Utility of colposcopy for the screening and management of cervical cancer in Africa: a cross-sectional analysis of providers’ training and practices

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The success of screening programs depends on the appropriate investigation and management of women who test positive for screening. Colposcopic assessment following positive screening results is a noteworthy issue in Africa. This study aimed to assess the utilization of colposcopy by providers in the region. Methods : A cross-sectional study was conducted in 2021-2022 among healthcare providers involved in cervical cancer prevention activities in Africa. They were invited to report prior colposcopy training, whether they performed colposcopy and the indications of colposcopy in their practice. Results: Of the 130 providers from 23 African countries who responded to the survey (mean age [SD]: 39.0 years [9.4]), half were female (65 [50.0%]), and 90.7% were working in urban areas. Overall, only 12.6% of respondents indicated having received prior training on colposcopy, and 11.7% reported that they were performing colposcopy in their current practice. Among the providers who reported performing colposcopy in their practice, colposcopy was indicated for routine visual screening in 21.2% of clinicians, to visualize the transformation zone in 15.2% of respondents, to assess vascularization of cervical mucosa in 33.3% of respondents, and to determine treatment modality in 12.1% of respondents. Conclusion : Providers’ training and utilization of colposcopy for cervical cancer screening remain suboptimal in Africa. To increase utilization of colposcopy in the region, further training is needed to improve providers' knowledge and engagement. With the development of lower-cost and portable colposcopes, efforts to equip cervical cancer prevention programs and facilities with colposcopy should be enhanced to ensure that women can be screened and managed appropriately in the clinical setting and communities. colposcopy cervical cancer cervical cancer screening early detection transformation zone visualization healthcare providers Africa Figures Figure 1 Introduction Assessing women presenting with positive cervical screening results and selecting those suitable for immediate therapy usually relies on the colposcopic assessment of the transformation zone to visualize and characterize cervical epithelium and guide biopsies. 1 In the standard practice, colposcopy guidance is required to perform excision of transformation zone for treatment of high grade cervical precancers. Thus, colposcopy is an essential part of an effective cervical cancer prevention program. A major challenge to the successful implementation of cervical cancer prevention activities is the lack of colposcopy utilization following positive screening results. Women’s participation in the entire cervical screening process has been assessed in several studies and barriers to access colposcopy services have been reported. 2 – 4 Various health systems and patient factors influence access to colposcopy in low and middle-income countries (LMICs). System barriers include a limited number of colposcopy services, which are mostly found in tertiary-level facilities, with long waiting times for patients and few opportunities for non-specialist clinicians to develop the required skills. 5 The limited numbers of specialist gynecologists, coupled with the high demands on these doctors for emergency and obstetrical and gynecology services, results in lesser time available for diagnostic or non-urgent procedures like colposcopy. 6 A colposcope is a binocular telescope used to directly visualize the cervical mucosa under a good light source. Since it was invented in 1925, 7 it has undergone modifications to improve its diagnostic accuracy and make it more suited to settings with poor health infrastructures. Traditionally, the colposcope has been developed as an optical diagnostic instrument designed for specialists in higher-level healthcare facilities and requires a minimum infrastructure (electricity, examination room, etc) to operate. In recent years, high-resolution images taken with digital cameras have improved the detection of cervical lesions and enabled images to be shared between senior colposcopists and less experienced ones. 8 Digital colposcopy has several advantages (including cost, portability, and ease of use) that make it more adapted to LMICs compared to its optical counterpart or traditional colposcopes. In LMICs, the need to create more opportunities for cancer care is growing considering the lack of specialist services and other constraints. 9 Primary healthcare professionals (PHPs) in these settings act as frontline providers in delivering preventive services, including cervical cancer prevention. They strengthen the coordination of care and educate patient using culturally adapted interventions. 10 Not only they assist women in the screening procedure, but also, they support those with abnormal results by offering them post-screening counseling and management. The contribution of PHPs in addressing cervical cancer has been highlighted in LMICs. 10 In the innovative approach developed by our team, hands-on training 11 is combined with distant learning through the use of a practical and low-cost tele-mentoring tool (the Project ECHO) aimed at sharing best care practices. In this model, PHPs diagnose and manage patients with the assistance of specialists who act as mentors and provide feedback, guidance, and didactical training. 10 , 12 Using this approach, PHPs are equipped with the skills, self-confidence, and knowledge to manage cervical pre-invasive or early-invasive disease. This reduces travel time, wait time, costs, and complications stemming from these delays. With this tele-mentoring model, PHPs retain their duty of care to patients as their competencies and independence build up, which reduces referral rates and improves patients’ outcomes. 10 Despite logistical and technological advances aimed at making colposcopy more accessible to LMICs, little is known about African providers’ training and knowledge of the utility of colposcopy. Thus, the present study aims to describe the utilization of colposcopy by PHPs involved in cervical cancer prevention activities in Africa. Methods Study population and study design The study population consisted of African-based clinicians involved in cervical cancer prevention activities from 23 African countries who were enrolled in a distance learning program focusing on cervical cancer and other HPV-related anogenital diseases. 12 In 2022, providers were invited to take an online survey (in English or French) to assess their training, knowledge, and attitudes toward cervical cancer screening and management of pre-invasive lesions, including the use of colposcopy. The questionnaire was pre-tested and validated before being administered to the target population. This was done in two steps: In the first step, after developing the survey tool, we shared it with 4 experts to get their feedback and remarks regarding content validity. Suggestions from these experts were then incorporated into the survey tool. In a second step, the self-administered survey was pilot-tested with a convenience sample of 20 individuals of varying healthcare provider professions based in Africa to ensure clarity of questions and ease of administration. Further comments from this set of HCPs were accounted for in the final revision of the questionnaire. Participation was anonymous and voluntary, and refusal to take the survey had no consequence on participation in the distance learning program. A detailed description of the survey design, content, and administration has been published elsewhere. 10 Measures Outcome measures We assessed whether African-based providers involved in cervical cancer prevention activities performed colposcopy in their practice using the following questions related to optical or digital colposcopy. "Do you currently perform colposcopy in your practice?" If the answer to this question was "yes," two follow-up questions were asked: "How many times have you performed colposcopy in the last 6 months?". In those who reported performing colposcopy in their practice, we also asked the question: “For what purpose do you use a colposcope?”, and the possible responses to this question were: “For routine visual screening," "To better visualize cervical mucosa," "To visualize the transformation zone," "To assess vascularization of the cervical mucosa," "To determine treatment modality in screen-positive women." Multiple responses were allowed for this question. Additional variables Prior training on colposcopy was assessed with the following question: "Have you previously had formal training in performing colposcopy?" (Yes/No). To better describe the study population, we collected the following socio-demographic variables: age (years), gender (Male/Female), and location according to the United Nation's classification of African regions (Eastern Africa, Middle Africa, Western Africa, Southern Africa, and Northern Africa), and setting (urban/rural). Providers were also classified according to their educational background into doctors/residents (including family medicine physicians, internists, obstetricians-gynecologists, oncologists, pediatricians, surgeons, pathologists, etc.), and nurses (including midwives). In addition to these variables, self-reported knowledge about colposcopy was assessed with the following statement: "My knowledge about colposcopy is adequate for my current practice." Possible responses to this statement included: "Agree," "Disagree," "Neither Agree nor Disagree," and "I don't know." Statistical analysis The descriptive statistical analyses, prevalence, and associated confidence intervals were obtained using statistical analysis software The SAS (v9.4). Ethics approval This research conformed to the principles embodied in the Declaration of Helsinki. All participants provided written informed consent. The study protocol was approved by the University of Texas MD Anderson Cancer Center’s IRB. Results Characteristics of the study population 153 healthcare professionals from Africa completed the survey, including 23 non-clinicians. Among the 130 respondents who were clinicians (mean age [SD]: 39.0 years [9.4]), half were female (65 [50.0%]), and 90.7% were working in urban areas. Participants were from 23 African countries, including 12 providers (9.2%) from Eastern Africa, 58 (44.6%) from Middle Africa, 6 (4.6%) from Northern Africa, 5 (3.8%) from Southern Africa, and 49 (37.7%) from Western Africa. (Table 1 ) Table 1 Characteristics of the study sample Variables n % 95%CI Age (years) 20–29 22 16.9 10.4 23.5 30–39 59 45.4 36.7 54.1 40–49 26 20.0 13.0 27.0 50–69 23 17.7 11.0 24.3 gender Female 65 50.0 41.3 58.7 Male 65 50.0 41.3 58.7 Facility type Primary 28 24.3 16.4 32.3 Secondary 18 15.7 8.9 22.4 Tertiary 46 40.0 30.9 49.1 Other 23 20.0 12.6 27.4 setting Urban 97 90.7 85.0 96.3 Rural 10 9.3 3.7 15.0 HCP type Doctor/Resident 103 79.2 72.2 86.3 Nurse/Midwife 27 20.8 13.7 27.8 African Region Eastern Africa 12 9.2 4.2 14.3 Middle Africa 58 44.6 36.0 53.3 Northern Africa 6 4.6 1.0 8.3 Southern Africa 5 3.8 0.5 7.2 Western Africa 49 37.7 29.3 46.1 Training, practice, and indications of colposcopy We assessed providers' prior training and practices regarding colposcopy (Table 2 ). Only 12.6% of respondents indicated having received prior training on colposcopy, and 11.7% reported that they were performing colposcopy in their current practice. Table 2 Training, self-reported knowledge and practice of colposcopy by African providers Variables n % 95% CI Have you previously had formal training in performing colposcopy using a colposcope? Yes 14 12.6 6.3 18.9 No 97 87.4 81.1 93.7 Do you currently perform colposcopy with a colposcope in your practice? Yes 13 11.7 5.6 17.8 No 98 88.3 82.2 94.4 My knowledge about colposcopy is adequate for my current practice Agree 46 50.0 39.6 60.4 Neither agree nor disagree 13 14.1 6.9 21.4 Disagree 33 35.9 25.9 45.9 Among providers who reported performing colposcopy in their practice, colposcopy was indicated for routine visual screening in 21.2% of clinicians, to visualize the transformation zone in 15.2% of respondents, to assess vascularization of cervical mucosa in 33.3% of respondents, and to determine treatment modality in 12.1% of respondents. (Fig. 1 ) In this group, the median number of colposcopies performed in the last 6 months was 30 (Interquartile range: 19–65). Perceived knowledge about colposcopy Providers were also asked if their knowledge about colposcopy was adequate for their current practice. Of the 92 providers who responded to this question, half (50.0%) agreed with this statement (Table 2 ). Discussion Colposcopy is a critical triaging investigation in the assessment, diagnosis, and management of women with positive cervical screening tests. 13 However, colposcopy typically is not available in a primary care setting, and in many LMICs, the alternative is to visualize the cervix with the naked eye after application of acetic acid and Lugol’s iodine, which may result in missed diagnoses. 14 , 15 Indeed, the sensitivity of triaging with VIA/VILI in detecting high-grade cervical lesions among HPV-positive women has been reportedly suboptimal. 15 , 16 A key role of colposcopy in cervical screening continuum is assessing the type of transformation zone and guiding treatment. Studies have reported higher residual disease after excisional treatment (positive excision margin) when treatment was performed without colposcopic guidance. 17 , 18 Further, colposcopy evaluation of screen-positive women has proven to reduce the rate of overtreatment, thereby increasing the effectiveness of screening programs. 19 , 20 Limited resource settings should be enhanced to provide quality healthcare, particularly when specialized physicians are lacking. Priority interventions include task-shifting and provision of more simple and cost-effective equipment for diagnosis and management of conditions of public health concern. Our findings that 12.6% of clinicians involved in cervical cancer prevention activities in Africa had been trained at performing colposcopy highlight the lack of skilled colposcopists in the region. While organizing colposcopy training courses is an effective way to strengthen the diagnostic ability of colposcopists, 11 setting-up these courses in practice may be challenging and difficult to scale. Therefore, distant continuing educational programs where expert colposcopists review cervical images of women screened for cervical cancer provide an opportunity for providers in LMICs to increase their experience and competence in accurately performing colposcopy. 10 , 12 While harmonized diagnostic standards and quality control procedures for colposcopy practice are released by relevant professional organizations, 13 many colposcopists in LMICs, because they lack adequate training, do not rigorously apply colposcopy guidelines in their practice, which leads to unharmonized reporting of colposcopy examinations. The clinical performance of colposcopy depends on the training and experience of colposcopists and the clinical setting, from basic to referral facilities. 21 When practiced by competent hands, colposcopy is more accurate and may barely miss severe disease, while it can lead to false-positive results when performed by less experienced providers. These weaknesses of colposcopy can be overcome by adequate training, continuing practice, and quality assessment. 10 , 22 Although only one in eight clinicians in our study sample had been trained to perform colposcopy, 50% of respondents reported that their knowledge about colposcopy was adequate for their clinical practice. This finding suggests that colposcopy is not considered by many African providers as a procedure that requires specific training, which is a matter of concern as it may have implications on the effectiveness of cervical cancer prevention programs in LMICs. The use of digital colposcopes as an alternative to optic colposcopes may help improve access to cervical cancer screening and early detection. 23 Previous studies found that certain digital colposcopes perform comparably to stationary colposcopes, 24 including when performed by mid-level providers like nurses. 25 , 26 While the feasibility and accuracy of portable colposcopes in LMICs have been reported, their effectiveness in routine clinical practice is yet to be proven, especially to triage HPV positive women. 27 , 28 The relevance of building capacity to perform colposcopy in African countries with high HIV prevalence has significantly increased after the publication by the World Health Organization (WHO) in 2021, of the new guidelines for cervical cancer screening and management. 29 This guideline recommended that all women living with HIV and tested positive for HPV require triaging with VIA, cytology, or colposcopy. In our model, frontline clinicians (including nurses) are trained to perform VIA and basic colposcopy. 10 , 11 Colposcopy in our study sample was used for routine cervical screening, to better visualize the transformation zone, and to determine treatment modality in screen-positive women. The practicability of colposcopy performed by trained PHPs using a portable colposcope implies that more women in LMICs can access colposcopy, especially in remote areas. Considering the dearth of providers skilled to perform colposcopy in Africa, a strategy with HPV testing followed by optic colposcopy may result in delays in early detection and increase the risk of lost-to-follow up. Therefore, portable colposcopy performed by trained nurses can be offered in the same setting where HPV testing is done and much earlier than a referral to a physician. While colposcopy practice has been limited to medical doctors in most LMICs, our experience shows that PHPs supervised by experienced gynecologists can perform colposcopy with little side effects. 10 , 11 In our program, capturing of cervical images with colposcopes and other digital equipment helps train PHPs through e-learning sessions (case-based presentation complemented by the review of cervigrams). Moreover, colposcopy with portable devices can be performed during outreaches and generate images that can be used for quality assurance. Quality assurance is critical to the effectiveness of a cervical cancer screening program. We employ a collaborative approach for quality assurance through regular meetings in which in-house and external experts discuss cases with attending providers. 10 Adding quality assurance review by specialists using colposcopy has been reported to improve the diagnostic accuracy of VIA. 30 PHPs in more remote facilities can also engage with expert colposcopists through anonymized cervigrams on social media platforms, and colposcopic images can be uploaded to the cloud for quality assurance assessment. This facilitates timely consultation with a distant colposcopist while the patient is still in the healthcare facility and reinforces quality control. 31 , 32 Artificial intelligence (AI) as an adjunct to colposcopy has raised concerns about the importance of training PHPs in basic colposcopy. Introducing AI-based evaluation and interpretation of cervigrams may reduce the learning curves for PHPs in performing colposcopy. While AI is expected to assist less skilled PHPs in providing more accurate diagnosis 33 , 34 , follow-up, and treatment of precancerous lesions of the cervix, its use will still require hands-on training and skilled providers. There were limitations to this study. First, most respondents to the survey were clinicians working in urban settings, suggesting that our findings may not representatively reflect colposcopy practices among providers living in rural areas. Second, respondents were selected among clinicians invited to attend a continuing education e-learning program aimed at building the capacity of African providers in the field of cervical cancer prevention and management, and the survey was administered online. As a result, providers in areas with limited internet penetration were underrepresented in our study sample. Conclusion Despite a high incidence of cervical cancer in Africa, provider training, self-reported knowledge, and utilization of colposcopy for cervical cancer screening remain suboptimal. To increase access to colposcopy in the region, further training is needed to improve providers' knowledge and engagement. With the development of lower-cost and portable colposcopes, efforts to equip cervical cancer prevention programs, and facilities with colposcopy should be enhanced to ensure that women can be screened and followed up adequately. Declarations Author Contribution JF: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing – original draft. ID: Project administration, Writing – review & editing. FG: Project administration, Writing – review & editing. SK: Writing – review & editing. CB: Writing – review & editing. NM: Project administration, Writing – review & editing. EG: Project administration, Writing – review & editing. NLA: Writing – review & editing. RY: Data curation, Formal analysis, Methodology, Writing – review & editing. FS: Writing – review & editing. JK: Conceptualization, Methodology, Supervision, Writing – review & editing. BT: Project administration, Writing – review & editing. P-MT: Supervision, Writing – review & editing. GH-E: Supervision, Writing – review & editing. MID: Supervision, Writing – review & editing. J-MD: Conceptualization, Supervision, Writing – original draft. FL: Supervision, Writing – review & editing. IA: Conceptualization, Supervision, Writing – review & editing. MP: Conceptualization, Supervision, Writing – review & editing. PB: Conceptualization, Supervision, Writing – review & editing. SS: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft. 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International Journal of Cancer. 2020;147(9):2416–2423. Hu LM, Bell D, Antani SK, et al. An Observational Study of Deep Learning and Automated Evaluation of Cervical Images for Cancer Screening. Jnci-J Natl Cancer I. 2019;111(9):923–932. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies 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-4029650","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":278844398,"identity":"7d2abaa3-e868-42db-abb4-2c36486f430b","order_by":0,"name":"Joel Fokom Domgue","email":"","orcid":"","institution":"The University of Texas MD Anderson Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Joel","middleName":"Fokom","lastName":"Domgue","suffix":""},{"id":278844399,"identity":"8bc8be9b-e96e-4b2f-a091-6c54ca71a1fa","order_by":1,"name":"Dille Issimouha","email":"","orcid":"","institution":"World Health Organization Regional Office for Africa","correspondingAuthor":false,"prefix":"","firstName":"Dille","middleName":"","lastName":"Issimouha","suffix":""},{"id":278844400,"identity":"99f840c3-2573-46ba-bc0a-482c371b6d1f","order_by":2,"name":"Freddy Gnangnon","email":"","orcid":"","institution":"University of Abomey-Calavi","correspondingAuthor":false,"prefix":"","firstName":"Freddy","middleName":"","lastName":"Gnangnon","suffix":""},{"id":278844401,"identity":"a815f140-5547-4899-93f3-8b2f759c9657","order_by":3,"name":"Sharon Kapambwe","email":"","orcid":"","institution":"World Health Organization Regional Office for Africa","correspondingAuthor":false,"prefix":"","firstName":"Sharon","middleName":"","lastName":"Kapambwe","suffix":""},{"id":278844402,"identity":"6ed5ce4f-e44a-4c5d-8c69-76ed5d41d4ff","order_by":4,"name":"Celine Bouchard","email":"","orcid":"","institution":"Centre Medical Sante 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Libreville","correspondingAuthor":false,"prefix":"","firstName":"Nathalie","middleName":"Ledaga","lastName":"Ambounda","suffix":""},{"id":278844406,"identity":"784b96a5-8e29-4dd6-8b5e-fe4ead2da164","order_by":8,"name":"Robert Yu","email":"","orcid":"","institution":"The University of Texas MD Anderson Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Yu","suffix":""},{"id":278844407,"identity":"62cfc303-4f29-4111-8d43-988dafb57d51","order_by":9,"name":"Fatoumata Sidibe","email":"","orcid":"","institution":"University of Bamako","correspondingAuthor":false,"prefix":"","firstName":"Fatoumata","middleName":"","lastName":"Sidibe","suffix":""},{"id":278844408,"identity":"6dd46c35-41d9-4df1-a88f-5afd75a1e19a","order_by":10,"name":"Joseph Kamgno","email":"","orcid":"","institution":"University of Yaounde","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Kamgno","suffix":""},{"id":278844409,"identity":"1a98d8bf-becb-4204-9d85-41ea3c8fd1c6","order_by":11,"name":"Bangaly Traore","email":"","orcid":"","institution":"University Gamal Abdel Nasser of Conakry","correspondingAuthor":false,"prefix":"","firstName":"Bangaly","middleName":"","lastName":"Traore","suffix":""},{"id":278844410,"identity":"f4119c24-ac3b-464f-a60c-24b12b059426","order_by":12,"name":"Pierre-Marie Tebeu","email":"","orcid":"","institution":"University of Yaounde","correspondingAuthor":false,"prefix":"","firstName":"Pierre-Marie","middleName":"","lastName":"Tebeu","suffix":""},{"id":278844411,"identity":"c113b857-8f2b-4624-b262-fd0a03616926","order_by":13,"name":"Gregory Halle-Ekane","email":"","orcid":"","institution":"University of Buea","correspondingAuthor":false,"prefix":"","firstName":"Gregory","middleName":"","lastName":"Halle-Ekane","suffix":""},{"id":278844412,"identity":"ba63a640-e3c8-4040-aabf-96f5122cd418","order_by":14,"name":"Mohenou Isidore Diomande","email":"","orcid":"","institution":"University Teaching Hospital of Cocody","correspondingAuthor":false,"prefix":"","firstName":"Mohenou","middleName":"Isidore","lastName":"Diomande","suffix":""},{"id":278844413,"identity":"4ac01267-650b-4d59-a084-9572e027e287","order_by":15,"name":"Jean-Marie Dangou","email":"","orcid":"","institution":"World Health Organization Regional Office for Africa","correspondingAuthor":false,"prefix":"","firstName":"Jean-Marie","middleName":"","lastName":"Dangou","suffix":""},{"id":278844414,"identity":"d568516f-6b58-4db9-b9ba-b3f96329b5da","order_by":16,"name":"Fabrice Lecuru","email":"","orcid":"","institution":"Institut Curie","correspondingAuthor":false,"prefix":"","firstName":"Fabrice","middleName":"","lastName":"Lecuru","suffix":""},{"id":278844415,"identity":"b0c1d6ac-ebe2-4138-bdf7-87416f63d715","order_by":17,"name":"Isaac Adewole","email":"","orcid":"","institution":"University of Ibadan","correspondingAuthor":false,"prefix":"","firstName":"Isaac","middleName":"","lastName":"Adewole","suffix":""},{"id":278844416,"identity":"be9285c2-2b1a-4780-84a1-a6577b3fca14","order_by":18,"name":"Marie Plante","email":"","orcid":"","institution":"University of Laval","correspondingAuthor":false,"prefix":"","firstName":"Marie","middleName":"","lastName":"Plante","suffix":""},{"id":278844417,"identity":"efd423e2-67ce-41d4-ae19-85d7b2be80e5","order_by":19,"name":"Partha Basu","email":"","orcid":"","institution":"World Health Organization Regional Office for Africa","correspondingAuthor":false,"prefix":"","firstName":"Partha","middleName":"","lastName":"Basu","suffix":""},{"id":278844418,"identity":"a8931a90-f157-4726-9165-bb7a52a26586","order_by":20,"name":"Sanjay Shete","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYFACHhBhw8BwgIFBgngtBxjSSNdymAQt8v1nDz7+UHE+mu/42YM3Pu6pkzNnYD728QseLQY38pINDpy5nTvzTF6y5Yxnh40tG9iSZ8vg0yLBYyZxsO127oYDOWbSPAcOJG44wGPMjM+J8v1nzH8c/Hcud8P5N2bSfw7UEdbCADSc4WDDgdwNN4C2MBxgBmth/IDXLznGEmeOJefOvPHG2LLnwGFjg8Nsycz4LAE6zPBDRY1dbt/5HMMbPw7UyRkcbz7M+AOfHkwAtIKZhzQtQECqLaNgFIyCUTC8AQBTyFcj9zyitQAAAABJRU5ErkJggg==","orcid":"","institution":"The University of Texas MD Anderson Cancer Center","correspondingAuthor":true,"prefix":"","firstName":"Sanjay","middleName":"","lastName":"Shete","suffix":""}],"badges":[],"createdAt":"2024-03-07 17:25:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4029650/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4029650/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52592525,"identity":"8d10d48b-9ab7-4c16-a767-5327b461e278","added_by":"auto","created_at":"2024-03-13 11:03:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":143796,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIndications of colposcopy among African clinicians practicing colposcopy\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4029650/v1/9b6a09f2cc3f664539a264ce.jpg"},{"id":52889416,"identity":"75dcb620-cd36-45b3-b618-d4fecece5673","added_by":"auto","created_at":"2024-03-18 11:12:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":483532,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4029650/v1/2b1c3b26-9697-4f81-92dc-721253e8446a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Utility of colposcopy for the screening and management of cervical cancer in Africa: a cross-sectional analysis of providers’ training and practices","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAssessing women presenting with positive cervical screening results and selecting those suitable for immediate therapy usually relies on the colposcopic assessment of the transformation zone to visualize and characterize cervical epithelium and guide biopsies.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In the standard practice, colposcopy guidance is required to perform excision of transformation zone for treatment of high grade cervical precancers. Thus, colposcopy is an essential part of an effective cervical cancer prevention program.\u003c/p\u003e \u003cp\u003eA major challenge to the successful implementation of cervical cancer prevention activities is the lack of colposcopy utilization following positive screening results. Women\u0026rsquo;s participation in the entire cervical screening process has been assessed in several studies and barriers to access colposcopy services have been reported.\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Various health systems and patient factors influence access to colposcopy in low and middle-income countries (LMICs). System barriers include a limited number of colposcopy services, which are mostly found in tertiary-level facilities, with long waiting times for patients and few opportunities for non-specialist clinicians to develop the required skills.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e The limited numbers of specialist gynecologists, coupled with the high demands on these doctors for emergency and obstetrical and gynecology services, results in lesser time available for diagnostic or non-urgent procedures like colposcopy.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA colposcope is a binocular telescope used to directly visualize the cervical mucosa under a good light source. Since it was invented in 1925,\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e it has undergone modifications to improve its diagnostic accuracy and make it more suited to settings with poor health infrastructures. Traditionally, the colposcope has been developed as an optical diagnostic instrument designed for specialists in higher-level healthcare facilities and requires a minimum infrastructure (electricity, examination room, etc) to operate. In recent years, high-resolution images taken with digital cameras have improved the detection of cervical lesions and enabled images to be shared between senior colposcopists and less experienced ones.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Digital colposcopy has several advantages (including cost, portability, and ease of use) that make it more adapted to LMICs compared to its optical counterpart or traditional colposcopes.\u003c/p\u003e \u003cp\u003eIn LMICs, the need to create more opportunities for cancer care is growing considering the lack of specialist services and other constraints.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Primary healthcare professionals (PHPs) in these settings act as frontline providers in delivering preventive services, including cervical cancer prevention. They strengthen the coordination of care and educate patient using culturally adapted interventions.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Not only they assist women in the screening procedure, but also, they support those with abnormal results by offering them post-screening counseling and management.\u003c/p\u003e \u003cp\u003eThe contribution of PHPs in addressing cervical cancer has been highlighted in LMICs.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In the innovative approach developed by our team, hands-on training\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e is combined with distant learning through the use of a practical and low-cost tele-mentoring tool (the Project ECHO) aimed at sharing best care practices. In this model, PHPs diagnose and manage patients with the assistance of specialists who act as mentors and provide feedback, guidance, and didactical training.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Using this approach, PHPs are equipped with the skills, self-confidence, and knowledge to manage cervical pre-invasive or early-invasive disease. This reduces travel time, wait time, costs, and complications stemming from these delays. With this tele-mentoring model, PHPs retain their duty of care to patients as their competencies and independence build up, which reduces referral rates and improves patients\u0026rsquo; outcomes.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite logistical and technological advances aimed at making colposcopy more accessible to LMICs, little is known about African providers\u0026rsquo; training and knowledge of the utility of colposcopy. Thus, the present study aims to describe the utilization of colposcopy by PHPs involved in cervical cancer prevention activities in Africa.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population and study design\u003c/h2\u003e \u003cp\u003eThe study population consisted of African-based clinicians involved in cervical cancer prevention activities from 23 African countries who were enrolled in a distance learning program focusing on cervical cancer and other HPV-related anogenital diseases.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e In 2022, providers were invited to take an online survey (in English or French) to assess their training, knowledge, and attitudes toward cervical cancer screening and management of pre-invasive lesions, including the use of colposcopy. The questionnaire was pre-tested and validated before being administered to the target population. This was done in two steps: In the first step, after developing the survey tool, we shared it with 4 experts to get their feedback and remarks regarding content validity. Suggestions from these experts were then incorporated into the survey tool. In a second step, the self-administered survey was pilot-tested with a convenience sample of 20 individuals of varying healthcare provider professions based in Africa to ensure clarity of questions and ease of administration. Further comments from this set of HCPs were accounted for in the final revision of the questionnaire. Participation was anonymous and voluntary, and refusal to take the survey had no consequence on participation in the distance learning program. A detailed description of the survey design, content, and administration has been published elsewhere.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eOutcome measures\u003c/h2\u003e \u003cp\u003eWe assessed whether African-based providers involved in cervical cancer prevention activities performed colposcopy in their practice using the following questions related to optical or digital colposcopy. \"Do you currently perform colposcopy in your practice?\" If the answer to this question was \"yes,\" two follow-up questions were asked: \"How many times have you performed colposcopy in the last 6 months?\". In those who reported performing colposcopy in their practice, we also asked the question: \u0026ldquo;For what purpose do you use a colposcope?\u0026rdquo;, and the possible responses to this question were: \u0026ldquo;For routine visual screening,\" \"To better visualize cervical mucosa,\" \"To visualize the transformation zone,\" \"To assess vascularization of the cervical mucosa,\" \"To determine treatment modality in screen-positive women.\" Multiple responses were allowed for this question.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAdditional variables\u003c/h2\u003e \u003cp\u003ePrior training on colposcopy was assessed with the following question: \"Have you previously had formal training in performing colposcopy?\" (Yes/No).\u003c/p\u003e \u003cp\u003eTo better describe the study population, we collected the following socio-demographic variables: age (years), gender (Male/Female), and location according to the United Nation's classification of African regions (Eastern Africa, Middle Africa, Western Africa, Southern Africa, and Northern Africa), and setting (urban/rural). Providers were also classified according to their educational background into doctors/residents (including family medicine physicians, internists, obstetricians-gynecologists, oncologists, pediatricians, surgeons, pathologists, etc.), and nurses (including midwives).\u003c/p\u003e \u003cp\u003eIn addition to these variables, self-reported knowledge about colposcopy was assessed with the following statement: \"My knowledge about colposcopy is adequate for my current practice.\" Possible responses to this statement included: \"Agree,\" \"Disagree,\" \"Neither Agree nor Disagree,\" and \"I don't know.\"\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe descriptive statistical analyses, prevalence, and associated confidence intervals were obtained using statistical analysis software The SAS (v9.4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthics approval\u003c/h2\u003e \u003cp\u003e This research conformed to the principles embodied in the Declaration of Helsinki. All participants provided written informed consent. The study protocol was approved by the University of Texas MD Anderson Cancer Center\u0026rsquo;s IRB.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the study population\u003c/h2\u003e \u003cp\u003e153 healthcare professionals from Africa completed the survey, including 23 non-clinicians. Among the 130 respondents who were clinicians (mean age [SD]: 39.0 years [9.4]), half were female (65 [50.0%]), and 90.7% were working in urban areas. Participants were from 23 African countries, including 12 providers (9.2%) from Eastern Africa, 58 (44.6%) from Middle Africa, 6 (4.6%) from Northern Africa, 5 (3.8%) from Southern Africa, and 49 (37.7%) from Western Africa. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the study sample\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003egender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFacility type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003esetting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHCP type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor/Resident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse/Midwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAfrican Region\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEastern Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorthern Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouthern Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWestern Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTraining, practice, and indications of colposcopy\u003c/h2\u003e \u003cp\u003eWe assessed providers' prior training and practices regarding colposcopy (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Only 12.6% of respondents indicated having received prior training on colposcopy, and 11.7% reported that they were performing colposcopy in their current practice.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTraining, self-reported knowledge and practice of colposcopy by African providers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHave you previously had formal training in performing colposcopy using a colposcope?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e93.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo you currently perform colposcopy with a colposcope in your practice?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e17.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e94.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMy knowledge about colposcopy is adequate for my current practice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e60.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeither agree nor disagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e45.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong providers who reported performing colposcopy in their practice, colposcopy was indicated for routine visual screening in 21.2% of clinicians, to visualize the transformation zone in 15.2% of respondents, to assess vascularization of cervical mucosa in 33.3% of respondents, and to determine treatment modality in 12.1% of respondents. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) In this group, the median number of colposcopies performed in the last 6 months was 30 (Interquartile range: 19\u0026ndash;65).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePerceived knowledge about colposcopy\u003c/h2\u003e \u003cp\u003eProviders were also asked if their knowledge about colposcopy was adequate for their current practice. Of the 92 providers who responded to this question, half (50.0%) agreed with this statement (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eColposcopy is a critical triaging investigation in the assessment, diagnosis, and management of women with positive cervical screening tests.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e However, colposcopy typically is not available in a primary care setting, and in many LMICs, the alternative is to visualize the cervix with the naked eye after application of acetic acid and Lugol\u0026rsquo;s iodine, which may result in missed diagnoses.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Indeed, the sensitivity of triaging with VIA/VILI in detecting high-grade cervical lesions among HPV-positive women has been reportedly suboptimal.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e A key role of colposcopy in cervical screening continuum is assessing the type of transformation zone and guiding treatment. Studies have reported higher residual disease after excisional treatment (positive excision margin) when treatment was performed without colposcopic guidance.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Further, colposcopy evaluation of screen-positive women has proven to reduce the rate of overtreatment, thereby increasing the effectiveness of screening programs.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Limited resource settings should be enhanced to provide quality healthcare, particularly when specialized physicians are lacking. Priority interventions include task-shifting and provision of more simple and cost-effective equipment for diagnosis and management of conditions of public health concern. Our findings that 12.6% of clinicians involved in cervical cancer prevention activities in Africa had been trained at performing colposcopy highlight the lack of skilled colposcopists in the region.\u003c/p\u003e \u003cp\u003eWhile organizing colposcopy training courses is an effective way to strengthen the diagnostic ability of colposcopists,\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e setting-up these courses in practice may be challenging and difficult to scale. Therefore, distant continuing educational programs where expert colposcopists review cervical images of women screened for cervical cancer provide an opportunity for providers in LMICs to increase their experience and competence in accurately performing colposcopy.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e While harmonized diagnostic standards and quality control procedures for colposcopy practice are released by relevant professional organizations,\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e many colposcopists in LMICs, because they lack adequate training, do not rigorously apply colposcopy guidelines in their practice, which leads to unharmonized reporting of colposcopy examinations.\u003c/p\u003e \u003cp\u003eThe clinical performance of colposcopy depends on the training and experience of colposcopists and the clinical setting, from basic to referral facilities.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e When practiced by competent hands, colposcopy is more accurate and may barely miss severe disease, while it can lead to false-positive results when performed by less experienced providers. These weaknesses of colposcopy can be overcome by adequate training, continuing practice, and quality assessment.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Although only one in eight clinicians in our study sample had been trained to perform colposcopy, 50% of respondents reported that their knowledge about colposcopy was adequate for their clinical practice. This finding suggests that colposcopy is not considered by many African providers as a procedure that requires specific training, which is a matter of concern as it may have implications on the effectiveness of cervical cancer prevention programs in LMICs.\u003c/p\u003e \u003cp\u003eThe use of digital colposcopes as an alternative to optic colposcopes may help improve access to cervical cancer screening and early detection.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Previous studies found that certain digital colposcopes perform comparably to stationary colposcopes,\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e including when performed by mid-level providers like nurses.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e While the feasibility and accuracy of portable colposcopes in LMICs have been reported, their effectiveness in routine clinical practice is yet to be proven, especially to triage HPV positive women.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e The relevance of building capacity to perform colposcopy in African countries with high HIV prevalence has significantly increased after the publication by the World Health Organization (WHO) in 2021, of the new guidelines for cervical cancer screening and management.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e This guideline recommended that all women living with HIV and tested positive for HPV require triaging with VIA, cytology, or colposcopy.\u003c/p\u003e \u003cp\u003eIn our model, frontline clinicians (including nurses) are trained to perform VIA and basic colposcopy.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Colposcopy in our study sample was used for routine cervical screening, to better visualize the transformation zone, and to determine treatment modality in screen-positive women. The practicability of colposcopy performed by trained PHPs using a portable colposcope implies that more women in LMICs can access colposcopy, especially in remote areas.\u003c/p\u003e \u003cp\u003eConsidering the dearth of providers skilled to perform colposcopy in Africa, a strategy with HPV testing followed by optic colposcopy may result in delays in early detection and increase the risk of lost-to-follow up. Therefore, portable colposcopy performed by trained nurses can be offered in the same setting where HPV testing is done and much earlier than a referral to a physician. While colposcopy practice has been limited to medical doctors in most LMICs, our experience shows that PHPs supervised by experienced gynecologists can perform colposcopy with little side effects.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e In our program, capturing of cervical images with colposcopes and other digital equipment helps train PHPs through e-learning sessions (case-based presentation complemented by the review of cervigrams). Moreover, colposcopy with portable devices can be performed during outreaches and generate images that can be used for quality assurance.\u003c/p\u003e \u003cp\u003eQuality assurance is critical to the effectiveness of a cervical cancer screening program. We employ a collaborative approach for quality assurance through regular meetings in which in-house and external experts discuss cases with attending providers.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Adding quality assurance review by specialists using colposcopy has been reported to improve the diagnostic accuracy of VIA.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e PHPs in more remote facilities can also engage with expert colposcopists through anonymized cervigrams on social media platforms, and colposcopic images can be uploaded to the cloud for quality assurance assessment. This facilitates timely consultation with a distant colposcopist while the patient is still in the healthcare facility and reinforces quality control.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eArtificial intelligence (AI) as an adjunct to colposcopy has raised concerns about the importance of training PHPs in basic colposcopy. Introducing AI-based evaluation and interpretation of cervigrams may reduce the learning curves for PHPs in performing colposcopy. While AI is expected to assist less skilled PHPs in providing more accurate diagnosis\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e, follow-up, and treatment of precancerous lesions of the cervix, its use will still require hands-on training and skilled providers.\u003c/p\u003e \u003cp\u003eThere were limitations to this study. First, most respondents to the survey were clinicians working in urban settings, suggesting that our findings may not representatively reflect colposcopy practices among providers living in rural areas. Second, respondents were selected among clinicians invited to attend a continuing education e-learning program aimed at building the capacity of African providers in the field of cervical cancer prevention and management, and the survey was administered online. As a result, providers in areas with limited internet penetration were underrepresented in our study sample.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDespite a high incidence of cervical cancer in Africa, provider training, self-reported knowledge, and utilization of colposcopy for cervical cancer screening remain suboptimal. To increase access to colposcopy in the region, further training is needed to improve providers' knowledge and engagement. With the development of lower-cost and portable colposcopes, efforts to equip cervical cancer prevention programs, and facilities with colposcopy should be enhanced to ensure that women can be screened and followed up adequately.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJF: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing \u0026ndash; original draft. ID: Project administration, Writing \u0026ndash; review \u0026amp; editing. FG: Project administration, Writing \u0026ndash; review \u0026amp; editing. SK: Writing \u0026ndash; review \u0026amp; editing. CB: Writing \u0026ndash; review \u0026amp; editing. NM: Project administration, Writing \u0026ndash; review \u0026amp; editing. EG: Project administration, Writing \u0026ndash; review \u0026amp; editing. NLA: Writing \u0026ndash; review \u0026amp; editing. RY: Data curation, Formal analysis, Methodology, Writing \u0026ndash; review \u0026amp; editing. FS: Writing \u0026ndash; review \u0026amp; editing. JK: Conceptualization, Methodology, Supervision, Writing \u0026ndash; review \u0026amp; editing. BT: Project administration, Writing \u0026ndash; review \u0026amp; editing. P-MT: Supervision, Writing \u0026ndash; review \u0026amp; editing. GH-E: Supervision, Writing \u0026ndash; review \u0026amp; editing. MID: Supervision, Writing \u0026ndash; review \u0026amp; editing. J-MD: Conceptualization, Supervision, Writing \u0026ndash; original draft. FL: Supervision, Writing \u0026ndash; review \u0026amp; editing. IA: Conceptualization, Supervision, Writing \u0026ndash; review \u0026amp; editing. MP: Conceptualization, Supervision, Writing \u0026ndash; review \u0026amp; editing. PB: Conceptualization, Supervision, Writing \u0026ndash; review \u0026amp; editing. SS: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing \u0026ndash; original draft.\u003c/p\u003e\n\u003cp\u003eDisclaimer: Where authors are identified as personnel of the International Agency for Research on Cancer/WHO, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the International Agency for Research on Cancer/WHO.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOgilvie G, Nakisige C, Huh WK, Mehrotra R, Franco EL, Jeronimo J. Optimizing secondary prevention of cervical cancer: Recent advances and future challenges. Int J Gynaecol Obstet. 2017;138 Suppl 1:15\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerkins RB, Adcock R, Benard V, et al. Clinical follow-up practices after cervical cancer screening by co-testing: A population-based study of adherence to U.S. guideline recommendations. Prev Med. 2021;153:106770.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlanckenberg ND, Oettle CA, Conradie HH, Krige FK. Impact of the introduction of a colposcopy service in a rural South African sub-district on uptake of colposcopy. Sajog-S Afr J Obstet. 2013;19(3):81\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChigbu CO, Aniebue UU. Non-uptake of colposcopy in a resource-poor setting. Int J Gynecol Obstet. 2011;113(2):100\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatz IT, Butler LM, Crankshaw TL, et al. Cervical Abnormalities in South African Women Living With HIV With High Screening and Referral Rates. J Glob Oncol. 2016;2(6):375\u0026ndash;380.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaimela G, Nene X, Mvundla N, et al. The impact of decentralising colposcopy services from tertiary-level to primary-level care in inner-city Johannesburg, South Africa: a before and after study. BMJ Open. 2019;9(3):e024726.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFusco E, Padula F, Mancini E, Cavaliere A, Grubisic G. History of colposcopy: a brief biography of Hinselmann. J Prenat Med. 2008;2(2):19\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpitzer M. The Era of \"Digital Colposcopy\" Will Be Here Soon. J Low Genit Tract Di. 2015;19(4):273\u0026ndash;274.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChallinor JM, Galassi AL, Al-Ruzzieh MA, et al. Nursing's Potential to Address the Growing Cancer Burden in Low- and Middle-Income Countries. J Glob Oncol. 2016;2(3):154\u0026ndash;163.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFokom Domgue J, Pande M, Yu R, et al. Development, Implementation, and Evaluation of a Distance Learning and Telementoring Program for Cervical Cancer Prevention in Cameroon. JAMA Netw Open. 2022;5(11):e2240801.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDomgue JF, Manjuh F, Nulah K, Welty T, Waxman A. Onsite training of clinicians on new techniques to improve cervical cancer prevention in sub-Saharan Africa. Int J Gynecol Cancer. 2020;30(4):551\u0026ndash;552.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDomgue JF, Dille I, Fry L, et al. Enhancing cervical and breast cancer training in Africa with e-learning. Lancet Glob Health. 2023;11(1):e28-e29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan MJ, Werner CL, Darragh TM, et al. ASCCP Colposcopy Standards: Role of Colposcopy, Benefits, Potential Harms, and Terminology for Colposcopic Practice. J Low Genit Tract Dis. 2017;21(4):223\u0026ndash;229.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFokom-Domgue J, Combescure C, Fokom-Defo V, et al. Performance of alternative strategies for primary cervical cancer screening in sub-Saharan Africa: systematic review and meta-analysis of diagnostic test accuracy studies. BMJ. 2015;351:h3084.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAwolude OA, Oyerinde SO, Ayeni AO, Adewole IF. Human papillomavirus-based cervical precancer screening with visual inspection with acetic acid triage to achieve same-day treatments among women living with human immunodeficiency virus infection: test-of-concept study in Ibadan, Nigeria. Pan African Medical Journal. 2021;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTebeu PM, Fokom-Domgue J, Crofts V, et al. 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Colposcopy Evaluation at the Time of Loop Electrosurgical Excision Procedure May Avoid Unnecessary Treatment. J Low Genit Tract Di. 2018;22(4):367\u0026ndash;374.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunmany M, Marimon L, Cardona M, et al. Small lesion size measured by colposcopy may predict absence of cervical intraepithelial neoplasia in a large loop excision of the transformation zone specimen. Bjog-Int J Obstet Gy. 2017;124(3):495\u0026ndash;502.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuwonge R, Mbalawa CG, Keita N, et al. Performance of colposcopy in five sub-Saharan African countries. BJOG. 2009;116(6):829\u0026ndash;837.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrendiville W, Sankaranarayanan R. In: \u003cem\u003eColposcopy and Treatment of Cervical Precancer.\u003c/em\u003e Lyon (FR)2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaghavi K, Rohner E, Basu P, Low N, Rutjes A, Bohlius J. 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Geneva2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFirnhaber C, Mao L, Levin S, et al. Evaluation of a cervicography-based program to ensure quality of visual inspection of the cervix in HIV-infected women in Johannesburg, South Africa. J Low Genit Tract Dis. 2015;19(1):7\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuinley KE, Gormley RH, Ratcliffe SJ, et al. Use of mobile telemedicine for cervical cancer screening. J Telemed Telecare. 2011;17(4):203\u0026ndash;209.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGallay C, Girardet A, Viviano M, et al. Cervical cancer screening in low-resource settings: a smartphone image application as an alternative to colposcopy. Int J Womens Health. 2017;9:455\u0026ndash;461.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXue ZY, Novetsky AP, Einstein MH, et al. A demonstration of automated visual evaluation of cervical images taken with a smartphone camera. International Journal of Cancer. 2020;147(9):2416\u0026ndash;2423.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu LM, Bell D, Antani SK, et al. An Observational Study of Deep Learning and Automated Evaluation of Cervical Images for Cancer Screening. Jnci-J Natl Cancer I. 2019;111(9):923\u0026ndash;932.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"colposcopy, cervical cancer, cervical cancer screening, early detection, transformation zone, visualization, healthcare providers, Africa","lastPublishedDoi":"10.21203/rs.3.rs-4029650/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4029650/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Cervical cancer is a public health issue in Africa with devastating socioeconomic consequences due to the lack of organized screening programs. The success of screening programs depends on the appropriate investigation and management of women who test positive for screening. Colposcopic assessment following positive screening results is a noteworthy issue in Africa. This study aimed to assess the utilization of colposcopy by providers in the region.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A cross-sectional study was conducted in 2021-2022 among healthcare providers involved in cervical cancer prevention activities in Africa. They were invited to report prior colposcopy training, whether they performed colposcopy and the indications of colposcopy in their practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Of the 130 providers from 23 African countries who responded to the survey (mean age [SD]: 39.0 years [9.4]), half were female (65 [50.0%]), and 90.7% were working in urban areas. Overall, only 12.6% of respondents indicated having received prior training on colposcopy, and 11.7% reported that they were performing colposcopy in their current practice. Among the providers who reported performing colposcopy in their practice, colposcopy was indicated for routine visual screening in 21.2% of clinicians, to visualize the transformation zone in 15.2% of respondents, to assess vascularization of cervical mucosa in 33.3% of respondents, and to determine treatment modality in 12.1% of respondents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Providers’ training and utilization of colposcopy for cervical cancer screening remain suboptimal in Africa. To increase utilization of colposcopy in the region, further training is needed to improve providers' knowledge and engagement. With the development of lower-cost and portable colposcopes, efforts to equip cervical cancer prevention programs and facilities with colposcopy should be enhanced to ensure that women can be screened and managed appropriately in the clinical setting and communities.\u003c/p\u003e","manuscriptTitle":"Utility of colposcopy for the screening and management of cervical cancer in Africa: a cross-sectional analysis of providers’ training and practices","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-13 11:02:56","doi":"10.21203/rs.3.rs-4029650/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6aab4626-843d-4b0f-9969-59200a58765b","owner":[],"postedDate":"March 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-18T11:04:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-13 11:02:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4029650","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4029650","identity":"rs-4029650","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}