Study protocol for a cluster-randomized trial to compare human papillomavirus based cervical cancer screening in community-health campaigns versus health facilities in western Kenya

Status quo and problem analysis of cervical cancer screening program in China: Based on RE-AIM framework

Background

An organized cervical cancer screening program is an effective method to prevent and control cervical cancer. This study aims to find barriers and facilitators in the implementation process of National Cervical Cancer Screening Program in Rural Areas (NACCSPRA) in China through program evaluation, and thus propose suggestions for optimization of the program.

Methods

Through stratified sampling, 8 provinces (autonomous cities/districts) in eastern, southern, western, northern, and central China were selected for evaluation of NACCSPRA based on the RE-AIM framework. We obtained 15 program providers' experience and perspectives through semi-structured interviews. The data was analyzed using a combination of deductive and inductive analysis methods.

Results

The study found that NACCSPRA mainly serves women with rural household registration or urban minimum living guarantee. Population mobility and certain demographic characteristics such as low education and poor health awareness are common participation barriers, while program publicity acts as a facilitator. A screening program's direct benefit is to promote early detection and treatment of cervical cancer, and its perceived indirect effect is to raise people's health awareness. The proportion of regions adopting the project is relatively high, and factors affecting employees' participation are screening workload, working environment, welfare benefits, degree of preference for grassroots work, and whether the project is included in the performance appraisal; In terms of implementation, there are disparities in screening methods, network informatization levels, and capital investment in various regions. Poor development of screening information system and insufficient screening funds are significant barriers to improvement of project implementation. In contrast, the overall implementation of follow-up is better; related policies issued by the local government and financial subsidies for poor women ensure the maintenance of the project.

Conclusion

Shortage of funds is an important problem faced by current screening project, which negatively influences upgrade of cervical cancer prevention strategy, implementors' working environment, and impedes improvement of information network. In addition, defects in population coverage, especially in mobile population also deserves attention. The study found barriers and facilitators of NACCSPRA perceived by project providers and provided a theoretical foundation for project optimization.

Improve the cervical cancer prevention behaviors through mobile-based educational intervention based on I-CHANGE model: study protocol for a randomized controlled trial

Background

Applications of mobile technologies (mHealth) have the potential to reduce health inequalities, give patients more control over their health, and improve health care’s cost-effectiveness. The widespread use of mobile phones offers us a new way to prevent cervical cancer. The objective of the study was to design and develop a mobile phone application (app) that aims to conduct a behavioral intervention for women and to evaluate the efficacy of the app-based intervention.

Methods

This study involves 5 phases. In the first phase, understanding women’s perspectives will be identified using a qualitative approach based on the I-Change model. In phase 2, the results from the qualitative approach and requirement prioritization through providing experts’ perspectives will be done. The main outputs of this phase will be resulted in prioritizing the main measurable effective variables of the I-Change model. Phase 3 will be processed for the development and psychometric of an assessment tool regarding selected constructs. In phase 4, the App framework and content development will be performed. In phase 5, a three-armed, parallel-design randomized controlled trial will be conducted on women. Two hundred ten women will be randomly assigned to three groups including two intervention groups and one control group. The intervention groups included the following: (1) a mobile application and (2) a digital book. The data will be evaluated using tools designed and constructed in phase 3 of the study at baseline in 3-month follow-up assessments. The impact of the two interventions on cervical cancer prevention behaviors through mobile-based educational intervention will then be evaluated.

Discussion

A theory-based health education program using a mobile app to improve cervical cancer-preventive behaviors will be implemented for the first time in Iran. With an effective health mobile-based educational design, it is very important to determine whether Iranian women will be motivated to adhere to preventive behavior related to CC.

Trial registration

Iranian Clinical Trial Register IRCT20181205041861N3. Registered V2.0 on 26 October 2021.

Barriers and Facilitators to Cervical Cancer Screening in Western Kenya: a Qualitative Study

About nine out of 10 cervical cancer deaths occur in low-resource countries, with a particularly high burden in sub-Saharan Africa. The objectives of this study were to assess barriers and facilitators to cervical cancer screening in western Kenya from the perspectives of community members and healthcare providers. We conducted two focus groups with female community members (n = 24) and one with providers (n = 12) in Migori County, Kenya. Discussion guides queried about knowledge and awareness of cervical cancer prevention; structural, social, and personal barriers; and facilitators towards cervical cancer screening uptake. Group discussions were recorded, transcribed, and analyzed for emerging themes. Participants in both groups reported low awareness of HPV and cervical cancer screening in the community, and identified that as a main barrier to screening. Community members reported fear of pain and embarrassment as significant barriers to a screening pelvic exam. They also reported that providers' lack of knowledge and discomfort with a sensitive subject were significant barriers. A personal connection to cervical cancer and/or screening was associated with willingness to screen and awareness. Providers reported workload and lack of supplies and trained staff as significant barriers to offering services. Based on these findings, we identified three intervention components to address these facilitators and barriers to screening. They include utilizing existing social networks to expand awareness of cervical cancer risk and screening, training non-physician health workers to meet the demand for screening, and employing female-driven screening techniques such as self-collection of specimens for HPV testing. Cervical cancer prevention programs must take into account the local realities in which they occur. In low-resource areas in particular, identifying low-cost, effective, and culturally appropriate strategies for addressing poor screening uptake is important given limited funding. This study took a formative approach to identify facilitators and barriers to cervical cancer screening based on focus groups and interviews with community members and healthcare providers.

Uptake and correlates of cervical cancer screening among women attending a community-based multi-disease health campaign in Kenya

INTRODUCTION

Despite the increased risk of cervical cancer among HIV-positive women, many HIV-care programs do not offer integrated cervical cancer screening. Incorporating self-collected Human Papillomavirus (HPV) testing into HIV programs is a potential strategy to identify women at higher risk for cervical cancer while leveraging the staffing, infrastructure and referral systems for existing services. Community-based HIV and HPV testing has been effective and efficient when offered in single-disease settings.

METHODS

This cross-sectional study was conducted within a community outreach and multi-disease screening campaigns organized by the Family AIDS Care and Education Services in Kisumu County, Kenya. In addition to HIV testing, the campaigns provided screening for TB, malaria, hypertension, diabetes, and referrals for voluntary medical male circumcision. After these services, women aged 25-65 were offered self-collected HPV testing. Rates and predictors of cervical cancer screening uptake and of HPV positivity were analyzed using tabular analysis and Fisher's Exact Test. Logistic regression was performed to explore multivariate associations with screening uptake.

RESULTS

Among the 2016 women of screening age who attended the outreach campaigns, 749 women (35.6%) were screened, and 134 women (18.7%) were HPV-positive. In bivariate analysis, women who had no children (p < 0.01), who were not pregnant (p < 0.01), who were using contraceptives (p < 0.01), who had sex without using condoms (p < 0.05), and who were encouraged by a family member other than their spouse (p < 0.01), were more likely to undergo screening. On multivariable analysis, characteristics associated with higher screening uptake included: women aged 45-54 (OR 1.62, 95% CI 1.05-2.52) compared to women aged 25-34; no children (OR 1.65, 95% CI 1.06-2.56); and family support other than their spouse (OR 1.53, 95% CI 1.09-2.16). Women who were pregnant were 0.44 times (95% CI 0.25-0.76) less likely to get screened. Bivariate analyses with participant characteristics and HPV positivity found that women who screened HPV-positive were more likely to be HIV-positive (p < 0.001) and single (p < 0.001).

CONCLUSIONS

The low screening uptake may be attributed to implementation challenges including long waiting times for service at the campaign and delays in procuring HPV test kits. However, given the potential benefits of integrating HPV testing into HIV outreach campaigns, these challenges should be examined to develop more effective multi-disease outreach interventions.

Comparison of the costs of HPV testing through community health campaigns versus home-based testing in rural Western Kenya: a microcosting study

OBJECTIVES

To estimate the cost of human papillomavirus (HPV)-based screening through community health campaigns (CHCs) and home-based testing.

SETTING

CHCs and home-based testing in six communities in rural Western Kenya.

PARTICIPANTS

CHCs and home-based screening reached 2297 and 1002 women aged 25-65 years, respectively.

OUTCOME MEASURES

Outcome measures were overall cost per woman screened achieved through the CHCs and home-based testing and the cost per woman for each activity comprising the screening intervention.

RESULTS

The mean cost per woman screened through CHCs and home-based testing were similar, at $37.7 (range $26.4-$52.0) and $37.1 (range $27.6-$54.0), respectively. For CHCs, personnel represented 49% of overall cost, supplies 25%, services 5% and capital goods 23%. For home-based testing, these were: personnel 73%, supplies 25%, services 1% and capital goods 2%. A greater number of participants was associated with a lower cost per participant.

CONCLUSIONS

The mean cost per woman screened is comparable for CHC and home-based testing, with differences in type of input. The CHCs generally reached more eligible women in the six communities, whereas home-based strategies more efficiently reached populations with low screening rates.

TRIAL REGISTRATION NUMBER

NCT02124252.

Down-regulation of lncRNA PCGEM1 inhibits cervical carcinoma by modulating the miR-642a-5p/LGMN axis

LncRNA PCGEM1 (PCGEM1) has been reported to exert essential effects on the development and progress of various tumors, while the detailed effects and possible mechanisms of PCGEM1 in cervical carcinoma remain unknown. In the present study, PCGEM1 was over-expressed in cervical carcinoma cells as evidenced by real-time quantitative polymerase chain reaction (RT-qPCR) assay. Knockdown of PCGEM1 significantly repressed proliferation, migration, and invasion, while induced G1 arrest in cervical carcinoma cells. In addition, PCGEM1 was predicted to target miR-642a-5p by bioinformatics software, which was further confirmed by luciferase reporter assay. Besides, RT-qPCR assay indicated that miR-642a-5p expression was decreased in cervical carcinoma cells and knockdown of PCGEM1 could accelerate miR-642a-5p expression. Moreover, inhibition of miR-642a-5p partly abolished the functions of PCGEM1 knockdown on proliferation, cell cycle, migration and invasion of cervical carcinoma cells. Furthermore, miR-642a-5p could bind to the 3'-UTR of LGMN, which was over-expressed in the cervical carcinoma cells. Suppression of LGMN partly restored the functions of miR-642a-5p inhibitor on proliferation, cell cycle distribution, migration and invasion in the cervical carcinoma cells treated with the PCGEM1 shRNA. Taken together, our data indicated that knockdown of PCGEM1 inhibited proliferation, migration and invasion in cervical carcinoma by modulating the miR-642a-5p/ LGMN axis.

Systems-level barriers to treatment in a cervical cancer prevention program in Kenya: Several observational studies

OBJECTIVE

To identify health systems-level barriers to treatment for women who screened positive for high-risk human papillomavirus (hrHPV) in a cervical cancer prevention program in Kenya.

METHODS

In a trial of implementation strategies for hrHPV-based cervical cancer screening in western Kenya in 2018-2019, women underwent hrHPV testing offered through community health campaigns, and women who tested positive were referred to government health facilities for cryotherapy. The current analysis draws on treatment data from this trial, as well as two observational studies that were conducted: 1) periodic assessments of the treatment sites to ascertain availability of resources for treatment and 2) surveys with treatment providers to elicit their views on barriers to care. Bivariate analyses were performed for the site assessment data, and the provider survey data were analyzed descriptively.

RESULTS

Seventeen site assessments were performed across three treatment sites. All three sites reported instances of supply stockouts, two sites reported treatment delays due to lack of supplies, and two sites reported treatment delays due to provider factors. Of the 16 providers surveyed, ten (67%) perceived lack of knowledge of HPV and cervical cancer as the main barrier in women's decision to get treated, and seven (47%) perceived financial barriers for transportation and childcare as the main barrier to accessing treatment. Eight (50%) endorsed that providing treatment free of cost was the greatest facilitator of treatment.

CONCLUSION

Patient education and financial support to reach treatment are potential areas for intervention to increase rates of hrHPV+ women presenting for treatment. It is also essential to eliminate barriers that prevent treatment of women who present, including ensuring adequate supplies and staff for treatment.

A Qualitative Exploration of Women's Experiences with a Community Health Volunteer-Led Cervical Cancer Educational Module in Migori County, Kenya

Detection and treatment of human papillomavirus (HPV) and cervical precancer through screening programs is an effective way to reduce cervical cancer deaths. However, high cervical cancer mortality persists in low- and middle-income countries. As screening programs become more widely available, it is essential to understand how knowledge about cervical cancer and perceived disease risk impacts screening uptake and acceptability. We evaluated women's experiences with a cervical cancer education strategy led by community health volunteers (CHVs) in Migori County, Kenya, as part of a cluster randomized controlled trial of cervical cancer screening implementation strategies. The educational modules employed simple language and images and sought to increase understanding of the relationship between HPV and cervical cancer, the mechanisms of self-collected HPV testing, and the importance of cervical cancer screening. Modules took place in three different contexts throughout the study: (1) during community mobilization; (2) prior to screening in either community health campaigns or health facilities; and (3) prior to treatment. Between January and September 2016, we conducted in-depth interviews with 525 participants to assess their experience with various aspects of the screening program. After the context-specific educational modules, women reported increased awareness of cervical cancer screening and willingness to screen, described HPV- and cervical cancer-related stigma and emphasized the use of educational modules to reduce stigma. Some misconceptions about cervical cancer were evident. With effective and context-specific training, lay health workers, such as CHVs, can help bridge the gap between cervical cancer screening uptake and acceptability.

Silencing of Long Non-coding RNA RP1-93H18.6 Acts as a Tumor Suppressor in Cervical Cancer through the Blockade of the PI3K/Akt Axis

Cervical cancer (CC) remains a distinct public health stumbling block worldwide. Increasing evidence has highlighted long non-coding RNAs (lncRNAs) as tumor-associated biological molecules. In this study, by means of altering the expression of lncRNA RP1-93H18.6 in CC cells, its ability to influence the biological activities of CC cells was evaluated. Differentially expressed lncRNAs were initially screened from the GEO database. A series of RP1-93H18.6 vectors, small interfering RNA (siRNA) against RP1-93H18.6, and LY294002 (an inhibitor for the phosphatidylinositol 3-kinase [PI3K]/Akt [serine/threonine kinase] axis) were introduced in a respective manner to treat the HeLa cells in order to analyze their effects on cellular activities in vitro. Nude mice with xenograft tumors were utilized in order to assess CC tumor growth and metastasis in vivo. lncRNA RP1-93H18.6 was highly expressed in CC, which could activate the P13K/Akt axis. RP1-93H18.6 vectors exposure increased cell viability, adhesion, migration, and invasion, which resulted in more cells arrested at the S stage and reduced apoptosis, while acting to promote tumor growth and metastasis. The siRNA against RP1-93H18.6 or LY294002 exposure was observed to attenuate the effects induced by RP1-93H18.6 vectors. This study suggests that suppression of lncRNA RP1-93H18.6 exerts potent inhibitory effects on the development and progression of CC via blockade of the PI3K/Akt axis.

Patient factors affecting successful linkage to treatment in a cervical cancer prevention program in Kenya: A prospective cohort study

Objective

To identify patient factors associated with whether women who screened positive for high-risk human papillomavirus (hrHPV) successfully accessed treatment in a cervical cancer prevention program in Kenya.

Methods

A prospective cohort study was conducted as part of a trial of implementation strategies for hrHPV-based cervical cancer screening in western Kenya from January 2018 to February 2019. In this larger trial, women underwent hrHPV testing during community health campaigns (CHCs), and hrHPV+ women were referred to government facilities for cryotherapy. For this analysis, we looked at rates of and predictors of presenting for treatment and presenting within 30 days of receiving positive hrHPV results (“timely” presentation). Data came from questionnaires completed at the time of screening and treatment. Multivariable logistic regression was used to identify factors associated with each outcome.

Results

Of the 505 hrHPV+ women, 266 (53%) presented for treatment. Cryotherapy was performed in 236 (89%) of the women who presented, while 30 (11%) were not treated: 15 (6%) due to gas outage, six (2%) due to pregnancy, five (2%) due to concern for cervical cancer, and four (2%) due to an unknown or other reason. After adjusting for other factors in the multivariable analysis, higher education level and missing work to come to the CHC were associated with presenting for treatment. Variables that were associated with increased likelihood of timely presentation were missing work to come to the CHC, absence of depressive symptoms, told by someone important to come to the CHC, and shorter distance to the treatment site.

Conclusion

The majority of hrHPV+ women who did not get treated were lost at the stage of decision-making or accessing treatment, with a small number encountering barriers at the treatment sites. Patient education and financial support are potential areas for intervention to increase rates of hrHPV+ women seeking treatment.

Female perspectives on male involvement in a human-papillomavirus-based cervical cancer-screening program in western Kenya

BACKGROUND

To be effective, population-based cervical cancer prevention programs must be tailored to meet the needs of the target population. One important factor in cervical cancer screening may include male involvement. To iteratively improve a screening program employing self-collected vaginal swabs for human-papillomavirus (HPV) testing in western Kenya, we examined the role of male partners and community leaders in decision-making and accessing screening services.

METHODS

We carried out 604 semi-structured, in-depth interviews (IDIs) with women and community health volunteers who took part in a multiphase trial of implementation strategies for HPV-based cervical cancer screening. IDIs were coded and themes related to decision-making, screening and treatment barriers, and influence of male partners and community leaders were identified and analyzed.

RESULTS

Women experienced both support and opposition from their male partners. Partner support took the form of financial support for transportation and emotional support and encouragement, while opposition ranged from anticipated negative reactions to lack of permission, isolation, and abandonment. Though most women described their own partners as supportive, many felt that other male partners would not be supportive. Most participants believed that increased HPV and cervical cancer knowledge would increase partner support. Women reported a general acceptance of involvement of community leaders in education and screening campaigns, in a setting where such leaders may hold influence over men in the community.

CONCLUSION

There was a clear interest in involving male partners in the cervical cancer prevention process, specifically in increasing knowledge and awareness. Future research should explore the feasibility and effectiveness of engaging male partners in cervical cancer screening and prevention programs.

'I'm here to save my life': a qualitative study of experiences navigating a cryotherapy referral system for human papillomavirus-positive women in western Kenya

BACKGROUND

We sought to understand the beliefs, social norms and logistical factors that affect human papillomavirus (HPV)-positive women's uptake of cryotherapy treatment as part of a two-part cervical cancer screening strategy in rural Kenya.

METHODS

In-depth interviews within a parent cluster-randomised trial.

SETTING

Government-run county hospital in western Kenya.

PARTICIPANTS

273 of 372 (73.4%) HPV-positive women who underwent cryotherapy RESULTS: Many women feared that an HPV infection meant they would develop cancer. Almost all women reported initial fear of the treatment procedure, followed by a more positive experience than anticipated. Lacking funds for transportation to the treatment site was the most common barrier. Women felt that decentralised treatment would be the most important facilitator of greater access. Spousal encouragement and financial support were key facilitators of treatment access, however many women felt that other husbands in the community would not be supportive. Women described successfully acquiring treatment as empowering, and almost all would recommend seeking cryotherapy to other women who test HPV-positive. Most felt eager to share their own experiences with others to encourage treatment.

CONCLUSIONS

The main facilitators of treatment access were understanding of the health risks and sense of empowerment. A decentralised treatment model or transportation support may facilitate access, along with improved health messaging about HPV infection, cancer and the treatment process. Focusing on women's personal feelings of empowerment may further improve uptake and satisfaction. These data will be used to design a strategy to improve linkage to treatment.

TRIAL REGISTRATION

NCT02124252.

Perspectives of women participating in a cervical cancer screening campaign with community-based HPV self-sampling in rural western Kenya: a qualitative study

BACKGROUND

Despite cervical cancer being preventable with effective screening programs, it is the most common cancer and the leading cause of cancer-related death among women in many countries in Africa. Screening involving pelvic examination may not be feasible or acceptable in limited-resource settings. We sought to evaluate women's perspectives on human papillomavirus (HPV) self-sampling as part of a larger trial on cervical cancer prevention implementation strategies in rural western Kenya.

METHODS

We invited 120 women participating in a cluster randomized trial of cervical cancer screening implementation strategies in Migori County, Kenya for in-depth interviews. We explored reasons for testing, experience with and ability to complete HPV self-sampling, importance of clinician involvement during screening, factors and people contributing to screening decision-making, and ways to encourage other women to come for screening. We used validated theoretical frameworks to analyze the qualitative data.

RESULTS

Women reported having positive experiences with the HPV self-sampling strategy. The factors facilitating uptake included knowledge and beliefs such as prior awareness of HPV, personal perception of cervical cancer risk, desire for improved health outcomes, and peer and partner encouragement. Logistical and screening facilitators included confidence in the ability to complete HPV self-sampling strategy, proximity to screening sites and feelings of privacy and comfort conducting the HPV self- sampling. The barriers to screening included fear of need for a pelvic exam, fear of disease and death associated with cervical cancer. We classified these findings as capabilities, opportunities and motivations for health behavior using the COM-B framework.

CONCLUSIONS

Overall, HPV self-sampling was an acceptable cervical cancer screening strategy that seemed to meet the needs of the women in this community. These findings will further inform aspects of implementation, including outreach messaging, health education, screening sites and emphasis on availability and effectiveness of preventative treatment for women who screen positive.

Comparison of patient flow and provider efficiency of two delivery strategies for HPV-based cervical cancer screening in Western Kenya: a time and motion study

Background: Improving patient flow and reducing over-crowding can improve quality, promptness of care, and patient satisfaction. Given low utilization of preventive care in low-resource countries, improved patient flows are especially important in these settings.

Objective: Compare patient flow and provider efficiency between two cervical cancer screening strategies via self-collected human papillomavirus (HPV).

Methods: We collected time and motion data for patients screened for cervical cancer in 12 communities in rural Migori County, Kenya as part of a larger cluster randomized trial. Six communities were randomized to screening in community health campaigns (CHCs) and six to screening at government clinics. We quantified patient flow: duration spent on each active stage of screening and wait times, and the number of patients arriving at CHCs and clinics each hour of the day. In addition, for four CHCs, we collected time and motion data for providers, and measured provider efficiency as a ratio of active (service delivery) time to total time spent at the clinic.

Results: Total duration of screening visits, at CHCs and clinics was 42 and 87 minutes, respectively (p < 0.001 for difference). Total active time lasted longer at CHCs, with a mean of 28 minutes per patient versus 15 minutes at clinics, largely due to differences in duration for group education (p < 0.001). Wait time for registration at clinics was 36 minutes, explaining most of the difference between settings, but sometimes incorporated other health services.

Conclusions: There is a substantial difference in patient flow at clinics compared to CHCs. Shorter duration at CHCs suggests that the model is favorable for patients in limiting time spent on screening. Future cervical cancer screening programs designed for scale-up should consider how this advantage may enhance satisfaction and uptake. For clinic-based screening programs, efforts could be made towards reducing registration wait times.