: \u003cstrong\u003eFrom cancer screening to treatment: service delivery and referral in the National Breast and Cervical Cancer Early Detection Program\u003c/strong\u003e. \u003cem\u003eCancer \u003c/em\u003e2014, \u003cstrong\u003e120 Suppl 16\u003c/strong\u003e(0 16):2549-2556.\u003c/li\u003e\n\u003cli\u003eHanna TP, King WD, Thibodeau S, Jalink M, Paulin GA, Harvey-Jones E, O\u0026apos;Sullivan DE, Booth CM, Sullivan R, Aggarwal A: \u003cstrong\u003eMortality due to cancer treatment delay: systematic review and meta-analysis\u003c/strong\u003e. \u003cem\u003eBmj \u003c/em\u003e2020, \u003cstrong\u003e371\u003c/strong\u003e:m4087.\u003c/li\u003e\n\u003cli\u003eShen SC, Hung YC, Kung PT, Yang WH, Wang YH, Tsai WC: \u003cstrong\u003eFactors involved in the delay of treatment initiation for cervical cancer patients: A nationwide population-based study\u003c/strong\u003e. \u003cem\u003eMedicine \u003c/em\u003e2016, \u003cstrong\u003e95\u003c/strong\u003e(33):e4568.\u003c/li\u003e\n\u003cli\u003eChen CP, Kung PT, Wang YH, Tsai WC: \u003cstrong\u003eEffect of time interval from diagnosis to treatment for cervical cancer on survival: A nationwide cohort study\u003c/strong\u003e. \u003cem\u003ePLoS One \u003c/em\u003e2019, \u003cstrong\u003e14\u003c/strong\u003e(9):e0221946.\u003c/li\u003e\n\u003cli\u003eMwaka AD, Garimoi CO, Were EM, Roland M, Wabinga H, Lyratzopoulos G: \u003cstrong\u003eSocial, demographic and healthcare factors associated with stage at diagnosis of cervical cancer: cross-sectional study in a tertiary hospital in Northern Uganda\u003c/strong\u003e. \u003cem\u003eBMJ open \u003c/em\u003e2016, \u003cstrong\u003e6\u003c/strong\u003e(1):e007690.\u003c/li\u003e\n\u003cli\u003eFerreira da Silva I, Ferreira da Silva I, Koifman RJ: \u003cstrong\u003eCervical Cancer Treatment Delays and Associated Factors in a Cohort of Women From a Developing Country\u003c/strong\u003e. \u003cem\u003eJ Glob Oncol \u003c/em\u003e2019, \u003cstrong\u003e5\u003c/strong\u003e:1-11.\u003c/li\u003e\n\u003cli\u003eMwaka AD, Orach CG, Were EM, Lyratzopoulos G, Wabinga H, Roland M: \u003cstrong\u003eAwareness of cervical cancer risk factors and symptoms: cross-sectional community survey in post-conflict northern Uganda\u003c/strong\u003e. \u003cem\u003eHealth Expect \u003c/em\u003e2015.\u003c/li\u003e\n\u003cli\u003eMwaka AD, Okello ES, Kiguli J, Rutebemberwa E: \u003cstrong\u003eUnderstanding cervical cancer: an exploration of lay perceptions, beliefs and knowledge about cervical cancer among the Acholi in northern Uganda\u003c/strong\u003e. \u003cem\u003eBMC Womens Health \u003c/em\u003e2014, \u003cstrong\u003e14\u003c/strong\u003e:84.\u003c/li\u003e\n\u003cli\u003eMwaka AD, Okello ES, Wabinga H, Walter FM: \u003cstrong\u003eSymptomatic presentation with cervical cancer in Uganda: a qualitative study assessing the pathways to diagnosis in a low-income country\u003c/strong\u003e. \u003cem\u003eBMC women\u0026apos;s health \u003c/em\u003e2015, \u003cstrong\u003e15\u003c/strong\u003e:15.\u003c/li\u003e\n\u003cli\u003eOrem JN, Zikusooka CM: \u003cstrong\u003eHealth financing reform in Uganda: How equitable is the proposed National Health Insurance scheme?\u003c/strong\u003e \u003cem\u003eInternational journal for equity in health \u003c/em\u003e2010, \u003cstrong\u003e9\u003c/strong\u003e:23.\u003c/li\u003e\n\u003cli\u003eMeara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eGlobal Surgery 2030: evidence and solutions for achieving health, welfare, and economic development\u003c/strong\u003e. \u003cem\u003eInternational journal of obstetric anesthesia \u003c/em\u003e2016, \u003cstrong\u003e25\u003c/strong\u003e:75-78.\u003c/li\u003e\n\u003cli\u003eDubowitz G, Detlefs S, McQueen KA: \u003cstrong\u003eGlobal anesthesia workforce crisis: a preliminary survey revealing shortages contributing to undesirable outcomes and unsafe practices\u003c/strong\u003e. \u003cem\u003eWorld journal of surgery \u003c/em\u003e2010, \u003cstrong\u003e34\u003c/strong\u003e(3):438-444.\u003c/li\u003e\n\u003cli\u003eEpiu I, Tindimwebwa JV, Mijumbi C, Chokwe TM, Lugazia E, Ndarugirire F, Twagirumugabe T, Dubowitz G: \u003cstrong\u003eChallenges of Anesthesia in Low- and Middle-Income Countries: A Cross-Sectional Survey of Access to Safe Obstetric Anesthesia in East Africa\u003c/strong\u003e. \u003cem\u003eAnesthesia and analgesia \u003c/em\u003e2017, \u003cstrong\u003e124\u003c/strong\u003e(1):290-299.\u003c/li\u003e\n\u003cli\u003eLund TC, Hume H, Allain JP, McCullough J, Dzik W: \u003cstrong\u003eThe blood supply in Sub-Saharan Africa: needs, challenges, and solutions\u003c/strong\u003e. \u003cem\u003eTransfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis \u003c/em\u003e2013, \u003cstrong\u003e49\u003c/strong\u003e(3):416-421.\u003c/li\u003e\n\u003cli\u003eLeBrun DG, Chackungal S, Chao TE, Knowlton LM, Linden AF, Notrica MR, Solis CV, McQueen KA: \u003cstrong\u003ePrioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries\u003c/strong\u003e. \u003cem\u003eSurgery \u003c/em\u003e2014, \u003cstrong\u003e155\u003c/strong\u003e(3):365-373.\u003c/li\u003e\n\u003cli\u003eAbdel-Wahab M, Bourque JM, Pynda Y, Izewska J, Van der Merwe D, Zubizarreta E, Rosenblatt E: \u003cstrong\u003eStatus of radiotherapy resources in Africa: an International Atomic Energy Agency analysis\u003c/strong\u003e. \u003cem\u003eThe Lancet Oncology \u003c/em\u003e2013, \u003cstrong\u003e14\u003c/strong\u003e(4):e168-175.\u003c/li\u003e\n\u003cli\u003eDatta NR, Samiei M, Bodis S: \u003cstrong\u003eRadiation therapy infrastructure and human resources in low- and middle-income countries: present status and projections for 2020\u003c/strong\u003e. \u003cem\u003eInternational journal of radiation oncology, biology, physics \u003c/em\u003e2014, \u003cstrong\u003e89\u003c/strong\u003e(3):448-457.\u003c/li\u003e\n\u003cli\u003eSwanson M, Nakalembe M, Chen LM, Ueda S, Namugga J, Nakisige C, Huchko MJ: \u003cstrong\u003eSurgical candidacy and treatment initiation among women with cervical cancer at public referral hospitals in Kampala, Uganda: a descriptive cohort study\u003c/strong\u003e. \u003cem\u003eBMJ Open \u003c/em\u003e2020, \u003cstrong\u003e10\u003c/strong\u003e(12):e039946.\u003c/li\u003e\n\u003cli\u003eZikusooka CM, Kyomuhang R, Orem JN, Tumwine M: \u003cstrong\u003eIs health care financing in Uganda equitable?\u003c/strong\u003e \u003cem\u003eAfr Health Sci \u003c/em\u003e2009, \u003cstrong\u003e9 Suppl 2\u003c/strong\u003e(Suppl 2):S52-58.\u003c/li\u003e\n\u003cli\u003eChuang LT, Feldman S, Nakisige C, Temin S, Berek JS: \u003cstrong\u003eManagement and Care of Women With Invasive Cervical Cancer: ASCO Resource-Stratified Clinical Practice Guideline\u003c/strong\u003e. \u003cem\u003eJ Clin Oncol \u003c/em\u003e2016, \u003cstrong\u003e34\u003c/strong\u003e(27):3354-3355.\u003c/li\u003e\n\u003cli\u003eBenedetti-Panici P, Greggi S, Colombo A, Amoroso M, Smaniotto D, Giannarelli D, Amunni G, Raspagliesi F, Zola P, Mangioni C\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eNeoadjuvant chemotherapy and radical surgery versus exclusive radiotherapy in locally advanced squamous cell cervical cancer: results from the Italian multicenter randomized study\u003c/strong\u003e. \u003cem\u003eJ Clin Oncol \u003c/em\u003e2002, \u003cstrong\u003e20\u003c/strong\u003e(1):179-188.\u003c/li\u003e\n\u003cli\u003eChang TC, Lai CH, Hong JH, Hsueh S, Huang KG, Chou HH, Tseng CJ, Tsai CS, Chang JT, Lin CT\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eRandomized trial of neoadjuvant cisplatin, vincristine, bleomycin, and radical hysterectomy versus radiation therapy for bulky stage IB and IIA cervical cancer\u003c/strong\u003e. \u003cem\u003eJ Clin Oncol \u003c/em\u003e2000, \u003cstrong\u003e18\u003c/strong\u003e(8):1740-1747.\u003c/li\u003e\n\u003cli\u003eKokka F, Bryant A, Brockbank E, Powell M, Oram D: \u003cstrong\u003eHysterectomy with radiotherapy or chemotherapy or both for women with locally advanced cervical cancer\u003c/strong\u003e. \u003cem\u003eCochrane Database Syst Rev \u003c/em\u003e2015(4):Cd010260.\u003c/li\u003e\n\u003cli\u003eWalter F, Webster A, Scott S, Emery J: \u003cstrong\u003eThe Andersen Model of Total Patient Delay: a systematic review of its application in cancer diagnosis\u003c/strong\u003e. \u003cem\u003eJournal of health services research \u0026amp; policy \u003c/em\u003e2012, \u003cstrong\u003e17\u003c/strong\u003e(2):110-118.\u003c/li\u003e\n\u003cli\u003eScott SE, Walter FM, Webster A, Sutton S, Emery J: \u003cstrong\u003eThe model of pathways to treatment: conceptualization and integration with existing theory\u003c/strong\u003e. \u003cem\u003eBritish journal of health psychology \u003c/em\u003e2013, \u003cstrong\u003e18\u003c/strong\u003e(1):45-65.\u003c/li\u003e\n\u003cli\u003eAndersen BL, Cacioppo JT: \u003cstrong\u003eDelay in seeking a cancer diagnosis: delay stages and psychophysiological comparison processes\u003c/strong\u003e. \u003cem\u003eThe British journal of social psychology \u003c/em\u003e1995, \u003cstrong\u003e34 ( Pt 1)\u003c/strong\u003e:33-52.\u003c/li\u003e\n\u003cli\u003eUnger-Saldana K, Pelaez-Ballestas I, Infante-Castaneda C: \u003cstrong\u003eDevelopment and validation of a questionnaire to assess delay in treatment for breast cancer\u003c/strong\u003e. \u003cem\u003eBMC Cancer \u003c/em\u003e2012, \u003cstrong\u003e12\u003c/strong\u003e:626.\u003c/li\u003e\n\u003cli\u003eAhn S, Lim J, Paik MC, Sacco RL, Elkind MS: \u003cstrong\u003eCox model with interval-censored covariate in cohort studies\u003c/strong\u003e. \u003cem\u003eBiom J \u003c/em\u003e2018, \u003cstrong\u003e60\u003c/strong\u003e(4):797-814.\u003c/li\u003e\n\u003cli\u003eZhang Z, Sun J: \u003cstrong\u003eInterval censoring\u003c/strong\u003e. \u003cem\u003eStat Methods Med Res \u003c/em\u003e2010, \u003cstrong\u003e19\u003c/strong\u003e(1):53-70.\u003c/li\u003e\n\u003cli\u003eDunyo P, Effah K, Udofia EA: \u003cstrong\u003eFactors associated with late presentation of cervical cancer cases at a district hospital: a retrospective study\u003c/strong\u003e. \u003cem\u003eBMC Public Health \u003c/em\u003e2018, \u003cstrong\u003e18\u003c/strong\u003e(1):1156.\u003c/li\u003e\n\u003cli\u003ePark PH, Davey S, Fehr AE, Butonzi J, Shyirambere C, Hategekimana V, Bigirimana JB, Borg R, Uwizeye R, Tapela N\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003ePatient Characteristics, Early Outcomes, and Implementation Lessons of Cervical Cancer Treatment Services in Rural Rwanda\u003c/strong\u003e. \u003cem\u003eJ Glob Oncol \u003c/em\u003e2018, \u003cstrong\u003e4\u003c/strong\u003e:1-11.\u003c/li\u003e\n\u003cli\u003eDeBoer RJ, Umutoni V, Bazzett-Matabele L, Katznelson E, Nguyen C, Umwizerwa A, Bigirimana JB, Paciorek A, Nsabimana N, Ruhangaza D\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eCervical cancer treatment in Rwanda: Resource-driven adaptations, quality indicators, and patient outcomes\u003c/strong\u003e. \u003cem\u003eGynecol Oncol \u003c/em\u003e2022, \u003cstrong\u003e164\u003c/strong\u003e(2):370-378.\u003c/li\u003e\n\u003cli\u003eDereje N, Addissie A, Worku A, Gebremariam A, Kantelhardt EJ, Assefa M, Jemal A: \u003cstrong\u003eAssociation between waiting time for radiotherapy initiation and disease progression among women with cervical cancer in Addis Ababa, Ethiopia\u003c/strong\u003e. \u003cem\u003eInt J Cancer \u003c/em\u003e2021, \u003cstrong\u003e149\u003c/strong\u003e(6):1284-1289.\u003c/li\u003e\n\u003cli\u003eMumba JM, Kasonka L, Owiti OB, Andrew J, Lubeya MK, Lukama L, Kasempa C, Msadabwe SC, Kalinda C: \u003cstrong\u003eCervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia\u003c/strong\u003e. \u003cem\u003eGynecol Oncol Rep \u003c/em\u003e2021, \u003cstrong\u003e37\u003c/strong\u003e:100784.\u003c/li\u003e\n\u003cli\u003eKantelhardt EJ, Moelle U, Begoihn M, Addissie A, Trocchi P, Yonas B, Hezkiel P, Stang A, Thomssen C, Vordermark D\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eCervical cancer in Ethiopia: survival of 1,059 patients who received oncologic therapy\u003c/strong\u003e. \u003cem\u003eOncologist \u003c/em\u003e2014, \u003cstrong\u003e19\u003c/strong\u003e(7):727-734.\u003c/li\u003e\n\u003cli\u003eLevi F, Lucchini F, Negri E, Franceschi S, la Vecchia C: \u003cstrong\u003eCervical cancer mortality in young women in Europe: patterns and trends\u003c/strong\u003e. \u003cem\u003eEur J Cancer \u003c/em\u003e2000, \u003cstrong\u003e36\u003c/strong\u003e(17):2266-2271.\u003c/li\u003e\n\u003cli\u003eDrolet M, B\u0026eacute;nard \u0026Eacute;, P\u0026eacute;rez N, Brisson M: \u003cstrong\u003ePopulation-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis\u003c/strong\u003e. \u003cem\u003eLancet \u003c/em\u003e2019, \u003cstrong\u003e394\u003c/strong\u003e(10197):497-509.\u003c/li\u003e\n\u003cli\u003eBrisson M, Kim JJ, Canfell K, Drolet M, Gingras G, Burger EA, Martin D, Simms KT, B\u0026eacute;nard \u0026Eacute;, Boily MC\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eImpact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries\u003c/strong\u003e. \u003cem\u003eLancet \u003c/em\u003e2020, \u003cstrong\u003e395\u003c/strong\u003e(10224):575-590.\u003c/li\u003e\n\u003cli\u003eCanfell K, Kim JJ, Brisson M, Keane A, Simms KT, Caruana M, Burger EA, Martin D, Nguyen DTN, B\u0026eacute;nard \u0026Eacute;\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eMortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries\u003c/strong\u003e. \u003cem\u003eLancet \u003c/em\u003e2020, \u003cstrong\u003e395\u003c/strong\u003e(10224):591-603.\u003c/li\u003e\n\u003cli\u003eSimms KT, Steinberg J, Caruana M, Smith MA, Lew JB, Soerjomataram I, Castle PE, Bray F, Canfell K: \u003cstrong\u003eImpact of scaled up human papillomavirus vaccination and cervical screening and the potential for global elimination of cervical cancer in 181 countries, 2020-99: a modelling study\u003c/strong\u003e. \u003cem\u003eLancet Oncol \u003c/em\u003e2019, \u003cstrong\u003e20\u003c/strong\u003e(3):394-407.\u003c/li\u003e\n\u003cli\u003eMwaka AD, Okello ES, Orach CG: \u003cstrong\u003eBarriers to biomedical care and use of traditional medicines for treatment of cervical cancer: an exploratory qualitative study in northern Uganda\u003c/strong\u003e. \u003cem\u003eEur J Cancer Care (Engl) \u003c/em\u003e2015, \u003cstrong\u003e24\u003c/strong\u003e(4):503-513.\u003c/li\u003e\n\u003cli\u003eGrover S, Chiyapo SP, Puri P, Narasimhamurthy M, Gaolebale BE, Tapela N, Ramogola-Masire D, Kayembe MKA, Moloi T, Gaolebale PA: \u003cstrong\u003eMultidisciplinary Gynecologic Oncology Clinic in Botswana: A Model for Multidisciplinary Oncology Care in Low- and Middle-Income Settings\u003c/strong\u003e. \u003cem\u003eJ Glob Oncol \u003c/em\u003e2017, \u003cstrong\u003e3\u003c/strong\u003e(5):666-670.\u003c/li\u003e\n\u003cli\u003eTumba N, Adewuyi SA, Eguzo K, Adenipekun A, Oyesegun R: \u003cstrong\u003eRadiotherapy waiting time in Northern Nigeria: experience from a resource-limited setting\u003c/strong\u003e. \u003cem\u003eEcancermedicalscience \u003c/em\u003e2020, \u003cstrong\u003e14\u003c/strong\u003e:1097.\u003c/li\u003e\n\u003cli\u003eDoll KM, Hempstead B, Alson J, Sage L, Lavallee D: \u003cstrong\u003eAssessment of Prediagnostic Experiences of Black Women With Endometrial Cancer in the United States\u003c/strong\u003e. \u003cem\u003eJAMA Netw Open \u003c/em\u003e2020, \u003cstrong\u003e3\u003c/strong\u003e(5):e204954.\u003c/li\u003e\n\u003cli\u003eDoll KM, Nguyen A, Alson JG: \u003cstrong\u003eA conceptual model of vulnerability to care delay among women at risk for endometrial cancer\u003c/strong\u003e. \u003cem\u003eGynecol Oncol \u003c/em\u003e2022, \u003cstrong\u003e164\u003c/strong\u003e(2):318-324.\u003c/li\u003e\n\u003cli\u003eBodeker G, Kabatesi D, King R, Homsy J: \u003cstrong\u003eA regional task force on traditional medicine and AIDS\u003c/strong\u003e. \u003cem\u003eLancet \u003c/em\u003e2000, \u003cstrong\u003e355\u003c/strong\u003e(9211):1284.\u003c/li\u003e\n\u003cli\u003eDowhaniuk N: \u003cstrong\u003eExploring country-wide equitable government health care facility access in Uganda\u003c/strong\u003e. \u003cem\u003eInt J Equity Health \u003c/em\u003e2021, \u003cstrong\u003e20\u003c/strong\u003e(1):38.\u003c/li\u003e\n\u003cli\u003eSsali A, Butler LM, Kabatesi D, King R, Namugenyi A, Kamya MR, Mandel J, Chen SY, McFarland W: \u003cstrong\u003eTraditional healers for HIV/AIDS prevention and family planning, Kiboga District, Uganda: evaluation of a program to improve practices\u003c/strong\u003e. \u003cem\u003eAIDS Behav \u003c/em\u003e2005, \u003cstrong\u003e9\u003c/strong\u003e(4):485-493.\u003c/li\u003e\n\u003cli\u003eAkol A, Moland KM, Babirye JN, Engebretsen IMS: \u003cstrong\u003e\u0026quot;We are like co-wives\u0026quot;: Traditional healers\u0026apos; views on collaborating with the formal Child and Adolescent Mental Health System in Uganda\u003c/strong\u003e. \u003cem\u003eBMC Health Serv Res \u003c/em\u003e2018, \u003cstrong\u003e18\u003c/strong\u003e(1):258.\u003c/li\u003e\n\u003cli\u003eKiwanuka SN, Ekirapa EK, Peterson S, Okui O, Rahman MH, Peters D, Pariyo GW: \u003cstrong\u003eAccess to and utilisation of health services for the poor in Uganda: a systematic review of available evidence\u003c/strong\u003e. \u003cem\u003eTrans R Soc Trop Med Hyg \u003c/em\u003e2008, \u003cstrong\u003e102\u003c/strong\u003e(11):1067-1074.\u003c/li\u003e\n\u003cli\u003eBeaulieu N BD, Bloom R, Stein R: \u003cstrong\u003eBreakaway: the global burden of cancer - challenges and opportunities. A report from the Economist Inteligence Unit\u003c/strong\u003e. In\u003cem\u003e.\u003c/em\u003e; 2009.\u003c/li\u003e\n\u003cli\u003eInstitute of Medicine Committee on Cancer Control in L, Middle-Income C: \u003cstrong\u003eThe National Academies Collection: Reports funded by National Institutes of Health\u003c/strong\u003e. In: \u003cem\u003eCancer Control Opportunities in Low- and Middle-Income Countries.\u003c/em\u003e edn. Edited by Sloan FA, Gelband H. Washington (DC): National Academies Press (US) National Academy of Sciences.; 2007.\u003c/li\u003e\n\u003cli\u003eRamey SJ, Asher D, Kwon D, Ahmed AA, Wolfson AH, Yechieli R, Portelance L: \u003cstrong\u003eDelays in definitive cervical cancer treatment: An analysis of disparities and overall survival impact\u003c/strong\u003e. \u003cem\u003eGynecol Oncol \u003c/em\u003e2018, \u003cstrong\u003e149\u003c/strong\u003e(1):53-62.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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":"cervical cancer, delay, treatment access","lastPublishedDoi":"10.21203/rs.3.rs-5467551/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5467551/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCervical cancer is the fourth most common cancer among women with significant global disparities in disease burden. In lower-resource settings, where routine screening is uncommon, delays in diagnosis and treatment contribute to morbidity and mortality. Understanding care delays may inform strategies to decrease time to treatment, improving patient outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e We collected sociodemographic, reproductive health and care journey data from 268 Ugandan women newly diagnosed with cervical cancer. We explored the influence of patient, health provider, system, and disease factors on time to presentation (patient interval), diagnosis (diagnostic interval) and treatment (treatment interval) using survival analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMedian patient, diagnostic and treatment intervals were 74 days (IQR 26\u0026ndash;238), 83 days (IQR 34\u0026ndash;229), and 34 days (IQR 18\u0026ndash;58), respectively. Patient interval was delayed by belief that symptoms would resolve (aHR 0.37, 95% CI 0.24\u0026ndash;0.57), confusion about where to seek care (aHR 0.64, 95% CI 0.47\u0026ndash;0.88), and utilization of traditional care (aHR 0.70, 95% CI 0.51\u0026ndash;0.96). Patient interval facilitators included perceiving symptoms as serious (aHR 2.14, 95% CI 1.43\u0026ndash;3.19) and suspecting cancer (aHR 1.82, 95% CI 1.12\u0026ndash;2.97). Diagnostic interval delays included symptomatic bleeding (aHR 055, 95% CI 0.35\u0026ndash;0.85) and visiting\u0026thinsp;\u0026gt;\u0026thinsp;2 clinics (aHR 0.69, 95% CI 0.49\u0026ndash;0.97); facilitators included early-stage disease (aHR 1.41, 95% CI 1.03\u0026ndash;1.95) and direct tertiary care presentation (aHR 2.13, 95% CI 1.20\u0026ndash;3.79). Treatment interval delays included anticipating long waits (aHR 0.68, 95% CI 0.46\u0026ndash;1.02) and requiring blood transfusions (aHR 0.63, 95% CI 0.37\u0026ndash;1.07); no facilitators were identified.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe identified potentially modifiable barriers and facilitators along the cervical cancer care cascade. Interventions targeting these factors may improve care timeliness but are unlikely to significantly improve morbidity or mortality. Expanding cervical cancer screening and vaccination are of utmost importance.\u003c/p\u003e","manuscriptTitle":"Predictors of delay in the cervical cancer care cascade in Kampala, Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-18 17:56:04","doi":"10.21203/rs.3.rs-5467551/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-13T13:07:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-20T20:13:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74527340612508343502090154159471462964","date":"2025-02-19T18:06:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265777402269265700016734127010244168758","date":"2025-02-16T07:38:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-11T23:47:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70398092612584829857872146269097215837","date":"2025-02-10T20:39:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-10T15:17:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-11-18T11:20:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-18T06:47:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-18T06:46:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2024-11-16T21:25:20+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":"d2ef3426-80c9-49d7-b5fb-caf00e8c8265","owner":[],"postedDate":"December 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:13:54+00:00","versionOfRecord":{"articleIdentity":"rs-5467551","link":"https://doi.org/10.1186/s12905-026-04292-7","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2026-02-13 15:58:45","publishedOnDateReadable":"February 13th, 2026"},"versionCreatedAt":"2024-12-18 17:56:04","video":"","vorDoi":"10.1186/s12905-026-04292-7","vorDoiUrl":"https://doi.org/10.1186/s12905-026-04292-7","workflowStages":[]},"version":"v1","identity":"rs-5467551","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5467551","identity":"rs-5467551","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}