Institutional and Health System Barriers to Cervical Cancer Screening in Uganda: A Qualitative Study of Healthcare Workers' Perspectives in Greater Hoima

Institutional and Health System Barriers to Cervical Cancer Screening in Uganda: A Qualitative Study of Healthcare Workers' Perspectives in Greater Hoima | 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 Institutional and Health System Barriers to Cervical Cancer Screening in Uganda: A Qualitative Study of Healthcare Workers' Perspectives in Greater Hoima Ronald Arineitwe Kibonire, David Ditaba Mphuthi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6971025/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Introduction: Cervical cancer, a silent killer, claims far too many lives among women in Sub-Saharan Africa, including Uganda. While we often point to women's awareness or willingness as the main reasons for low screening rates, our study highlights a crucial, often overlooked, truth: the very health system itself can be a major roadblock. In Uganda, where fewer than 21% of women get screened, it's vital to understand these "supply-side" challenges to truly make a difference. Aim: Our goal was simple: to hear directly from healthcare workers in Hoima district, Uganda, about the institutional and health system issues that prevent women from getting screened for cervical cancer and stop providers from offering these vital services. Methods: We used a qualitative approach, interviewing 95 healthcare professionals nurses, midwives, clinical officers, and doctors from 20 public and private-not-for-profit health facilities across Hoima. We carefully selected facilities and participants, using semi-structured questionnaires to gather their insights. Then, we analyzed their responses to find the common themes revealing these institutional barriers. Results: What we found points to significant gaps in service provision. A major issue is the extreme centralization and scarcity of services ; shockingly, screening is only consistently available at one regional hospital for the entire district. Healthcare workers at smaller, lower-level facilities told us they simply don't have the trained staff to perform Visual Inspection with Acetic Acid (VIA). This problem is made worse by a severe lack of basic equipment and supplies , like specula and acetic acid. On top of that, staff reported an absence of supportive supervision and no clear system for referring suspected cases , making it incredibly difficult to run a proper screening program. Conclusion: Our study clearly shows that deep-seated problems within the health system and institutions are the primary reasons why cervical cancer screening isn't expanding in Hoima. Simply trying to increase demand among patients won't work if the services aren't there to meet it. To truly improve screening coverage, we must focus on bringing services closer to people, thoroughly training existing healthcare workers, and ensuring a steady supply of necessary equipment and resources. Cervical Cancer Screening Health System Barriers Institutional Factors Healthcare Workers Uganda Qualitative Research Supply-Side 1. Introduction Cervical cancer is a global health challenge, ranking as the fourth most common cancer among women worldwide, with a staggering 604,000 new cases and approximately 342,000 deaths in 2020 [ 1 , 2 ]. While it may not be a top five cancer in wealthier nations, it tragically takes the first or second spot in developing countries, especially across Sub-Saharan Africa [ 3 , 4 ]. This stark difference really drives home the vast health inequalities we face globally. Sub-Saharan Africa bears a disproportionately heavy burden of cervical cancer, largely because access to screening remains so limited [ 5 , 6 ]. Of the 48 countries in the region, cervical cancer is the leading cause of death among women in 21 of them. It's crucial to remember that nearly all cases of cervical cancer are linked to Human Papillomavirus (HPV) [ 5 ]. Uganda, our focus, is particularly affected, with an age-standardized incidence rate of 54.8 per 100,000 women and a mortality rate of 40.5 per 100,000 women [ 7 ]. This isn't just a statistic; it's a pressing public health crisis. Our limited screening programs severely hinder early detection compared to developed nations where these services are readily available [ 8 ]. The truth is, cervical cancer screening rates in Uganda are alarmingly low, with only about 20.6% of women ever having been screened [ 9 ]. This low uptake is especially concerning given that cervical cancer is now the most prevalent cancer among women in Uganda [ 7 ]. The consequences of this low screening rate are dire. It means more women are diagnosed at late stages, when treatment often becomes palliative, only managing symptoms rather than curing the disease. This perpetuates a tragic cycle of high mortality. While many studies rightly focus on what stops women from seeking screening, it's equally if not more important to look at the institutional and health system factors that prevent services from being offered in the first place. That's why our study dives deep into these "supply-side" barriers, exploring them through the eyes of the healthcare workers in Hoima district who are on the front lines. 2. Methods To understand the institutional factors impacting cervical cancer screening, we chose a health facility-based cross-sectional study design, utilizing qualitative methods. We wanted to capture rich, nuanced insights. 2.1. Study Area Our study took place in the greater Hoima region, which includes Hoima District, Kikuube district, and Hoima city, home to an estimated 653,200 people [ 10 ]. We worked with various health facilities, from the Hoima Regional Referral Hospital down to two Health Centre IVs and 17 Health Centre IIIs, to get a comprehensive picture. 2.2. Study Population and Sampling Our key informants were healthcare workers themselves. We interviewed a total of 45 health workers. We used purposive sampling to select the health facilities that would give us the best insights, and then convenience sampling to recruit the health workers who were available and willing to share their experiences. 2.2.1. Who We Included Nurses, general medical doctors, clinical officers, and midwives. Participants who were clear-headed and gave us their full consent. Only staff from public and private not-for-profit health facilities. 2.2.2. Who We Excluded Specialists at Hoima Regional Referral Hospital (like surgeons, gynecologists, and physicians). Any health workers who seemed impaired or who asked for payment to participate. 2.3. Data Collection We collected our data through interviewer-administered, semi-structured questionnaires. To make sure our questions were clear and effective, we pre-tested them with three health workers at a nearby facility a week before our main data collection began. All interviews were conducted in English by our trained research assistants. 2.4. Data Analysis We took the rich qualitative data from our open-ended questions and systematically coded it based on predefined themes. This thematic analysis approach helped us identify and organize the major institutional barriers that emerged from the health workers' perspectives. 2.5. Ethical Considerations We took ethics very seriously. We received full approval from the Institute of Health Policy and Management and the Research and Ethics Committee of International Health Sciences University under IHSU/REC/2011/022. We also got official permission from the Hoima district health officer. Most importantly, every single participant provided their informed consent before joining the study. 3. Results When we analyzed what the health workers told us, four major themes consistently emerged, painting a clear picture of the institutional barriers preventing effective cervical cancer screening in Hoima district. Theme 1: Extreme Centralization and Scarcity of Services : This was a universal complaint among our key informants: the severe lack of accessible screening services. Healthcare workers repeatedly told us that, throughout the entire district , services were officially available at just one place: the Hoima Regional Referral Hospital. This extreme centralization means that for most people, especially the 66.8% living in rural areas, screening is simply out of reach due to long travel times and high costs. Staff at Health Centre IIIs and IVs described the painful experience of having to turn away women asking about screening, because they literally had nothing to offer. Theme 2: Lack of Trained and Skilled Personnel : Across all the smaller facilities, health workers pointed to a critical shortage of skilled staff. The vast majority of nurses, midwives, and clinical officers reported having received no formal training either during their studies or on the job on how to perform cervical cancer screening, specifically using the recommended Visual Inspection with Acetic Acid (VIA) method. Many expressed a strong desire to learn but lamented that there were no training opportunities available, leaving them unable to provide this essential service. Theme 3: Inadequate Equipment, Supplies, and Infrastructure : Another recurring barrier, mentioned by almost everyone outside the regional hospital, was the complete absence of necessary equipment and supplies. Health workers listed a litany of missing basic items: vaginal speculums, acetic acid, cotton swabs, and even adequate light sources. They stressed that even if they were trained, they couldn't perform VIA without these fundamental tools. Furthermore, they highlighted the lack of private, properly equipped rooms to ensure patient dignity during examinations, seeing this as a significant structural impediment. Theme 4: Weak Health System Support and Referral Pathways : Our informants consistently described a profound lack of systemic support for cervical cancer screening. There are simply no established programs for supportive supervision or quality assurance for cervical screening at the district level. Health workers at lower-level facilities were particularly worried about the absence of clear and functional referral pathways. They questioned the ethics of screening women for a condition when there was no reliable way to refer those with positive results for further diagnosis and timely treatment, like cryotherapy, which was also unavailable locally. 4. Discussion Our study strongly suggests that the persistently low cervical cancer screening rates in Uganda, particularly in Hoima district, aren't primarily about individual women's awareness or choices. Instead, they are fundamentally driven by deep-seated health system and institutional failures. These findings echo loudly across other low-resource settings in Africa, where similar "supply-side" barriers are consistently identified as major roadblocks to effective cervical cancer control programs [ 11 , 12 , 13 ]. The extreme centralization of services that we found is a critical bottleneck. When screening is only available at one regional hospital, geographic distance and financial costs become insurmountable obstacles for most people, especially the 66.8% living in rural areas. This aligns with many studies on service accessibility in Sub-Saharan Africa, which show how centralized models disproportionately harm vulnerable populations [ 5 ]. The fact that healthcare workers at lower-level facilities (Health Centre IIIs and IVs) are forced to turn away women seeking screening powerfully illustrates the direct consequences of this centralization. Furthermore, the pervasive lack of trained health workers and the severe shortage of essential equipment and supplies at primary care facilities as so passionately reported by our informants unequivocally confirm that our current health system is profoundly ill-equipped to support any decentralized screening model. Without adequately trained staff proficient in methods like Visual Inspection with Acetic Acid (VIA) and the consistent availability of basic tools such as vaginal specula and acetic acid, cervical cancer screening remains an abstract policy goal rather than an accessible and tangible service. This reinforces the urgent call from healthcare professionals for decentralization of care and service integration to overcome such challenges [ 14 , 15 ]. The concerns raised by health workers about the absence of clear and functional referral pathways are particularly troubling. This points to a dangerously fragmented system where screening isn't properly linked into a full continuum of care. Healthcare workers rightly questioned the ethical implications of screening for a condition when there was no reliable way to refer those with positive results for further diagnosis and timely treatment, such as cryotherapy, which was also locally unavailable. This finding strongly supports the broader evidence emphasizing how crucial robust health systems are for any successful cancer control program [ 16 ]. Moreover, while exciting digital health tools, such as smartphone-based telemedicine systems, offer promising avenues for improving cervical visualization and clinical data management [ 17 ], our findings underscore that such innovations alone cannot compensate for fundamental systemic deficiencies like a lack of trained personnel or basic equipment. Similarly, efforts to boost patient demand like increasing awareness or engaging male partners will have minimal impact if the underlying health system is not adequately equipped to supply the service safely, effectively, and accessibly. Studies have identified various "client-side" barriers including lack of awareness, social stigma, and limited access [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ], but also the potential for self-sampling to enhance uptake [ 29 ]. However, these efforts are futile if the supply-side failures are not addressed first. In essence, our results powerfully argue that to truly improve cervical cancer screening in Uganda and across Africa, we need a comprehensive approach that tackles individual, community, and, most crucially, health system barriers [ 11 , 12 ]. This isn't just about good intentions; it demands significant political will and concerted effort from all stakeholders to fundamentally rethink and adequately fund our health system to support decentralized, integrated, and well-resourced screening programs [ 14 ]. 5. Conclusion The voices of healthcare workers in Hoima district reveal a stark truth: the inability to establish a functional cervical cancer screening program isn't just an oversight, it's rooted in critical institutional failings. The primary obstacles are clear: a severe lack of trained personnel, the absence of essential equipment, and the extreme centralization of services at a single, often inaccessible, point. To meaningfully boost cervical cancer screening rates and ultimately reduce mortality in this region, our policies and programmatic efforts must pivot to address these fundamental supply-side challenges. Our Recommendations : Decentralize Services : The Ministry of Health and district health authorities must work together to bring screening closer to the people by training and equipping staff at Health Centre IIIs and IVs to confidently perform VIA screening. Ensure Essential Supplies : The Ministry of need to provide the necessary equipment and establish a reliable supply chain for consumables like acetic acid. Invest in Training : Screening must be integrated into health training institution curricula to build a sustainable and skilled workforce for the future. Strengthen Referral Pathways : Establish clear referral systems and improve connections between primary facilities and treatment centers to ensure a complete and seamless continuum of care. Addressing these systemic issues is not just important; it is the absolutely essential first step toward building a resilient and equitable cervical cancer prevention program in Uganda. Declarations Ethics Approval: This research was conducted with the highest ethical standards, strictly following the guidelines of the Declaration of Helsinki. We secured full approval from the Institute of Health Policy and Management and the Research and Ethics Committee of International Health Sciences University under IHSU/REC/2011/022, and also obtained official permission from the District Health Officer of Hoima District. Consent to Participate: Every single participant in our study provided their informed consent before they were included. Their willingness to share their experiences was invaluable. Consent for Publication: We also obtained written consent from participants to use their quotes in our publications, ensuring their voices could be heard while respecting their privacy. Competing Interests: The authors declare that they have no competing interests. Our findings are presented without any conflicts of interest influencing the research. Funding: This study was conducted independently, without any financial support or funding from external sources. Author Contribution RAK was the driving force behind this study, formulating the design, overseeing data collection, conducting the analysis and interpretation, and leading the preparation and review of the manuscript as the principal investigator. DDM played a crucial collaborative role, contributing to the writing of the article, reviewing the manuscript, and providing invaluable constructive feedback for its improvement Acknowledgement The authors extend their sincere gratitude to all the healthcare professionals in Hoima district who generously participated in this study, sharing their invaluable perspectives and experiences, which were fundamental to its successful completion. We also wish to express our appreciation for the ethical oversight and approvals received from the Institute of Health Policy and Management and the Research and Ethics Committee of International Health Sciences University(currently Clerke International University), as well as the official permission granted by the District Health Officer of Hoima District to conduct this study within the region. This research was carried out independently, without any external financial support or specific funding. I also acknowledge using Gemini to proofread some sections of my manuscript to ensure a proper grammar and spelling check. Availability of Data and Materials: The core documents of our study, including detailed information and the dataset used for this research, are available upon request from the corresponding author. We believe in transparency and open access to data where appropriate. References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. Cancer J Clin. 2021;71(3):209–49. World Health Organization. (2024). Cervical cancer . Geneva: World Health Organization. [cited 2024 Jan 10]. Available from: https://www.who.int/news-room/fact-sheets/detail/cervical-cancer Hull R, Mbele M, Makhafola T, Hicks C, Wang SM, Reis RM, Mehrotra R, Mkhize-Kwitshana Z, Kibiki G, Bates DO, Dlamini Z. Cervical cancer in low and middle-income countries. 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Fru CN, Andrew T, Cho FN, Tassang T, Fru PN. Socio-economic determinants influencing cervical cancer screening in Buea: a cross-sectional study. Int J Trop Disease Health. 2020;41(11):14–22. Gemeda EY, Kare BB, Negera DG, Bona LG, Derese BD, Akale NB, Kebede KM, Koboto DD, Tekle AG. Prevalence and predictor of cervical cancer screening service uptake among women aged 25 years and above in Sidama Zone, Southern Ethiopia, Using Health Belief Model. Cancer Control. 2020;27(1):1073274820954460. Gizaw AT, El-Khatib Z, Wolancho W, Amdissa D, Bamboro S, Boltena MT, Appiah SC, Asamoah BO, Wasihun Y, Tareke KG. Uptake of cervical cancer screening and its predictors among women of reproductive age in Gomma district, Southwest Ethiopia: a community-based cross-sectional study. Infect Agents Cancer. 2022;17(1):43. Kaneko N. Factors associated with cervical cancer screening among young unmarried Japanese women: results from an internet-based survey. BMC Womens Health. 2018;18(1):1–9. Manikandan S, Behera S, Naidu NM, Angamuthu V, Mohammed OF, Debata A. Knowledge and awareness toward cervical cancer screening and prevention among the professional college female students. J Pharm Bioallied Sci. 2019;11(Suppl 2):S314–20. Nwabichie CC, Manaf RA, Ismail SB. Factors Affecting Uptake of Cervical Cancer Screening Among African Women in Klang Valley, Malaysia. Asian Pac J Cancer Prev. 2018;19(3):825–31. Vega Crespo B, Neira VA, Ortíz Segarra J, Andrade A, Guerra G, Ortiz S, Flores A, Mora L, Verhoeven V, Gama A, Dias S, Verberckmoes B, Vermandere H, Michelsen K, Degomme O. Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals. BMC Public Health. 2022;22(1):1017. Yimer NB, Mohammed MA, Solomon K, Tadese M, Grutzmacher S, Meikena HK, Alemnew B, Sharew NT, Habtewold TD. Cervical cancer screening uptake in Sub-Saharan Africa: a systematic review and meta-analysis. Public Health. 2021;195:105–11. Dzobo M, Dzinamarira T, Jaya Z, Kgarosi K, Mashamba-Thompson T. (2024). Experiences and perspectives regarding human papillomavirus self-sampling in sub-Saharan Africa: A systematic review of qualitative evidence. Heliyon, 10(1), e23467. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Sep, 2025 Reviews received at journal 06 Sep, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviews received at journal 27 Aug, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers invited by journal 25 Aug, 2025 Editor assigned by journal 27 Jun, 2025 Submission checks completed at journal 27 Jun, 2025 First submitted to journal 25 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Introduction","content":"\u003cp\u003eCervical cancer is a global health challenge, ranking as the fourth most common cancer among women worldwide, with a staggering 604,000 new cases and approximately 342,000 deaths in 2020 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While it may not be a top five cancer in wealthier nations, it tragically takes the first or second spot in developing countries, especially across Sub-Saharan Africa [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This stark difference really drives home the vast health inequalities we face globally.\u003c/p\u003e\u003cp\u003eSub-Saharan Africa bears a disproportionately heavy burden of cervical cancer, largely because access to screening remains so limited [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Of the 48 countries in the region, cervical cancer is the leading cause of death among women in 21 of them. It's crucial to remember that nearly all cases of cervical cancer are linked to Human Papillomavirus (HPV) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eUganda, our focus, is particularly affected, with an age-standardized incidence rate of 54.8 per 100,000 women and a mortality rate of 40.5 per 100,000 women [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This isn't just a statistic; it's a pressing public health crisis. Our limited screening programs severely hinder early detection compared to developed nations where these services are readily available [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The truth is, cervical cancer screening rates in Uganda are alarmingly low, with only about 20.6% of women ever having been screened [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This low uptake is especially concerning given that cervical cancer is now the most prevalent cancer among women in Uganda [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe consequences of this low screening rate are dire. It means more women are diagnosed at late stages, when treatment often becomes palliative, only managing symptoms rather than curing the disease. This perpetuates a tragic cycle of high mortality. While many studies rightly focus on what stops women from seeking screening, it's equally if not more important to look at the institutional and health system factors that prevent services from being offered in the first place. That's why our study dives deep into these \"supply-side\" barriers, exploring them through the eyes of the healthcare workers in Hoima district who are on the front lines.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eTo understand the institutional factors impacting cervical cancer screening, we chose a health facility-based cross-sectional study design, utilizing qualitative methods. We wanted to capture rich, nuanced insights.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study Area\u003c/h2\u003e\u003cp\u003eOur study took place in the greater Hoima region, which includes Hoima District, Kikuube district, and Hoima city, home to an estimated 653,200 people [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. We worked with various health facilities, from the Hoima Regional Referral Hospital down to two Health Centre IVs and 17 Health Centre IIIs, to get a comprehensive picture.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Study Population and Sampling\u003c/h2\u003e\u003cp\u003eOur key informants were healthcare workers themselves. We interviewed a total of 45 health workers. We used purposive sampling to select the health facilities that would give us the best insights, and then convenience sampling to recruit the health workers who were available and willing to share their experiences.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\u003ch2\u003e2.2.1. Who We Included\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eNurses, general medical doctors, clinical officers, and midwives.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eParticipants who were clear-headed and gave us their full consent.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eOnly staff from public and private not-for-profit health facilities.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e2.2.2. Who We Excluded\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSpecialists at Hoima Regional Referral Hospital (like surgeons, gynecologists, and physicians).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAny health workers who seemed impaired or who asked for payment to participate.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Data Collection\u003c/h2\u003e\u003cp\u003eWe collected our data through interviewer-administered, semi-structured questionnaires. To make sure our questions were clear and effective, we pre-tested them with three health workers at a nearby facility a week before our main data collection began. All interviews were conducted in English by our trained research assistants.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Data Analysis\u003c/h2\u003e\u003cp\u003eWe took the rich qualitative data from our open-ended questions and systematically coded it based on predefined themes. This thematic analysis approach helped us identify and organize the major institutional barriers that emerged from the health workers' perspectives.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.5. Ethical Considerations\u003c/h2\u003e\u003cp\u003eWe took ethics very seriously. We received full approval from the Institute of Health Policy and Management and the Research and Ethics Committee of International Health Sciences University under IHSU/REC/2011/022. We also got official permission from the Hoima district health officer. Most importantly, every single participant provided their informed consent before joining the study.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eWhen we analyzed what the health workers told us, four major themes consistently emerged, painting a clear picture of the institutional barriers preventing effective cervical cancer screening in Hoima district.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 1: Extreme Centralization and Scarcity of Services\u003c/b\u003e: This was a universal complaint among our key informants: the severe lack of accessible screening services. Healthcare workers repeatedly told us that, throughout the \u003cem\u003eentire district\u003c/em\u003e, services were officially available at just one place: the Hoima Regional Referral Hospital. This extreme centralization means that for most people, especially the 66.8% living in rural areas, screening is simply out of reach due to long travel times and high costs. Staff at Health Centre IIIs and IVs described the painful experience of having to turn away women asking about screening, because they literally had nothing to offer.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2: Lack of Trained and Skilled Personnel\u003c/b\u003e: Across all the smaller facilities, health workers pointed to a critical shortage of skilled staff. The vast majority of nurses, midwives, and clinical officers reported having received \u003cem\u003eno formal training\u003c/em\u003e either during their studies or on the job on how to perform cervical cancer screening, specifically using the recommended Visual Inspection with Acetic Acid (VIA) method. Many expressed a strong desire to learn but lamented that there were no training opportunities available, leaving them unable to provide this essential service.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 3: Inadequate Equipment, Supplies, and Infrastructure\u003c/b\u003e: Another recurring barrier, mentioned by almost everyone outside the regional hospital, was the complete absence of necessary equipment and supplies. Health workers listed a litany of missing basic items: vaginal speculums, acetic acid, cotton swabs, and even adequate light sources. They stressed that even if they \u003cem\u003ewere\u003c/em\u003e trained, they couldn't perform VIA without these fundamental tools. Furthermore, they highlighted the lack of private, properly equipped rooms to ensure patient dignity during examinations, seeing this as a significant structural impediment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 4: Weak Health System Support and Referral Pathways\u003c/b\u003e: Our informants consistently described a profound lack of systemic support for cervical cancer screening. There are simply no established programs for supportive supervision or quality assurance for cervical screening at the district level. Health workers at lower-level facilities were particularly worried about the absence of clear and functional referral pathways. They questioned the ethics of screening women for a condition when there was no reliable way to refer those with positive results for further diagnosis and timely treatment, like cryotherapy, which was also unavailable locally.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eOur study strongly suggests that the persistently low cervical cancer screening rates in Uganda, particularly in Hoima district, aren't primarily about individual women's awareness or choices. Instead, they are fundamentally driven by deep-seated health system and institutional failures. These findings echo loudly across other low-resource settings in Africa, where similar \"supply-side\" barriers are consistently identified as major roadblocks to effective cervical cancer control programs [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe extreme centralization of services that we found is a critical bottleneck. When screening is only available at one regional hospital, geographic distance and financial costs become insurmountable obstacles for most people, especially the 66.8% living in rural areas. This aligns with many studies on service accessibility in Sub-Saharan Africa, which show how centralized models disproportionately harm vulnerable populations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The fact that healthcare workers at lower-level facilities (Health Centre IIIs and IVs) are forced to turn away women seeking screening powerfully illustrates the direct consequences of this centralization.\u003c/p\u003e\u003cp\u003eFurthermore, the pervasive lack of trained health workers and the severe shortage of essential equipment and supplies at primary care facilities as so passionately reported by our informants unequivocally confirm that our current health system is profoundly ill-equipped to support any decentralized screening model. Without adequately trained staff proficient in methods like Visual Inspection with Acetic Acid (VIA) and the consistent availability of basic tools such as vaginal specula and acetic acid, cervical cancer screening remains an abstract policy goal rather than an accessible and tangible service. This reinforces the urgent call from healthcare professionals for decentralization of care and service integration to overcome such challenges [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe concerns raised by health workers about the absence of clear and functional referral pathways are particularly troubling. This points to a dangerously fragmented system where screening isn't properly linked into a full continuum of care. Healthcare workers rightly questioned the ethical implications of screening for a condition when there was no reliable way to refer those with positive results for further diagnosis and timely treatment, such as cryotherapy, which was also locally unavailable. This finding strongly supports the broader evidence emphasizing how crucial robust health systems are for any successful cancer control program [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMoreover, while exciting digital health tools, such as smartphone-based telemedicine systems, offer promising avenues for improving cervical visualization and clinical data management [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], our findings underscore that such innovations alone cannot compensate for fundamental systemic deficiencies like a lack of trained personnel or basic equipment. Similarly, efforts to boost patient demand like increasing awareness or engaging male partners will have minimal impact if the underlying health system is not adequately equipped to supply the service safely, effectively, and accessibly. Studies have identified various \"client-side\" barriers including lack of awareness, social stigma, and limited access [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], but also the potential for self-sampling to enhance uptake [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, these efforts are futile if the supply-side failures are not addressed first.\u003c/p\u003e\u003cp\u003eIn essence, our results powerfully argue that to truly improve cervical cancer screening in Uganda and across Africa, we need a comprehensive approach that tackles individual, community, and, most crucially, health system barriers [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This isn't just about good intentions; it demands significant political will and concerted effort from all stakeholders to fundamentally rethink and adequately fund our health system to support decentralized, integrated, and well-resourced screening programs [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe voices of healthcare workers in Hoima district reveal a stark truth: the inability to establish a functional cervical cancer screening program isn't just an oversight, it's rooted in critical institutional failings. The primary obstacles are clear: a severe lack of trained personnel, the absence of essential equipment, and the extreme centralization of services at a single, often inaccessible, point. To meaningfully boost cervical cancer screening rates and ultimately reduce mortality in this region, our policies and programmatic efforts must pivot to address these fundamental supply-side challenges.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOur Recommendations\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDecentralize Services\u003c/b\u003e: The Ministry of Health and district health authorities must work together to bring screening closer to the people by training and equipping staff at Health Centre IIIs and IVs to confidently perform VIA screening.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEnsure Essential Supplies\u003c/b\u003e: The Ministry of need to provide the necessary equipment and establish a reliable supply chain for consumables like acetic acid.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInvest in Training\u003c/b\u003e: Screening must be integrated into health training institution curricula to build a sustainable and skilled workforce for the future.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eStrengthen Referral Pathways\u003c/b\u003e: Establish clear referral systems and improve connections between primary facilities and treatment centers to ensure a complete and seamless continuum of care.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eAddressing these systemic issues is not just important; it is the absolutely essential first step toward building a resilient and equitable cervical cancer prevention program in Uganda.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval:\u003c/strong\u003e\u003cp\u003e This research was conducted with the highest ethical standards, strictly following the guidelines of the Declaration of Helsinki. We secured full approval from the Institute of Health Policy and Management and the Research and Ethics Committee of International Health Sciences University under IHSU/REC/2011/022, and also obtained official permission from the District Health Officer of Hoima District.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003e\u003cp\u003e Every single participant in our study provided their informed consent before they were included. Their willingness to share their experiences was invaluable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003cp\u003eWe also obtained written consent from participants to use their quotes in our publications, ensuring their voices could be heard while respecting their privacy.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests:\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests. Our findings are presented without any conflicts of interest influencing the research.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis study was conducted independently, without any financial support or funding from external sources.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRAK was the driving force behind this study, formulating the design, overseeing data collection, conducting the analysis and interpretation, and leading the preparation and review of the manuscript as the principal investigator. DDM played a crucial collaborative role, contributing to the writing of the article, reviewing the manuscript, and providing invaluable constructive feedback for its improvement\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors extend their sincere gratitude to all the healthcare professionals in Hoima district who generously participated in this study, sharing their invaluable perspectives and experiences, which were fundamental to its successful completion. We also wish to express our appreciation for the ethical oversight and approvals received from the Institute of Health Policy and Management and the Research and Ethics Committee of International Health Sciences University(currently Clerke International University), as well as the official permission granted by the District Health Officer of Hoima District to conduct this study within the region. This research was carried out independently, without any external financial support or specific funding. I also acknowledge using Gemini to proofread some sections of my manuscript to ensure a proper grammar and spelling check.\u003c/p\u003e\u003ch2\u003eAvailability of Data and Materials:\u003c/h2\u003e\u003cp\u003eThe core documents of our study, including detailed information and the dataset used for this research, are available upon request from the corresponding author. We believe in transparency and open access to data where appropriate.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. Cancer J Clin. 2021;71(3):209\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 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Factors associated with cervical cancer screening uptake: implications for the health of women in Jordan. \u003cem\u003eInfectious Diseases in Obstetrics and Gynecology\u003c/em\u003e, \u003cem\u003e2020\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmin R, Kolahi AA, Jahanmehr N, Abadi AR, Sohrabi MR. Disparities in cervical cancer screening participation in Iran: a cross-sectional analysis of the 2016 nationwide STEPS survey. BMC Public Health. 2020;20(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFru CN, Andrew T, Cho FN, Tassang T, Fru PN. Socio-economic determinants influencing cervical cancer screening in Buea: a cross-sectional study. Int J Trop Disease Health. 2020;41(11):14\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGemeda EY, Kare BB, Negera DG, Bona LG, Derese BD, Akale NB, Kebede KM, Koboto DD, Tekle AG. Prevalence and predictor of cervical cancer screening service uptake among women aged 25 years and above in Sidama Zone, Southern Ethiopia, Using Health Belief Model. Cancer Control. 2020;27(1):1073274820954460.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGizaw AT, El-Khatib Z, Wolancho W, Amdissa D, Bamboro S, Boltena MT, Appiah SC, Asamoah BO, Wasihun Y, Tareke KG. Uptake of cervical cancer screening and its predictors among women of reproductive age in Gomma district, Southwest Ethiopia: a community-based cross-sectional study. Infect Agents Cancer. 2022;17(1):43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaneko N. Factors associated with cervical cancer screening among young unmarried Japanese women: results from an internet-based survey. BMC Womens Health. 2018;18(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eManikandan S, Behera S, Naidu NM, Angamuthu V, Mohammed OF, Debata A. Knowledge and awareness toward cervical cancer screening and prevention among the professional college female students. J Pharm Bioallied Sci. 2019;11(Suppl 2):S314\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNwabichie CC, Manaf RA, Ismail SB. Factors Affecting Uptake of Cervical Cancer Screening Among African Women in Klang Valley, Malaysia. Asian Pac J Cancer Prev. 2018;19(3):825\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVega Crespo B, Neira VA, Ort\u0026iacute;z Segarra J, Andrade A, Guerra G, Ortiz S, Flores A, Mora L, Verhoeven V, Gama A, Dias S, Verberckmoes B, Vermandere H, Michelsen K, Degomme O. Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals. BMC Public Health. 2022;22(1):1017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYimer NB, Mohammed MA, Solomon K, Tadese M, Grutzmacher S, Meikena HK, Alemnew B, Sharew NT, Habtewold TD. Cervical cancer screening uptake in Sub-Saharan Africa: a systematic review and meta-analysis. Public Health. 2021;195:105\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDzobo M, Dzinamarira T, Jaya Z, Kgarosi K, Mashamba-Thompson T. (2024). Experiences and perspectives regarding human papillomavirus self-sampling in sub-Saharan Africa: A systematic review of qualitative evidence. Heliyon, 10(1), e23467.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cervical Cancer Screening, Health System Barriers, Institutional Factors, Healthcare Workers, Uganda, Qualitative Research, Supply-Side","lastPublishedDoi":"10.21203/rs.3.rs-6971025/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6971025/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eCervical cancer, a silent killer, claims far too many lives among women in Sub-Saharan Africa, including Uganda. While we often point to women's awareness or willingness as the main reasons for low screening rates, our study highlights a crucial, often overlooked, truth: the very health system itself can be a major roadblock. In Uganda, where fewer than 21% of women get screened, it's vital to understand these \"supply-side\" challenges to truly make a difference.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim: \u003c/strong\u003eOur goal was simple: to hear directly from healthcare workers in Hoima district, Uganda, about the institutional and health system issues that prevent women from getting screened for cervical cancer and stop providers from offering these vital services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe used a qualitative approach, interviewing 95 healthcare professionals nurses, midwives, clinical officers, and doctors from 20 public and private-not-for-profit health facilities across Hoima. We carefully selected facilities and participants, using semi-structured questionnaires to gather their insights. Then, we analyzed their responses to find the common themes revealing these institutional barriers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWhat we found points to significant gaps in service provision. A major issue is the extreme \u003cstrong\u003ecentralization and scarcity of services\u003c/strong\u003e; shockingly, screening is only consistently available at one regional hospital for the entire district. Healthcare workers at smaller, lower-level facilities told us they simply don't have the \u003cstrong\u003etrained staff\u003c/strong\u003e to perform Visual Inspection with Acetic Acid (VIA). This problem is made worse by a severe \u003cstrong\u003elack of basic equipment and supplies\u003c/strong\u003e, like specula and acetic acid. On top of that, staff reported an absence of \u003cstrong\u003esupportive supervision\u003c/strong\u003e and no clear system for \u003cstrong\u003ereferring suspected cases\u003c/strong\u003e, making it incredibly difficult to run a proper screening program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eOur study clearly shows that deep-seated problems within the health system and institutions are the primary reasons why cervical cancer screening isn't expanding in Hoima. Simply trying to increase demand among patients won't work if the services aren't there to meet it. To truly improve screening coverage, we must focus on bringing services closer to people, thoroughly training existing healthcare workers, and ensuring a steady supply of necessary equipment and resources.\u003c/p\u003e","manuscriptTitle":"Institutional and Health System Barriers to Cervical Cancer Screening in Uganda: A Qualitative Study of Healthcare Workers' Perspectives in Greater Hoima","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-02 17:08:27","doi":"10.21203/rs.3.rs-6971025/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-09T10:30:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-06T18:08:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"241150732511002802715407068961980488230","date":"2025-08-27T18:56:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-27T11:01:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2086405642274605551371878317738790633","date":"2025-08-27T09:31:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-25T12:37:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-27T05:27:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-27T05:27:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Health Systems","date":"2025-06-25T06:05:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"58060162-15c5-4706-b332-e8ab5e5d3f30","owner":[],"postedDate":"September 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T09:32:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-02 17:08:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6971025","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6971025","identity":"rs-6971025","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}