Recruitment strategies for cervical cancer screening in three Mediterranean low and middle-income countries: Albania, Montenegro, and Morocco

Introduction Cervical cancer (CC) poses a substantial burden in low-and middle-income countries (LMICs), where challenges in implementing effective screening programs and achieving high participation rates persist. Aims This study sought to compare different strategies for recruiting women for CC screening in Albania, Montenegro, and Morocco, and compared usual care (ongoing invitation method) with an alternative approach (intervention strategy). Methods Within each country, the following comparisons were made: face-to-face (FF) invitations versus phone calls (PCs) in Albania, PCs versus letter invitations in Montenegro, and FF invitations to women attending healthcare centers versus a combined approach termed “Invitation made in Morocco” (utilizing PC and FF for hard-to-reach women) in Morocco. Questionnaires that assessed facilitators and barriers to participation were administered to women who either attended or refused screening. Results In Albania, significant differences in the examination coverage were observed between the invitation methods (PC: 46.1% vs. FF: 87.1%, p 0.01) and between the rural and urban settings (rural: 89.1% vs. urban: 76.3%, p 0.01). In Montenegro, the coverage varied based on the recruitment method (PC: 17.7% vs. letter invitation: 7.6%; p 0.01), the setting (urban: 28.3% vs. rural: 13.2%; p 0.01), and age (34 years: 10.9% vs. 34+: 9.6%, p 0.01). In Morocco, no significant differences were observed. Common screening facilitators included awareness of CC prevention and understanding the benefits of early diagnosis, while key barriers included a limited perception of personal CC risk and the fear of testing positive. Discussion FF appeared to be effective in promoting participation, but its broader implementation raised sustainability concerns. PC invitations proved feasible, albeit necessitating updates to population registries. Restricting FF contacts for hard-to-reach communities may enhance the affordability and equity.