Knowledge, attitude and practice of cervical cancer screening among women infected with HIV in Africa: Systematic review and meta-analysis

Abstract

Background: To establish successful strategies and increasing the utilization of preventive services, there is a need to explore the extent to which the general female population is aware and use the service for cervical cancer-screening among women infected with HIV in Africa. Available evidences in this regard are controversial and non-conclusive on this potential issue and therefore, we estimated the pooled effect of the proportion of knowledge, attitude and practice of HIV infected African women towards cervical cancer screening to generate evidence for improved prevention strategies.

Methods: We applied a systematic review and meta-analysis of studies conducted in Africa and reported the proportion of knowledge, attitude and practice towards cervical cancer screening. We searched electronic databases: PubMed/Medline, SCOPUS, ScienceDirect, Web of science, Cumulative Index of Nursing and allied Health Sciences (CINAHL) and Google scholar databases to retrieve papers published in English language till August 2020. We used random-effects model to estimate the pooled effect, and funnel plot to assess publication bias. The registration number of this review study protocol is CRD42020210879.

Results: In this review, we included eight published papers comprising 2,186 participants. The estimated pooled proportion of knowledge of the participants was 43.0% (95%CI:23.0-64.0) while the pooled estimates of attitudes and practices were 38.0% (95%CI: 1.0-77.0) and 41.0% (95%CI: 4.0-77.0), respectively. The proportion of the outcome variables were extremely heterogeneous across the studies with I2> 98%).

Conclusion: The pooled estimates of knowledge, attitude and practice were lower than other middle income countries calls for further activities to enhance the uptake of the services and establish successful strategies.

Fig 1. Flow diagram of studies reviewed, screened and included.

Fig 2. Forest plot to estimates the proportion of knowledge among HIV infected women towards cervical cancer screening in Africa with 95% CI (the estimate weighted based on random effects model): ES-Effect size equivalent to the proportion, CI-Confidence interval.

In the plot, the diamond shows the pooled result and the boxes show the effect estimates from the single studies. The purple dotted vertical line indicates pooled estimate. The purple solid vertical line indicates the reference line at zero indicating no effect. The horizontal line through the boxes illustrate the length of the confidence interval and the boxes show the effect estimates from the single studies.

Fig 3. Forest plot to estimates the proportion of attitude among HIV infected women towards cervical cancer screening in Africa with 95% CI (the estimate weighted based on random effects model): ES-Effect size equivalent to the proportion, CI-Confidence interval.

In the plot, the diamond shows the pooled result and the boxes show the effect estimates from the single studies. The purple dotted vertical line indicates pooled estimate. The purple solid vertical line indicates the reference line at zero indicating no effect. The horizontal line through the boxes illustrate the length of the confidence interval and the boxes show the effect estimates from the single studies.

Fig 4. Forest plot to estimates the proportion of practice among HIV infected women towards cervical cancer screening in Africa with 95% CI (the estimate weighted based on random effects model): ES-Effect size equivalent to the proportion, CI-Confidence interval.

In the plot, the diamond shows the pooled result and the boxes show the effect estimates from the single studies. The purple dotted vertical line indicates pooled estimate. The purple solid vertical line indicates the reference line at zero indicating no effect. The horizontal line through the boxes illustrate the length of the confidence interval and the boxes show the effect estimates from the single studies.

Fig 5. Publication bias assessment: a) Funnel plot of the 6 estimates of knowledge (k) towards cervical cancer screening available for meta-analysis (SE-Standard error, ES-Effect size: proportion), b) Funnel plot of the 3 estimates of attitude (A) towards cervical cancer screening available for meta-analysis (SE-Standard error, ES-Effect size: proportion), c) Funnel plot of the 3 estimates of practice towards cervical cancer screening available for meta-analysis (SE-Standard error, ES-Effect size: proportion).

In this plot, the blue broken line indicates Pseudo 95% CI, the solid red line indicates pooled estimate of the proportion of knowledge, attitude and practice, and the scattered circle dots indicates included studies in the meta-analysis. The scale on the X-axis indicates Effect size estimate or proportion and the Y-axis indicates the precision estimate using standard Error.