Background: Cervical cancer affects women worldwide, but sub-Saharan Africa (SSA) bears the highest burden of the disease due to multiple factors including limited knowledge, unavailability of services, cultural and religious views, and a high burden of HIV infection. Nigeria, through its National Cancer Control Plan 2018-2022, has the ambition to ensure that at least 50% of eligible women receive cervical screening through a nationwide routine screening programme, using human papillomavirus (HPV) testing or visual inspection with acetic acid (VIA), and management of precancerous lesions based on a "see and treat" model at the primary health care level, by 2022. Nigeria, however, cannot afford this goal due to a weak health system, limited resources, competing demands such as HIV and, more recently the COVID-19 pandemic. Nevertheless, communities in SSA have a noble culture of communality, kinship and interdependency. Therefore, understanding and harnessing these practices and beliefs, and the decision-making process for seeking health care, will be strategic to eliminating cervical cancer in the region. My PhD explored these opportunities for sustainable community-based cervical screening services in Gombe State, Nigeria. The objectives were to: 1. Review the literature for evidence regarding community involvement in supporting cervical cancer screening in SSA; 2. Assess the knowledge of cervical cancer and factors influencing health seeking behaviour for cervical screening services among women in Gombe State, Nigeria; and 3. Explore community readiness for community-based cervical screening services in Gombe State, Nigeria, through stakeholder interviews. Methods: My study used mixed-methods (a convergent, parallel-database variant design) research in 3 stages concurrently: 1) A systematic review (study 1a) of studies with a community focus for evidence of effectiveness and implementation of interventions by community-based resources (CBRs), such as community health workers (CHWs) and community-based civil society organisations (CBOs), in increasing uptake and/or continuing participation in cervical cancer screening in SSA (I chose to restrict coverage to SSA for findings to be of immediate applicability to my target population). A narrative framework was employed for the review's data synthesis. I also undertook a scoping review (study 1b) of recent evidence (2016-2020) describing the role of CBRs in cervical cancer screening; it focused on studies from low-and-medium-income countries (LMICs), and explored and compared findings between SSA and LMICs sub regions; 2) A community-based participant survey (study 2) of 2,158 women aged 18-70 years, attending a community health facility, which explored the understanding of cervical cancer and cervical screening seeking behaviour of women in Gombe State, Nigeria; and 3) A key informant interview (study 3) with 31 stakeholders - community and religious leaders, women leaders, health facility staff, primary care agency staff, leaders of women's organisations and NGOs supporting HIV and reproductive health services in communities in Gombe State, Nigeria. Thematic analysis was undertaken using an Ecological Model approach, to obtain insights into community factors affecting readiness for cervical screening, and a community readiness assessment scoring for overall readiness level. Results: Study 1a: 49 studies published between January 1980 and March 2019 were included. Studies were representative of 4 SSA regions: Eastern (n=20), Western (n=13), Southern (n=9), and Central (n=4); 29 cross-sectional, 6 RCTs, 6 pre-test/post-test, 1 controlled before and after study, and 5 qualitative studies were included. Most studies were of weak quality, with selection bias the most common weakness. Narrative synthesis findings: 1) Mapping of CBRs-based interventions showed that interventions provided by CBRs had multi-level impacts in three main domains: to increase demand (uptake) for cervical screening, to increase access to cervical screening, and through innovative approaches to enhance screening provision; 2) Multi-level CBRs-based interventions showed evidence of effectiveness at increasing uptake of cervical screening irrespective of study design; and 3) The facilitators and barriers affecting implementation of community-based cervical screening are reported in three major domains: factors associated with increasing demand for screening, factors associated with increasing access to screening, and factors associated with sustainability of screening services. Study 1b: From the international literature, the roles of CBRs across LMICs are broadly similar, although nuanced differences exist. Study 2: 2,158 women took part in the survey, with a mean age of 30 years (range 18-70 years). Overall, awareness of cervical cancer was low with 85% of women unaware of cervical cancer: out of the 15% that reported having awareness, less than 30% had good cervical cancer-related knowledge. The factors associated with the lowest level of awareness of cervical cancer were: being aged less than 30 years, being married, living in rural areas, lower education level (in woman and husband), no current occupation, lack of use of contraceptives, and living with HIV. The major preferences (outcomes) affecting cervical screening seeking behaviours included: 1) very low intention to screen for cervical cancer; 2) high gender preference for female health worker to perform screening; 3) high proportion of women needing permission from husband to go for screening; 4) high proportion of women preferring to be accompanied by husband to place of screening; and 5) high proportion of women preferring to get screening at general hospital rather than community clinic. The predictors associated with these behaviours included: poor cervical cancer-related knowledge, unavailability of screening services, being married, and Muslim faith. I also identified three cervical screening seeking behaviour preferences among women living with HIV compared to those without HIV: 1). 29.4% vs 70.6% for those who said they needed permission from husband to get screening; 2). 27.4% vs 72.6% for those who said they prefer to be accompanied by husband to place of screening; 3). 30.2% vs 69.8% for those who ever had cervical screening. However, no predictors were found to be associated with screening seeking behaviour preferences among women living with HIV. Therefore, women living with HIV reported a higher likelihood of accepting cervical screening services compared with those who did not have HIV, possibly due to frequent contact with health services. Study 3: Thirty one stakeholders were interviewed: 16 were female and 15 male; 16/31 were aged 40-49 years, 14/31 were health facility staff, and 7/31 were community leaders. An in-depth analysis of stakeholder perspectives identified that factors affecting readiness for community-based cervical screening services occur at multiple levels of the ecological model in the community. These factors form four broad categories of primarily negative factors affecting readiness, namely: limited knowledge, some negative attitudes and behaviours, insufficient resources and momentum, and unfavourable contextual factors, e.g. high levels of poverty and illiteracy. Interestingly, stakeholders indicated that there was a well-developed sense of community, with huge commitment from community and religious leaders, community-based organisations, women's networks and local health care workers, to overcome the identified barriers to accessing services. The overall level of readiness score for communities in Gombe State was assessed to be low, i.e. vague awareness, which is linked to the four categories of primarily negative factors listed above. Discussion: My thesis has identified strategic opportunities for future implementation of sustainable community-based cervical screening services in Gombe State, Nigeria. Among CBRs in SSA, CHWs mainly provided: educational interventions to increase demand for screening, reduction of structural barriers to increase access to screening, and innovative interventions by supporting or conducting screening. CBOs were mainly involved in providing educational interventions to increase community demand for screening, and supporting screening provision within their institutions. Women in Gombe State have limited knowledge of screening, mainly due to unavailability of services, and their characteristics, e.g. living in rural areas, having education below secondary, being married, having no occupation, and having never used contraceptives. They also indicated likely behaviour preferences, linked to their cultural and religious values and practices, which would be potential barriers to their participation in screening services. More interestingly, cervical screening seeking behaviour preferences of women who had HIV were less affected by cultural values and practices. The low level of readiness for community-based cervical screening services from stakeholders' interviews highlights the need to leverage CBRs and local health workers to raise awareness about cervical cancer and overcome barriers to accessing services. Conclusion: My thesis has highlighted the altruistic qualities in communities in SSA. Future implementation of community-based cervical screening services should draw on the skills and established roles of CBRs: to increase demand and access to screening, and to ensure sustainability of screening campaigns and programmes. It should prioritise awareness raising, integration with cultural values and practices of the community, integration with HIV services and leveraging existing HIV structures in the community, and collaboration with relevant NGOs and CBRs.