Mapping evidence on the distribution of human papillomavirus-related cancers in sub-Saharan Africa: scoping review protocol
Lekoane et al. Systematic Reviews
Mapping evidence on the distribution of human papillomavirus-related cancers in sub-Saharan Africa: scoping review protocol
Bridget K. M. Lekoane 0
Tivani P. Mashamba-Thompson 0
Themba G. Ginindza 0
0 Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal , Mazisi Kunene Road, Durban 4041 , South Africa
Background: Despite the introduction of HPV vaccines, the incidence of HPV-related cancers (cervical, penile, anal, vulvar, vagina, head, and neck) in sub-Saharan Africa has been rising. The increasing incidence of these HPV-related cancers has been attributed to changes in lifestyle-related risk factors, most notably sexual behavior. The main objective of this study is to map evidence on the distribution of HIV-related cancers in sub-Saharan Africa (SSA). Methods and analysis: We will conduct a scoping review to explore, describe, and map literature on the distribution of HPV-related cancers in sub-Saharan Africa. The primary search will include peer-reviewed and review articles. The list of references from included studies will also be searched. The search will be performed using EBSCOhost platform by searching the following databases within the platform: Academic search complete, health source: nursing/academic edition, CINAHL with full text, PubMed, Science Direct, Google scholar and World Health Organization (WHO) library databases, and gray literature. The researcher will search the articles using keywords, from the included studies; abstract and full articles will be screened by two independent reviewers. The screening will be guided by the inclusion and exclusion criteria. A thematic content analysis will be used to present the narrative account of the reviews, using NVivo version 10. Discussion: We anticipate finding relevant literature on the distribution of HPV-related cancers in sub-Saharan Africa. The study findings will help reveal research gaps to guide future research. Systematic review registration: PROSPERO CRD42017062403.
HPV-related cancers; Risk factors; Prevalence; Incidence; Mortality; Trends; HIV
The International Agency for Research on Cancer (IARC)
defined human papilloma virus (HPV)-associated cancers
as a specific cellular type of cancers diagnosed in a part of
the body where HPV DNA is found [
cancers are found on the parts of the body such as cervix,
vulva, vagina, anal, penile, and oropharynx [
worldwide estimates, HPV infection is responsible for 5.2% of
all cancers [
]. Cancers associated with HPV are more
prevalent in developing countries as compared to
developed countries . HPV is implicated in 99.7% of cervical
cancer, 85% of anal cancers, 20% of oropharyngeal
cancers, and 50% of cancers of the vulva, vagina, and penis
cases worldwide [
]. According to estimates, cervical
cancer is the fourth most common cancer among women
with 572,624 new cases worldwide, which around 85%
occurred in less developed regions. Around 266,000
females died of cervical cancer, accounting for 7.5% of all
female cancer deaths [
WHO developed guidelines for prevention and control
of cervical cancer; the main elements in the guideline
were to vaccinate 9–13-year-old girls with two doses of
HPV vaccine, use HPV tests to screen women for
cervical cancer prevention, and communicate more
widely to reach a wider audience e (http://www.who.int/
vaccines are now broadly used in the prevention of cervical
cancer; quadrivalent and bivalent are the two HPV
vaccines developed towards mitigating the burden of
cervical cancer. They have been pre-qualified by the
World Health Organization (WHO) and approved by
national government in many counties [
]. Also, the
adoption of Papanicolaou(Pap) smear screening
programs became successful and resulted in declining
cervical cancer rates in Canada and the USA, but the
incidence of other HPV-related cancers has been
]. These increasing incidences of
HPVrelated cancers have been attributed to changes in
lifestyle-related risk factors, most notably sexual
A scoping review of the literature regarding the
distribution of HPV-related cancers in sub-Saharan
Africa (SSA) is to be conducted. Interventions aimed
at preventing and controlling cervical cancer in high
endemic regions such as SSA are encouraged.
However, research studies aimed at helping improve the
efficiency of implementing these interventions are
required. The aim of the study is to map evidence on
the distribution of HPV-related cancers in
subSaharan Africa. It is anticipated that the results of
this study will reveal research gaps to guide future
primary research and scoping reviews on HPV-related
cancers in sub-Saharan Africa.
Methods and materials
The current scoping review protocol is to be performed
according to Preferred Reporting Items for Systematic
Reviews and Meta-Analysis Protocols (PRISMA-P)
] (Additional file 1: Figure S1), and the protocol is
registered with PROSPERO under registration number
CRD42017062403 and accessible via this link: https://
Scoping review framework
The framework proposed review by Arksey H and
O’Malley will be influential in conducting the
scoping review [
]. The framework involves (I)
identifying the research question, (II) identifying relevant
studies, (III) study selection, (IV) charting the data,
and (V) collating, summarizing, and reporting the
I. Identifying the research question
The major research question is “What is the evidence on
the burden of HPV-related cancers in Sub-Saharan
Research sub-questions are as follows:
What is the burden of HPV-related cancers in
subSaharan Africa with estimation on the prevalence,
incidence, and mortality?
What are the risk factors associated with
What are the trends of HPV-related cancers?
What is the association of HIV and HPV-related
Eligibility criteria Studies will be selected according to
the PEO (population, exposure, and outcomes)
framework outlined below (Table 1).
II. Identifying relevant studies
There will be no date and language restrictions
applied on literature search. We will perform a
keyword search from the following electronic databases:
PubMed; World Health Organization (WHO) library;
Science Direct; Google scholar; EBSCOhost platform
for the following databases: Academic search
complete, Health Source: Nursing/Academic Edition,
and CINAHL with full text. We will use the
following keywords while searching the above databases:
HPV-related cancers, risk factors, prevalence,
incidence, trends, HIV, and sub-Saharan Africa. Boolean
terms AND and OR will be used to separate the
keywords during the search. Mesh terms (Medical
Subject Headings) will also be included in the
search. The researcher will do a hand search of
eligible studies from the list of references of included
III. Study selection and eligibility
Following title screening from the above databases,
articles with relevant title to the subject of the
research will be uploaded on the Endnote X7 X7.7.1
software. Search results from different electronic
databases will be combined in a single EndNote library
(Appendix 1). Studies which do not address the
research question and the duplicates of the same
records will be excluded. From the included studies,
abstract and full articles will be screened by two
independent reviewers. An abstract screening form
with questions will be developed based on the review
eligibility criteria. The screening will be guided by the
eligibility criteria. Discrepancies between reviewers at
the abstract stage will be resolved through consensus
and will involve a third reviewer. Discrepancies between
reviewers at full article stage will be resolved by involving
a third screener.
The relevant studies will be identified with
guidance from the inclusion and exclusion criteria
which were formulated according to the research
Eligibility criteria Inclusion criteria
Study will include individuals with HPV-related
All study designs with relevant intervention
Studies that focus on HPV-related cancers;
prevalence, incidence, mortality, risk factors,
Studies that focus on HIV and HPV-related
Studies that do not focus on HPV-related cancers
Studies that do not focus on humans
Qualitative studies will also be excluded
PRISMA flow chart will be used to report the
Table 2 will be used to show the results of the titles
searched from different databases.
PRISMA flow chart (Additional file 1: Figure S1) will
be used to summarize the inclusion and exclusion
IV. Charting the data
Data from included studies will be extracted using an
extraction form (Appendix 2). A data charting form
will be developed and will be used to determine
which variables to extract that will help to answer the
research question. The extraction form will
continually be updated. The form will include the following:
author with date, study title, study design, study
setting, population, study aim, intervention,
percentages, outcomes of the study, key findings,
and comments (Table 3).
V. Collating, summarizing, and reporting the results.
The aim of this study is to map the existing evidence
and to summarize the findings as presented in
articles. A narrative account of findings from existing
literature will be presented through thematic content
analysis. Literature will be extracted and structured
around the following outcomes: prevalence, incidence,
mortality, risk factors, trends, and HIV. The resulting
themes will be analyzed and results will inspect the
relationship between the findings and the research
question. The meaning of the findings will be
considered as they relate to the overall study purpose and
the implications of these findings for future research,
policy, and practice.
The quality of the evidence obtained from the studies
will be assessed to make sure the study design is
appropriate for the research objectives and the studies
are reported well and to eliminate risk of bias. A
quality appraisal tool which focuses on the study
methods, the Mixed Method Quality Appraisal Tool
(MMAT) Version 2011, will be used [
]. The tool
will be used to examine the quality of an article
looking at the following aspects: the appropriateness
of the aim of the study, adequacy and methodology,
study design, participant recruitment, data collection,
data analysis, presentation of findings, authors’
discussions, and conclusions.
The current scoping review aims to map available
evidence regarding the distribution of HPV-related
cancers, the risk factors, and its association with HIV and
AIDS in sub-Saharan Africa in order to reveal research
gaps in this area. High-risk HPV types are the cause of all
cervical cancers, anogenital cancers including the vulva,
and anal and penile cancers [
], as well as head and
neck cancers . Sub-Saharan Africa has the highest
incidence of HPV and cervical cancer in the world
]. HPV-related cancers are rising and they are a
major public health concern exacerbating current
disease burden in sub-Saharan Africa [
burden of HPV-associated diseases is substantially
increased where there is a HIV-1 co-infection [
and with diverse HIV/AIDS epidemic in sub-Saharan
Africa, the burden of HPV-related cancers might still
rise. The Sustainable Development Goals (SDG)
include targets relevant to women’s cancers, including a
one-third reduction in premature mortality from
noncommunicable diseases through prevention and
treatment by 2030 and achievement of universal health
coverage, with access to quality essential health-care
services and access to safe, effective, quality, and
affordable essential medicines and vaccines for all [
The focus of this review is on HPV-related cancers,
hence excluding studies that do no focus on
HPVrelated cancers and humans as the data will be irrelevant
and will not report according to the set research
questions. The study will focus on all individuals with
HPVrelated cancers regardless of gender. There is a latency
period of 10 years or more between the initial high-risk
HPV infection and the development of cancer; hence,
there are no date restrictions on the literature search.
Since the study is aimed on mapping the distribution of
the HPV-related cancer, qualitative studies will be
excluded in this review.
Despite information about HPV vaccine and testing
within cervical cancer screening programs, it has been
shown that patients’ and public’s knowledge of
HPVrelated cancers is still very little [
]. Therefore, the
results of this study will help address this knowledge
gap. It is anticipated that our study findings will help to
strengthen a need for policy implementation for
prevention of HPV-related cancers and raise more awareness of
HPV-related cancers. Also, government and stakeholders
can be able to ensure that HPV vaccines are introduced
everywhere as part of a coordinated and comprehensive
strategy to prevent cervical cancer and other diseases
caused by HPV. There will also be proper
implementation of education on reducing behaviors that increase
the risk of acquiring HPV infection, training of health
workers and information to women about screening,
diagnosis, and treatment of precancerous lesions and
cancer especially in underdeveloped and financially
constrained countries in sub-Saharan Africa. The finding
will also help strengthen the need of HPV vaccines to be
included in national immunization programs in the
whole of sub-Saharan Africa.
Additional file 1: Figure S1. PRISMA flow diagram. (DOCX 33 kb)
AIDS: Acquired immunodeficiency syndrome; DNA: Deoxyribonucleic acid;
HIV: Human immunodeficiency virus; HPV: Human papilloma virus;
IARC: International Agency for Research on Cancer; MMAT: Mixed Methods
Appraisal Tool; PRISMA-P: Preferred Reporting Items for Systematic Reviews
and Meta-Analysis Protocols; SDG: Sustainable Development Goals;
SSA: Sub-Saharan Africa; WHO: World Health Organization
The authors would like to thank the University of KwaZulu-Natal (UKZN) for the
provision of resources towards this review and the UKZN Systematic Review
Unit for the training and technical support.
Availability of data and materials
All data generated or analyzed during this study will be included in the
published systematic review article.
BL conceptualized the study under the supervision of TG and TPM-T and designed
data collection methods. BL, TG, and TPM-T contributed to writing the first draft of
the manuscript. All authors critically reviewed and approved of the final manuscript.
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
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