BackgroundCancer screening programs hold much potential for reducing the cervical cancer disease burden in developing countries. The aim of this study was to determine the feasibility of mobile health (mHealth) phone technology to improve management and follow-up of clients with cervical cancer precursor lesions.MethodsA sequential mixed methods design was employed for this study. Quantitative data was collected using a cross-sectional survey of 364 women eligible for a Pap smear at public sector health services in Cape Town, South Africa. Information was collected on socio-demographic status; cell phone ownership and patterns of use; knowledge of cervical cancer prevention; and interest in Pap smear results and appointment reminders via SMS-text messages. Descriptive statistics, crude bivariate comparisons and logistic regression models were employed to analyze survey results. Qualitative data was collected through 10 in-depth interviews with primary health care providers and managers involved in cervical cancer screening. Four focus group discussions with 27 women attending a tertiary level colposcopy clinic were also conducted. Themes related to loss of mobile phones, privacy and confidentiality, interest in receiving SMS-text messages, text language and clinic-based management of a SMS system are discussed. Thematic analyses of qualitative data complemented quantitative findings.ResultsPhone ownership amongst surveyed women was 98% with phones mostly used for calls and short message service (SMS) functions. Over half (58%) of women reported loss/theft of mobile phones. Overall, there was interest in SMS interventions for receiving Pap smear results and appointment reminders. Reasons for interest, articulated by both providers and clients, included convenience, cost and time-saving benefits and benefits of not taking time off work. However, concerns were expressed around confidentiality of SMS messages, loss/theft of mobile phones, receiving negative results via SMS and accessibility/clarity of language used to convey messages. Responsibility for the management of a clinic-based SMS system was also raised.ConclusionsResults indicated interest and potential for mHealth interventions in improving follow-up and management of clients with abnormal Pap smears. Health system and privacy issues will need to be addressed for mHealth to achieve this potential. Next steps include piloting of specific SMS messages to test feasibility and acceptability in this setting.

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Cervical cancer remains an important cause of morbidity and mortality in South Africa (SA). [1] The age-standardised incidence rate of cervical cancer in southern Africa is approximately 27/100 000, [2] and most cases are diagnosed in late stages. Persistent infection with oncogenic human papillomavirus (HPV) is an essential step in the development of invasive cervical cancer. [3] HPV is highly infectious, but does not cause disease in all cases, and most individuals will clear infections. Since HPV is almost exclusively an epithelial disease, most transient HPV infections do not confer longterm immunity owing to a poor immune response. A national cervical cancer prevention programme was launched in SA in 2000, offering three Papanicolaou smears in a woman's lifetime, starting after the age of 30 at 10-year intervals, but has had limited success in reducing the incidence of HPV-associated disease. Some provinces in SA have fairly well-developed cytology screening services, but there is poor uptake of prevention services for cancer. Among women with abnormal cytology, there is also significant loss to follow-up after the initial screening test. [4] Since the introduction of effective HPV vaccines, a primary preventive strategy became available to combat the epidemic. Currently there are two vaccines registered in SA: the bivalent vaccine Cervarix, containing virus-like particles (VLPs) for HPV types 16 and 18, and the quadrivalent vaccine Gardasil, containing VLP antigens for HPV types 16 and 18 as well as non-oncogenic HPV types 6 and 11. VLPs are combined with an adjuvant, which leads to an improved immune response and long-term efficacy. Both vaccines have been extensively tested in large populations, and have also been found to be safe and immunogenic among African populations. [5] The bivalent HPV vaccine has also shown sustained immune responses in HIV-positive women, and was well tolerated. [6] Local reactions such as pain, swelling and redness can occur, as may systemic adverse events including fever, nausea, dizziness, fatigue, headache and myalgia. Cost-effectiveness studies have shown universal, femaleonly HPV vaccination before exposure to be an effective and economically viable option in developed countries. [7] Recently there has been increasing emphasis on the inclusion of low-and middle-income countries in the drive to reduce the global cancer burden. Evidence from qualitative studies suggests that South Africans will support introduction of HPV vaccination, but that education remains a key ingredient in any roll-out. [8] Adolescent health was identified as an area for development in the SA National Health Initiative Green Paper, with preventive health an important part of this plan. This focus is linked to a re-engineered primary healthcare plan and a newly developed school health programme (SHP). In May 2013, Dr Aaron Motsoaledi, national Minister of Health, announced during the health budget speech that: '... we shall commence to administer the HPV vaccines as part of our SHP ... '. This courage...

ObjectiveThe aim of this study was to explore and understand women's experience with cervical cancer screening and with the referral pathways for abnormal Papanicolau (Pap) smears.Design and settingFocus group discussions were conducted with first time colposcopy clinic attendees at a tertiary hospital colposcopy clinic in Cape Town, South Africa during November 2014. A thematic analysis was conducted to identify key themes. Initial coding categories were drawn from the interview guide.Participants27 women participated in 4 focus group discussions.ResultsParticipants mean age was 34 years, most did not complete secondary level education and were unemployed. Negative community opinions relating to Pap smears and colposcopy referral might deter women from seeking treatment. Having a gynaecological symptom was the most commonly cited reason for having a Pap smear. Fear of having a HIV test performed at the same time as Pap smear and low encouragement from peers, were factors identified as potential access barriers. Participants commented on insufficient or lack of information from primary providers on referral to the colposcopy clinic and concerns and apprehension during waiting periods between receiving results and the colposcopy appointment were discussed.ConclusionsThere is a strong and urgent need to improve current knowledge about cervical cancer and Pap smears and the necessity and benefits of timely access to screening programmes, results and treatment. Strategies such as community health education programmes and mass media interventions could be employed to disseminate cervical cancer information and address negative community perceptions. Better training and support mechanisms to equip healthcare providers with the skills to convey cervical cancer information to women are needed. The use of short message service (SMS) to deliver Pap smear results and provide patients with more information should be considered to improve waiting times for results and alleviate apprehension during waiting periods.

Aims: To present a structured review of the literature published on semen parameters and in vivo fertility potential and to establish fertility/subfertility thresholds for sperm morphology using Tygerberg strict criteria, sperm concentration, and sperm motility. Method: The published literature comparing fertile and subfertile populations between 1983 and 2002 was reviewed. Results: A total of 265 articles were identified by the sourcing methodology, but only four articles provided data that could be tabulated and analyzed. Using receiver-operating characteristics curves, morphology proved to be the best predictor of subfertility in 2 of the 4 articles, with concentration and motility also showing good predictive power. The thresholds calculated ranged between 4 and 10% for morphology, between 13.5 × 10⁶/ml and 34 × 10⁶/ml for concentration, and between 32 and 52% for motility. A second set of much lower thresholds was calculated in three of the articles using either a 15 or 50% prevalence of subfertility in the population or the tenth percentile of the fertile population. The adjusted thresholds were between 3 and 5% for morphology, between 9 × 10⁶/ml and 20 × 10⁶/ml for concentration, and between 20 and 30% for motility. Conclusions: Because these lower thresholds have a much higher positive predictive value, we suggest that thresholds of <5% normal sperm morphology, a concentration <15 × 10⁶/ml, and a motility <30% should be used to identify the subfertile male. The lower threshold for morphology also fits in vitro fertilization and intrauterine insemination data calculated previously. Using the parameters in combination increases the clinical value of semen analysis.

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. Methods: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. Results: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. Conclusions: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. Clinical trial registration: NCT03044899.

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