 So I'd like to introduce to you our speaker for the day. Our speaker is Elvis O'Colier. He's a Commonwealth scholar, double distinction holder and a valedictorian from the University of Calabar and T-Side University UK where he bagged the Bachelor of Public Health, first class honors and Masters of Public Health and PH distinction respectively. He's a public health practitioner with over eight years of experience in volunteering, health and behavioral research, project management, capacity building, section reproductive health, monitoring and evaluation, advocacy and social mobilization. He has led and supported advocacy, demand generation and program implementation efforts directed at malaria prevention, cancer prevention and treatment, section reproductive health including HIV AIDS, maternal and child health nutrition and health system strengthening in several Nigerian states. Elvis' research interest spans non-communicable diseases, especially cervical cancer, health systems strengthening, community engagement and health promotion and sexual and reproductive health. He is passionate about tackling gross inequities in women's access to cervical cancer information services in Sub-Saharan Africa including Nigeria. Via a range of methods, research, advocacy and program implementation. Importantly, he believes that female nurses and midwives have a critical role to play in addressing missed opportunities for cervical cancer prevention and screening especially in resource limited settings where the disease burden is high. He's a program coordinator of TL-DHI Nigeria, project manager at Anami, Nigeria and a Cumberland Lord emerging international leader. Furthermore, Elvis has contributed immensely to the development of policies and health improvement strategies in several Nigerian states such as Imo, Rivers, Cross River, Bielcia and beyond work, he is a football lover, music enthusiast and loves mentoring the next cohort of African scholars. So join me in welcoming Elvis O'Colier. He will make a presentation on systemic review of cervical cancer screening practices among female health workers, FHWs in Nigeria. Welcome. Thank you so much Caroline for the introduction. I'll make you into a presenter. You're now a presenter so you can scroll to the slides. All right, thank you so much. Thank you once again, I'm happy to be here. A big thank you to the organizers of the Virtual International Day of the Midwife and I also appreciate the presence of everyone here from the US, the UK, Liberia, Nigeria, Kenya and every part of the world joining. I'm also happy that we are recording this program. Because prior to us coming up with this research, even from the point of developing the protocol, we're very interested in moving beyond the traditional way of disseminating research findings. So beyond the publication route, we are also very interested in presenting in platforms and conferences such as this because we want our research to translate into the improvement in practice, improvement in workplace culture, improvement in women's health generally. So thank you. I'll be making this presentation. I meant to be making this presentation with Deborah Baker who's a senior midwifery lecturer at T-Side University, but due to unforeseen circumstances, she couldn't join me. I'll try to be very brief. Hopefully if there are questions, comments, I know that Caroline would be looking forward to taking some of them in the comment box and also opening of the session at the end of this presentation. So just for the background, we'll be looking at three cardinal areas. We'll be looking at the overview of Savakau Cancer and Savakau Cancer Screening. We'll be looking at why the focus on Nigeria, why not a global focus, a global perspective since the global health issue. And then why female health workers? Why am I here? Why am I making this presentation? To midwives, to people concerned with midwifery, to researchers and the general public. Just to put us in perspective, there are just a number of diseases that typify inequality. The ways Savakau Cancer typifies inequality. So when we start mentioning diseases that represent global health inequalities, one of the diseases we should be thinking of is Savakau Cancer. You could see from the slide that over 90% of the body in terms of the disease incidents, in terms of mortality, or core and lower middle income countries in sub-Saharan Africa, in Middle East Asia. And now, if you look at the global statistics, Savakau Cancer ranks fourth in terms of cancer diagnosis and mortality in women. The question is, what are we doing about it? In 2006, we entered a new phase in the efforts to prevent and control Savakau Cancer. That was the time we had the HPV vaccines. When it was licensed and when we first started to administer some of these vaccines. While these vaccines have shown promise in terms of providing immunity against some of the high risk causing human papillomavirus that leads to Savakau Cancer. There are still a whole lot of issues in the background. One, we've known that some of these vaccines do not protect against all cancer-inducing HPV strains. So some of them are bivalent, which protects against two strains. Some are quadrivalent, which protects against four strains. Then some are non-valent, which is about nine strains. But we know that we have over 150 strains of HPV. And why some are high risk, some are low risk HPV strains. So that is why screening remains the go-to in efforts to control and prevent Savakau Cancer. Now, people could be asking the question, oh, why are we saying it defies inequality? What's the cardinal difference? What's the major difference between how high-income countries and low-income countries? What's the major difference? The major difference between these two settings is the establishment or the existence of a population-based Savakau Cancer screening program. Now, when we are saying, if you go to literature, there's a whole lot of people saying population-based Savakau Cancer screening program. We need to make a distinction as to why we say this. It is a program that actively seeks to screen eligible women, including female health workers and every midwife here. It's a program that is funded. It's a program that has a system of sending our reminders to women as to when they are due for screening. So these are some of the important things we need to also know as we progress. Why Nigeria? Data has shown us that in Nigeria, behind only breast cancer, Savakau Cancer is the leading cause of cancer mortality. However, these statistics could just be a tip of an iceberg. So the iceberg phenomenon, because of issues around quality of data, issues around establishment of cancer registries that can give us quality data to sort of estimate what the true body of the disease is. We are also in a very scary situation as the HPV Center has projected that 53 million Nigerian women and girls, eight, 15 and above are at risk of Savakau cancer. If Nigeria does not do anything to change the current narrative. In Nigeria, we do not have a population-based screening. All we have are opportunistic and these opportunistic screening services do not reach all the women that should screen. It will interest you to know that only 9% of eligible Nigerian women out of the millions of women that should be screening have ever screened in their lives. We also know that this is quite a regrettable start for my country, but Nigeria is currently described as the world capital for poverty. And for Savakau cancer, which affects women in their prime, it's not only facilitates that vicious cycle, it sort of also affects nation-building and the social economy growth of Nigeria. So why am I concerned about female health workers? Before we start this study, we had a whole lot of studies on women in the general population. And because I've worked in the health system space, I've seen the impact that female health workers, midwives, female nurses, nurses in general, why I'm being practical about female is because this is a female-based issue. But generally, the work of nurses, health workers in general are acknowledged. Now we've seen that even beyond Savakau cancer, the efforts of health workers to scale up access to services, to scale up access to information for the general population is vital. And if we are to make any significant progress in turning the tides against Savakau cancer, we must have female health workers at the fall of efforts to achieve this goal. What are some of the reasons why we're concerned and we're focusing our studies on female health workers? It's because they occupy a very strategic position. So in the Nigerian health system, we have a three-tier health system, the tertiary, the secondary, and the primary healthcare system. And in each of those health system tiers, you can easily have access to a female health worker, whether it's a JTU, a CHU, a nurse, a midwife, a female doctor, you can easily have access to a female health worker. Importantly, female health workers are not precluded, like they are not, they are also susceptible to coming down with Savakau cancer. As long as there is presence of a service, they're also at risk of coming down with Savakau cancer. And we believe that because they are women in similar settings, they can relate to the experiences of other women. So for a screening test that has social and religious implications, a screening test that is intimate, a screening test that has implications for bodily autonomy for the woman, we also felt that it's important that we look at what female health workers can do. And as part of the global strategy for the elimination of Savakau cancer, which was launched in 2020, the 90s, 70s, 90s strategy, we believe that if we want to achieve those strategies, we must integrate female health workers at all steps of the way. What was the aim of this particular study? We wanted to investigate what the barriers and facilitators were there for female health workers because if you can address this, we are also paving way to scale up coverage for underserved women, for women in general population, and for women that come into contact with female health workers, nurses, midwives, and all the cadets that female health workers can follow. So some of the things we wanted to look out for was what was their knowledge because you can't give what you don't have. So we wanted to know what their knowledge is. I've seen in the past where, example, in the UK, there is a case of Imaswani, a 22-year-old woman, she's lit, she died because some of her screening results were misread, so she had a misdiagnosis. So we wanted to know what was the knowledge levels, what were the attitudes of female health workers to screening, to recommending this service for women using their health facilities. So just like the title of this presentation, so this was a systematic review. We wanted to have a comprehensive overview and in terms of research evidence, systematic review ranks highly because what it does is it looks at primary studies that have been done on a particular issue and provides a robust comprehensive evidence in a very systematic way. So for this particular study we set six databases, Medline, M-Base, Sinal, Scopus, African Index Medicines, which is hosted by the WHO and then the Web of Science. Between May to June 2020 and in October 2020, we had a repeat search to check whether there are new studies that have been published and to also ensure that we're in place, we try to stick to the Cochrane Methods of study selection and then use the Prisma Flow Diagram to elaborate on how we made our decisions pertaining to studies. At the end of the day, we decided that because of the heterogeneity of the studies, most of our studies were cross-sectional, we couldn't do a meta-analysis which looks like the gold standard for analyzing evidence if it is a randomized control trial. But we had studies that were cross-sectional studies and some of the modes of measurements were quite different, it was heterogeneous. So we decided to do a narrative synthesis of all the included studies. My Prisma Diagram is not looking so clear from my head, but it shows you how we searched the, how we searched the, it shows you how we searched the, okay, it shows you how we searched the databases, the number of studies we got from each databases, how we removed the duplicates, what were the reasons for taking a particular paper forward to check, to have a full text read. Initially, we removed papers with their titles and abstracts if they do not fit into our eligibility criteria. So this particular diagram shows how we came up with a final 15 primary studies that were included for this systematic review. Now just to give us an overview of some of the studies we included, so all of them were quantitative cross-sectional studies. Some put a total of 3,392 female health workers and the study sample sizes range from 40 to 503. The majority of the studies, about eight of them, included different KDA of female health workers, doctors, nurses, medical lab scientists, people that provide direct care to individuals using the health facility. Only five focused on nurses. So these studies were published between 2003 to 2019. So we also, as part of good practice for systematic reviews, we do quality appraisal to understand the quality of the studies you're trying to draw an inference from, the papers you're trying to analyze to come out with a robust evidence on a particular issue. So we did the analysis. Majority of the studies were moderate in terms of quality. We consider that two were low. Some of these considerations for them being low could be that maybe they didn't justify, there were no justifications for their sample size. We didn't get statements on conflicting or competing interests. Maybe it wasn't present in the study, but they could have as well submitted that during their submission to any particular journal of their choice. Now, what were the results of our study? So we looked at these results under the following titles, which I've already looked at the study characteristics. We looked at awareness and knowledge of cervical cancer screen among female health workers. We looked at their attitudes towards cervical cancer screening. We looked at the practices. So do they attend screening sessions? And then we looked at what the barriers of facilitators were for female health workers. As expected, as expected, awareness and knowledge levels were moderate to high. So for instance, awareness levels were as high as 61 to 100%. Knowledge was also similar. 54.5 to 90.5%. However, where it starts to differ is we already looked at the knowledge of female health workers on recommended cervical cancer screening interval and the target population eligible. So it's important that beyond them knowing that screening is important for early detection of cervical cancer, they should be able to know the interval when you can tell the woman, if you have the screening, this is when you expect her to come back for the next screening. So that was four. While screening intervals might differ from setting to setting, it's expected that if a woman is screening with the HPV DNA test, it's from 25 to 65 years, she's expected to have that once in every five years. If she's using a pap smear, she's expected to have that once in every three years. If she's also doing a HPV pap smear cortex, she's also have it once in five years. So we found out that knowledge across some of the studies we looked at in terms of screening interval was poor. And then there are knowledge on target population. So there are countries where they don't screen anybody beyond 25 years. So there are countries that could also be open to screening a 21-year-old, a 20-year-old that comes to the health facility and demands to be screened. It's a bit nuanced, but they still showed that knowledge of that target population that is available for screening was poor among the Nigerian female health workers that were sampled. And knowledge was also profession dependent. We found out that doctors and nurses who are more clinical had more knowledge compared to other care day of female health workers. We also try to look at the source of the information because we believe that the source of your health information, the source of your education in terms of survival cancer could also affect the quality of your knowledge and awareness. So we have things like media school, health professional and all that as the major source of survival cancer information for female health workers in Nigeria. So going in front, we see why this party, why some of these sources will consider it to be a problem for this set of individuals. So in terms of attitude, majority of the female health workers, they had a positive attitude. They wanted to screen. They felt that screening was good and beneficial to women's health. They felt that screening is paramount to early detection. Part of attitude also covered the intention to recommend because female health workers are an important asset in terms of educating other women, in terms of recommending survival cancer screening for other women. While the intention to recommend was as high as 81%, the actual practice of recommending. So the intention to do something and actually doing it is quite different. So the intention to recommend was as high as 81.9%. But when we looked at some of the studies that were included for this systematic review, we saw that actual practice of recommending of telling women about cervical cancer screening, recommending them to go for a screening test was quite poor, about 34 to 43.3%. Then what was the practice? So it's expected that, because female health workers are role models. I don't know what the health system would have done without them. It's expected that they should take the lead in taking up screening. However, we noticed that screening practices were poor among Nigerian female health workers. So for those that had screened, it rained from the power 33% to 54.1%. Those that had never screened range from 45.9 to 97%. That is a significant number. If people that have been trained medically have this high number of non-screening, how much more about women in the general population that are not informed or do not have some form of healthy tracing? So we also found out that uptake was also associated with the cadre of female health workers. We saw that nurses and female doctors took up cervical cancer screening more than other cadre of female health workers. So what were some of the barriers? So when we looked at the barriers across the primary studies, we're able to categorize them into individual and health system factors. So we try to look at it from the perspective of what is within the sphere of the individual, the individual female health worker and what is within the sphere of the health system. For the individual level barriers, we had factors such as fear of a positive result, low risk perception, maybe because of their status, because of the education, because of their medical training, they felt they had little or no risk for cervical cancer, lack of test awareness and ignorance generally. Being sexually inactive and lack of time and being busy. So some female auto-cars in the health system are already overburdened. They might not be able to create time to go for screening. So we also looked at some of the health system barriers which were cost of screening, the kumbasum nature of the procedure, the lack of recommendation. So recommendation is also an issue that it's coming up. The lack of services. We've initially established that in Nigeria, services are opportunistic and sparsely distributed. And the gender of the screening provider. It is a screening practice that has a social and a religious undertone. It's not quite easy for women to easily present themselves to be screened by maybe a male service provider, except it is actually necessary. But it's something we need to start considering. And that is also one of the reasons why we put out a spotlight on female health workers. So these were some of the facilitators. Being married, it's been suggested that married people have more need of using the health facility than people that are married. However, it's up for debate. Increasing age. It could be that increasing age improves the experience or helps them to understand their risk more. We had awareness, being ill, decision recommendation, members being membership of a clinical department. We're also some of the facilitators for female health workers in Nigeria to go for screening. Now it's important that we put all these results into context and as a group ask ourselves certain questions. So we've seen that while female health workers had a very high knowledge and awareness of the benefits of screening, it did not translate into actual screening practices. It did not also translate into higher rates of recommendation within themselves and for women in the general population. And then in our study we found that the media was a major source of cervical cancer information. And we felt that this raised a couple of concerns. What is the authenticity of the information we receive from media? We influence that information on the media. Which media is responsible for all this information? What is the powerness of the information? So what you suggested to us is that there's a low prioritization of cervical cancer education in the agenda for continuing medical education activities that they are having in Nigeria. We're also seeing that some of the variants for female health workers, especially at the individual level, are preventable issues around low risk perception, fear of positive results, are opportunities for public health intervention, for sensitization, for improving their knowledge, to understand that the benefits without way any risk and the benefits of screening is quite very vital, not just for them, but for the women they come in contact with. The facilitators will also identify, also creates that avenue for program implementers to expand on them, to sort of leverage them to improve practices among female health workers. It's also important that as we are looking at all these studies, as we are trying to draw in from this primary studies and our systematic review, that we understand that there are limitations and strengths and it's also a good practice that we share some of these limitations and some of the things we believe are the strength of our study. Some of the key limitations included that all the studies we used for this systematic review were all cross-sectional. So cross-sectional studies provide a snapshot of the variables of interest at a particular point in time. It might not give us opportunity to understand or study the underlying issues at that moment. We were also not able to include two eligible primary studies. We didn't get the full test. We tried sending emails to the authors. We couldn't get it. So we had to progress with 15 of the studies, which is quite a significant number. Because there were heterogeneities, some of the studies, about two or three of the studies used the like-hand scale to measure their knowledge and our attitudes were not happy. It was also a bit difficult to draw a convergence across all these studies. And that is also one of the reasons we used in narrative synthesis. What were the key strengths of our study? We had independent reviewers at the critical areas of the methodology, selecting the study, quality appraisal, and data extraction. So we had two or three different reviewers do each of these and then compare results at the end. So we used a robust and exhaustive search strategy. We extensively search the database using Boolean operators and all. So sort of ensure sensitivity and precision in our search. We had head to different guidelines, protocol registration. We registered this systematic review with Prospero. We used the Cochrane guidelines for our systematic review. Conclusion, we can see that the factors influencing the practice of the Savakakas and Skrimiakakas among Khrimiakakas in Nigeria are complex, both at the individual and at the health system level. It's also very critical that we see how we translate significant levels of knowledge into practice, not just for themselves, but for us to also translate such knowledge into opportunities for educating women in the general public and recommending Savakakas screening for them. It's also important that future studies will need to use methods beyond the cross-sectional method to explore some of these issues we identify. Issues like fear of positive results, issues like low risk perception, and even explore the curriculum of our continuing medical education. And then it's also important because one of the big issues we have in Nigeria is that we do not have a focused Savakakas cancer control policy. It's also important that we're developing that policy in line with the global strategy that we provide clarity on what the health workforce, particularly female health workers, can do in efforts to eliminate Savakakas cancer in Nigeria and globally. It's time for us to reflect. It's just a question you can answer personally and within yourself. How can I make a difference in my position as a midwife, as a researcher, as a health worker, as an advocate, or as a stakeholder? How can I also make a difference as an individual? Savakakas cancer is robbing us of the prime ages of women. It's robbing us of our sisters, our mothers, our wives. I think it's important that we take the fight just beyond Savakakas cancer for every cancer as seriously as we take whatever we are doing for other communicable and non-communicable diseases. I thank you for listening and I leave the line open for any questions, comments, and suggestions. And then the link to the article, I'll have to put it in the chat box if there are any body interested in reading the full paper. Thank you. Kay, thank you very much. Elvis, very, very thought provoking, very informative presentation and lots of learning. I have learned quite a bit. In fact, one of the questions that I had written and you actually articulated to it when you were making your presentation at the beginning, when you were mentioning about how uptake is low. And I had written the question is, what are the main reasons that women do not go out for screening? And I think you've alluded to it in your presentation. And I know I am a victim. Several other women on this platform can also attest to the fact that they have met people who are very resistant. And I don't know whether you want to dwell on that a little bit more, but again, we have fast, we have comments that are coming in online. I'm not sure whether you can see the public chat. Meris is a very interesting topic. Then Edna says many thanks for the presentation and information and inform. I want to believe very informative one. Please think, please, I think it will also be key to include all service providers, including the male health workers. Then Edna also continues and says, surge awareness and sensitization going forward. And at all levels, Halima mentions amazing presentation. Mary continues to say, is there any, is there some difference between the age of women, but linked cervical cancer, e.g. 31 years and a 70 year old for survival. The older women survived for 10 years, while 31 year old survived for two years. What are the factors? Katie from US says, thanks very much. In other health conditions, processes, conditions through processes and screening, uptake of screening practices may be low. If there is not access to diagnostic testing as the follow-up in brackets speaking, some of the fear of positive results that you mentioned. What is the infrastructure like in Nigeria for Koloposki and diagnostic accession procedures? Is there opportunity to scale up the Koloposki and workforce to aid in screening? And we have somebody else. Sorry, I don't want to make an error in your name. I'm sure Elvis would pronounce it better than I do. Hola, Joe Moke. Thank you, Elvis. I love your presentation, well done. Ella says, thank you. I want to ask about provision of cervical screening. Oh, several of them. Goodness, they're coming in fast and furious. Is there a direct cost to the woman? I hope you're noting them, Elvis. I'm trying to, I'm also looking at the chat box. And I will try to respond to, I think we have more, many more minutes. Yes, we have a, it's now for, we've done 40 minutes. So 245, I think you have only about five, five to less than 10 minutes, yes. I'll try to start from, yeah, I'll try to open the public chat box and I'll try to respond to as many as possible. And then we can also connect beyond the conference platform and take this forum, take this knowledge sharing to other height. So, Edna says, thank you for your presentation. I also think it's key to include all service providers, including male health workers. And I totally agree, which is important that in the spirit of leaving no one behind that will include all service providers, even if it's not at the point of service delivery. I am more passionate about having more women providing services because it is a screening test that has some, it has some sort of intimacy. And in places where we don't have some chaperone to sort of monitor what a male provider is doing at the same time, we've had issues of sexual assault reported sometimes. So I'm also, while I agree that we need to open it up, especially for all providers, I am more passionate about having female health workers in that space. Mary Bada talks about the difference between a woman at 31 years and 70 years, they had cancer, cervical cancer. The older women survived better, survived more, while the 31 years old survived for just two years. So, while I cannot categorically state what the factor for this difference in survival rates are, quick things to note, the stage of diagnosis would also affect survival. Was it diagnosed at stage one, stage two, stage three, or the end stage? Other underlying medical conditions, access to palliative care, these are some of the issues, cost of treatment, generally access. These are some of the factors that could have made that difference. Thanks very much, Cathy Page. She says, thanks very much in other health conditions, process and screening, update of treatment by maybe low, if there is no access to diagnosis screening. What is the infrastructure like in Nigeria for coposcopy and diagnosis and precision procedures? Is the opportunity to scale up coposcopy workforce to aid in screening? All right, so, at the beginning of my presentation, I talked about Nigeria having a three tiered health system. Most of the screening in terms of coposcopy and diagnostic precision happens at the secondary level. However, we've seen that in the past that the task shifting and the task sharing approach has worked especially in skilled beds delivery. So we know that when we also train and provide some of these equipments at the primary care level, we can leverage such opportunities to expand screening. Alakane says, okay, Alagma says, thank you, Elvis. I love your presentation. Alakane says, thank you. I want to ask about the provision of cervical cancer screening. Is there a direct cost? So in Nigeria, there is actually a direct cost, but in most facilities, they are subsidized. I also know that the Medical Women Association in Nigeria have done exceptionally well in providing the services free of charge. Both at facility level or through outreaches. I only shared the link to the paper, I shared that you have screening services available in all different health sectors in Calabar. No, at the primary health care level, we do not really have screening available, but the secondary and tertiary, they provide screening or you also use the facility of the Medical Women Association. Excuse me, Elvis. I think let's continue this discussion offline because we only have, I think I only have a minute to go for this session to end. And thank you so much. I want to thank you because it's elicited a lot of discussions and it shows there's so much that we want to know, everybody wants to know, but again, time has caught up with us. So I will turn off the recording mode and I want to believe that this discussion will continue offline beyond this session.