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Réalisé en cotutelle avec Dr. Béatrice Godard, Professeure titulaire à l'Université de Montréal. / Les écrits scientifiques ont démontré un écart important entre les populations, quant à la survie du cancer du sein. Il s’avèrerait que les femmes immigrantes meurent davantage du cancer du sein que les non-immigrantes. Plusieurs études attribuent ce phénomène à une faible adhérence à la mammographie chez ces femmes. Ainsi, une détection trop tardive de la maladie réduit évidemment les chances de survie. Au Québec, le Programme Québécois de Dépistage du Cancer du Sein envoie une lettre d’invitation aux femmes dès qu’elles atteignent 50 ans. Cette lettre est une prescription pour une mammographie de dépistage. Cette étude a démontré que cette lettre est une barrière à la mammographie pour les communautés immigrantes de Montréal, plus précisément la communauté haïtienne défavorisée, et ce en raison de leur faible niveau de littératie. Suite aux résultats obtenus, nous suggérons des modifications à cette lettre d’invitation, afin qu’elle puisse être accessible à toutes les femmes, dont les femmes de milieux défavorisés. / Research has demonstrated significant disparities amongst populations in regard to chances of survival to breast cancer. It has proven to be the case that immigrant women are more likely to die of breast cancer than non-immigrants. Several studies attribute this to poor adherence to mammography testing within this group of women. Thus, late detection of this disease unavoidably reduces their chances of survival. In Quebec, the Quebec Breast Cancer Screening Program sends a letter of invitation to women when they attain 50 years of age. This letter is a prescription for a screening mammogram. The present study has demonstrated that this letter is a barrier for immigrant communities in Montreal, ore specifically the underprivileged Haitian community. This is due to their low level of literacy. Consecutive to the results obtained in this study, we suggest modifications to the letter of invitation, in order to ensure that its content is accessible to all women, including women in underprivileged circumstances.

Les écrits scientifiques ont démontré un écart important entre les populations, quant à la survie du cancer du sein. Il s’avèrerait que les femmes immigrantes meurent davantage du cancer du sein que les non-immigrantes. Plusieurs études attribuent ce phénomène à une faible adhérence à la mammographie chez ces femmes. Ainsi, une détection trop tardive de la maladie réduit évidemment les chances de survie. Au Québec, le Programme Québécois de Dépistage du Cancer du Sein envoie une lettre d’invitation aux femmes dès qu’elles atteignent 50 ans. Cette lettre est une prescription pour une mammographie de dépistage. Cette étude a démontré que cette lettre est une barrière à la mammographie pour les communautés immigrantes de Montréal, plus précisément la communauté haïtienne défavorisée, et ce en raison de leur faible niveau de littératie. Suite aux résultats obtenus, nous suggérons des modifications à cette lettre d’invitation, afin qu’elle puisse être accessible à toutes les femmes, dont les femmes de milieux défavorisés. / Research has demonstrated significant disparities amongst populations in regard to chances of survival to breast cancer. It has proven to be the case that immigrant women are more likely to die of breast cancer than non-immigrants. Several studies attribute this to poor adherence to mammography testing within this group of women. Thus, late detection of this disease unavoidably reduces their chances of survival. In Quebec, the Quebec Breast Cancer Screening Program sends a letter of invitation to women when they attain 50 years of age. This letter is a prescription for a screening mammogram. The present study has demonstrated that this letter is a barrier for immigrant communities in Montreal, ore specifically the underprivileged Haitian community. This is due to their low level of literacy. Consecutive to the results obtained in this study, we suggest modifications to the letter of invitation, in order to ensure that its content is accessible to all women, including women in underprivileged circumstances. / Réalisé en cotutelle avec Dr. Béatrice Godard, Professeure titulaire à l'Université de Montréal.

Text in English / Cervical cancer remains the leading cause of cancer mortality among women worldwide, a burden in the developing countries and commonly detected through symptoms at later invasive stages. The study aimed at establishing knowledge and awareness of the importance of cervical cancer screening in the Makhuduthamaga Sub-district by exploring the perceptions of women and professional nurses and through the review of the National Cervical Cancer Screening Policy (2013). Recommendations to address the gap in knowledge and to inform the National Cervical Cancer Screening Policy were developed based on the study findings. A mixed-method approach was used in this study through a sequential explanatory design, which is quantitatively driven was used. Quantitative data were obtained by using a researcher developed checklist. The checklist was developed from variables stated in the National Cervical Cancer Screening Policy and was used to review its implementation. Qualitative data was obtained through in-depth interviews with individual women and focus group discussions with professional nurses. The study was conducted in ten randomly selected clinics of Makhuduthamaga Sub-district. Purposive sampling was done to obtain qualitative data. An average score of 9.7 was obtained for all ten clinics that participated in the study with regard to the evaluation of the implementation of the National Cervical Cancer Screening Policy. Only 6 (60%) clinics implemented the policy whereas 4 (40%) clinics did not implement the policy. Women and professional nurses perceived cervical cancer screening as important. Lack of knowledge among women regarding cervical cancer screening contributed to the majority of women not screening for cervical cancer. Lack of resources, the 10 year interval of normal cervical cancer screening, the use of disposable vaginal speculums and brushes, lack of standardized cervical cancer screening training, centralization of cytology laboratories came out as factors that negatively influence the uptake of cervical cancer screening. Cervical cancer screening awareness campaigns, availability of resources and standardized in-service trainings on cervical cancer screening were recommended to enhance the cervical cancer screening uptake. Key concepts: / Health Studies / D. Litt. et Phil. (Health Studies)

A l'échelle mondiale, le cancer du col de l'utérus (CCU) constitue un problème majeur de santé publique touchant 528 000 femmes, il est responsable de 266 000 décès chaque année. Son taux d'incidence varie d'un pays à l'autre et reste remarquablement plus élève dans les pays en voie de | développement où l'accès aux soins, même primaires reste précaire. De nombreuses études I épidémiologiques ont démontré qu'environ 99,7 % des cancers du col de l'utérus sont associés à l'infection par des Papillomavirus Humains (HPV) oncogènes, en particulier les HPV16 et 18. Ces données ont permis le développement de vaccins prophylactiques dirigés contre ces deux génotypes viraux. Il s'agit d'un des! cancers les plus faciles à prévenir et à traiter a condition qu'il soit détecté suffisamment tôt et traité| correctement. L'objectif de ce travail de thèse était d'étudier deux populations de femmes à risque du CCU qui vivent sur deux continents différents (Afrique/Europe). Ces deux populations étaient référées auprès de médecins hospitaliers pour des problèmes gynécologiques. La majorité des femmes n'avaient pas été dépistées (femmes marocaines), ou avaient été sous-dépistées selon les recommandations de l'ANAES (femmes françaises de plus de 65 ans). Au cours de cette étude, les femmes ont eu un frottis cervico-utérin (FCU) pour une analyse cytologique et une recherche d'ADN d'HPV, soit par amplification de cible (PCR ; population marocaine), soit par amplification de signa! (test hc2 ; population française). Les échantillons; HPV positifs ont ensuite été génotypes, soit par génotypage complet (INNO-LiPA ; population marocaine),| soit par génotypage partiel (qPCR HPV16,18 et 45 ; population française). Les frottis étaient normaux dans la majorité des cas : chez 81,9% des femmes marocaines et 68,6% des femmes françaises. Les frottis de signification indéterminée (ASC-US) ont été diagnostiqués chez 15,8% des femmes françaises. Les frottis en faveur d'une lésion de bas grade (LGSIL) étaient observes chez 12,9% des femmes marocaines et 7,4% des femmes françaises. Les frottis en faveur d'une lésion de haut grade (HGSIL) étaient de 5,2% chez les femmes marocaines et 4% chez les femmes françaises. Les frottis évocateurs de cancer ont été décelés uniquement dans la population française (2,9%). La prévalence d'HPV était du même ordre de grandeur (23%) dans les 2 populations et augmentait avec la sévérité de la lésion cytologique pour atteindre 75% dans les frottis HGSIL chez les femmes marocaines et plus de 90% chez les femmes françaises. La quasi-totalité des échantillons en faveur d'un CCU étaient infectés par un HPV. Par ailleurs, dans les deux populations, le génotype prévalent dans tous les types de frottis était THPV16, génotype le plus cardnogène. Un tiers (36,2%) de la cohorte des femmes marocaines était infecté par le VIH, qui s'est avéré le plus important facteur prédictif de l'infection HPV, indépendamment des autres facteurs de risqueI étudiés (caractéristiques sociodémographiques, comportement sexuel, tabagisme...). En France, le dépistage du CCU est préconisé tous les trois ans chez les femmes de 25 à 65 ans. Toutefois, les femmes âgées de plus de 65 ans dont l'espérance de vie est élevée et qui n'ont pas été ou qui ont été mal dépistées pourraient bénéficier d'un test HPV dont la Valeur Prédictive Négative est très élevée. Au Maroc, en l'absence de dépistage organise, il est aussi souhaitable de proposer un test HPV dans le cadre du dépistage j du CCU. La vaccination anti-HPV pourrait aussi prévenir ce cancer. / Worldwide, cervical cancer (CC) is a major public health problem affecting 528 000 women and responsible for 266 000 deaths every year. Its incidence rate varies from one country to another and remains remarkably higher in developing countries where access to care, even primary remains precarious. Many epidemiological studies have shown that approximately 99.7% of cancers of the cervix are associated with infection with oncogenic Human Papillomavirus (HPV), especially HPV16 and 18. These data allowed the development of prophylactic vaccines directed against these two viral genotypes. It is one of the easiest cancers to prevent by early detection of precancerous lesions. The objective of this PhD thesis work was to study two populations of women at risk of CC who live on two different continents (Africa / Europe). These two populations were referred to hospital doctors for gynecological problems. The majority of women were not screened (Moroccan women) or were under-screened according to ANAES recommendations (French women over 65 years). At entry in the study, women had a cervical smear for cytology and HPV DNA research, either by target amplification (PCR; Moroccan population) or signal amplification (hc2 test; French population). HPV positive samples were then genotyped, either with full genotyping (INNO-LiPA; Moroccan population) or with partial genotyping (qPCR targeting HPV16,18 and 45; French population). Smears were normal in most cases: in 81.9% of Moroccan women and 68.6 % of French women. Atypical Squamous Cells of Undetermined Significance (ASC-US) were diagnosed in 15.8% of French women. Smears in favour of low grade lesion (LGSIL) were observed in 12.9% of Moroccan women and 7.4 % of French women. Smears in favour of high grade lesion (HGSIL) were in 5.2 % of Moroccan women and 4% of French women. Smears suggestive of cancer were detected only in the French population (2.9%). The prevalence of HPV was of the same order of magnitude (23%) in both populations; and increased with the severity of cytological lesions to reach 75% in HGSIL smears among: Moroccan women and over 90% among French women. Almost ail samples with CC were infected with high risk HPV. Furthermore, in both populations, the most prevalent genotype in ail types of smear wasHPV16, known to be the most carcinogenic. One third (36.2%) of the cohort of Moroccan women was infected with HIV, which was the most powerful predictor of HPV infection, independent of other risk factors studied (sociodemographic characteristics, sexual behavior, smoking ...).In France, CC screening is recommended every three years for women 25 to 65 years. However, women over 65 whose life expectancy is high and who have not been or have been poorly screened could benefit from an HPV test. In Morocco, in absence of organized screening, it is also desirable to provide an HPV test as a part of CC screening. The HPV vaccines could improve the situation by reducing the incidence and mortality from this cancer

Cervical cancer is an emerging public health problem in developing countries. Globally, it is the 3rd most common malignancy in women after breast and colorectal cancers and 4th most frequent cancer in women, with an estimated 570,000 new cases and 311,000 deaths in 2018. Cervical cancer screening in the developed countries is credited with the reductions in cervical cancer morbidity and mortality during the last 50 years. However, nearly 90% of cervical cancer deaths occur in less developed countries. Ghana has a cervical cancer rate of 26.4%. Further, it is the highest cancer incidence faced among women 25 to 44 years and has a mortality rate of 17.4% in this age group. Knowledge, culture, attitude, and beliefs are known to limit women's participation in Pap test screening programs. Guided by the health belief model, the purpose of this quantitative study was to examine how knowledge, attitude, culture, and religious beliefs affected intent to seek Pap test screening among adolescent girls in Accra, Ghana. A total of 155 participants ages 16 to 20 years completed a 30-item questionnaire. Descriptive frequencies were calculated. Correlation and Chi-square tests were also performed to assess associations with intent to screen with Pap test. Most girls (92%) had never heard about Pap test screening. There were statistically significant correlations between cervical cancer knowledge (p=0.032) and attitude (p=0.001) with intent to participate in Pap test screening. However, culture (p=0.049) and religious beliefs (p=0.529) were not significantly associated with screening intent. The implications for social change include informing practice and research on how cervical cancer prevention programs can be tailored to girls living in countries where different cultural and religious values are practiced.

Text in English / The purpose of the study was to explore perceptions, knowledge and attitudes of women undergoing cervical cancer screening in Omaheke, Namibia. A qualitative exploratory study was conducted. Data were collected from a purposive sample of eight participants using a self-developed interview guide. Data were analysed using Tesch’s descriptive method of open coding. Three themes were identified namely; cervical cancer as a disease, perception of cervical cancer and service delivery at the facility. The findings also revealed some suggestions for the facility that could improve screening uptake. The study proposes a community education programme on cervical cancer and related topics to be covered during health education sessions. In addition the study recommends the Omaheke directorate to look into operational issues in order to facilitate access to cervical cancer screening. / Health Studies / M.P.H.

Cette thèse s’intéresse à plusieurs questions posées par l’introduction et la généralisation, en France, d’incitatifs économiques de type P4P appliqués à la médecine générale. Ces schémas incitatifs (CAPI, ROSP) ont pour objectif d’améliorer la qualité des soins, mais ils sont débattus en termes d’efficience et d’effets indésirables potentiels. Dans un premier temps, nous évaluons l’impact du CAPI sur différents indicateurs de la qualité des soins : la durée de la consultation et le dépistage des cancers. Puis, nous étudions les modalités d’une meilleure implication du médecin généraliste (MG) dans le dépistage des cancers, en appliquant la méthodologie des choix discrets. Enfin, nous analysons la relation entre motivations intrinsèques et extrinsèques des MGs français. Nous montrons que le CAPI n’a pas eu d’impact significatif sur les indicateurs de qualité considérés et que les MGs seraient sensibles à d’autres dispositifs non monétaires potentiellement moins coûteux. Enfin, nous mettons en évidence une relation de substituabilité entre motivations intrinsèques et extrinsèques. Ces résultats invitent à davantage de prudence dans la définition des incitatifs économiques en médecine générale. / This thesis addresses several issues raised by the introduction in France of economic incentives such as pay-For-Performance applied to general practice. These incentive schemes are designed to improve the quality of care, but they are discussed both in terms of effectiveness and potential side effects. Initially, we assess the impact of the CAPI scheme on various indicators of quality of care: the consultation length and cancers screening. Then, using the discrete choice experiment methodology, we reveal general practitioners (GPs) preferences for devices aimed at improving the early detection of cancers. Finally, we analyse empirically the relationship between French GPs' intrinsic and extrinsic motivations. We show that the CAPI has not had a significant impact on the selected quality indicators. In addition, GPs would be sensitive to potentially less costly nonmonetary devices. Eventually, we highlight a negative relationship between GPs' intrinsic and extrinsic motivations. Our results call for greater caution in the definition of economic incentives in general practice.

The purpose of this study was to describe the factors that determine the utilisation of VIA, and to investigate the socio-economic status of women who undergone VIA. A retrospective document analysis of 323 clinical records was conducted at a specific rural hospital in Zimbabwe. A retrospective, cross-sectional, non-experimental, descriptive, analysis of clinical records was conducted using a checklist to extract data from the records of women who have undergone VIA for cervical screening at the specific rural hospital. The results revealed that 70% (N=225) were from outside the catchment area, 73% (N=234) were poor, 54% (N=173) were of high parity, 85% (N=275) were ill with conditions that included lower back and abdominal pains, excessive vaginal discharge and vaginal bleeding after intercourse. The study further revealed that 72% (N=226) had no prior cervical cancer screening and 87% (N=277) were screened by chance. The conclusion drawn was that socio-economic and logistical constraints hinder cervical cancer screening among rural women. It is recommended that VIA screening and health education on cervical cancer be offered to all women visiting healthcare facilities. Furthermore, the government should consider funding in order to prioritise women’s health issues. / Health Studies / M.A. (Nursing Science)