Health care workers' experiences with implementation of "screen and treat" for cervical cancer prevention in Malawi: A qualitative study

Catalyzing Change: Assessing Inner Setting Context of Cervical Cancer Prevention Efforts in Loreto, Peru, Prior to Transition from VIA to HPV Screen-and-Treat

Background

The objective of this study was to understand health care providers' perspectives regarding the facilitators of and barriers to the success of the former Pap and VIA-based cervical cancer program in Iquitos, Peru, using the Consolidated Framework for Implementation Research (CFIR) to inform the transition to the HPV screen-and-treat intervention. By exploring the pre-implementation organizational context, or inner setting, through the opinions of those who would implement the HPV-based intervention at the patient care level, this research lays the foundation to assess readiness before implementation and understand what's necessary to design contextually appropriate and sustainable interventions in LMIC settings.

Methods

We conducted 19 semi-structured interviews with health professionals (12 nurse-midwives, 4 doctors, and 3 laboratory technicians) who administered the former Pap- and VIA-based cervical cancer EDT program.

Results

Providers identified information gaps between the primary level of care, where cervical cancer screening occurs, and the hospital level of care, where diagnosis and treatment occurs. These gaps, which were caused in part by fragmented, antiquated, and overlapping data systems, resulted in the loss of patients between levels of care. Participants also noted a lack of trained personnel and basic materials. Some providers found their way around these gaps by facilitating informal information exchanges among providers to ensure women were not lost to follow-up.

Conclusions

PPC relied on these findings and other data from INSPIRE Phase 1 to implement a HPV-based screen-and-treat program that dramatically increased screening and treatment; however, challenges remain regarding resources and sustainability related to HPV technology.

Baseline assessment of cervical cancer screening and treatment capacity in 25 counties in Kenya, 2022

Background

Cervical cancer is the leading cause of cancer deaths among women in Kenya. In the context of the Global strategy to accelerate the elimination of cervical cancer as a public health problem, Kenya is currently implementing screening and treatment scale-up. For effectively tracking the scale-up, a baseline assessment of cervical cancer screening and treatment service availability and readiness was conducted in 25 priority counties. We describe the findings of this assessment in the context of elimination efforts in Kenya.

Methods

The survey was conducted from February 2021 to January 2022. All public hospitals in the target counties were included. We utilized healthcare workers trained in preparation for the scale-up as data collectors in each sub-county. Two electronic survey questionnaires (screening and treatment; and laboratory components) were used for data collection. All the health system building blocks were assessed. We used descriptive statistics to summarize the main service readiness indicators.

Results

Of 3,150 hospitals surveyed, 47.6% (1,499) offered cervical cancer screening only, while 5.3% (166) offered both screening and treatment for precancer lesions. Visual inspection with acetic acid (VIA) was used in 96.0% (1,599/1,665) of the hospitals as primary screening modality and HPV testing was available in 31 (1.0%) hospitals. Among the 166 hospitals offering treatment for precancerous lesions, 79.5% (132/166) used cryotherapy, 18.7% (31/166) performed thermal ablation and 25.3% (42/166) performed large loop excision of the transformation zone (LLETZ). Pathology services were offered in only 7.1% (17/238) of the hospitals expected to have the service (level 4 and above). Only 10.8% (2,955/27,363) of healthcare workers were trained in cervical cancer screening and treatment; of these, 71.0% (2,097/2,955) were offering the services. Less than half of the hospitals had cervical cancer screening and treatment commodities at time of survey. The main health system strength was presence of multiple screening points at hospitals, but frequent commodity stock-outs was a key weakness.

Conclusion

Training, commodities, and diagnostic services are major gaps in the cervical cancer program in Kenya. To meet the 2030 elimination targets, the national and county governments should ensure adequate financing, training, and service integration, especially at primary care level.

Implementation and scaling-up of an effective mHealth intervention to increase adherence to triage of HPV-positive women (ATICA study): perceptions of health decision-makers and health-care providers

BACKGROUND

The ATICA study was a Hybrid I type randomized effectiveness-implementation trial that demonstrated effectiveness of a multicomponent mHealth intervention (Up to four SMS messages sent to HPV-positive women, and one SMS message to CHWs to prompt a visit of women with no triage Pap 60 days after a positive-test), to increase adherence to triage of HPV positive women (ATICA Study). We report data on perceptions of health decision-makers and health-care providers regarding the intervention implementation and scaling-up.

METHODS

A qualitative study was carried out based on individual, semi-structured interviews with health decision-makers (n = 10) and health-care providers (n = 10). The themes explored were selected and analyzed using domains and constructs of the Consolidated Framework for Implementation Research (CFIR) and the maintenance dimension of the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework.

RESULTS

Both health-care providers and decision-makers had a positive assessment of the intervention through most included constructs: knowledge of the intervention, intervention source, design quality, adaptability, compatibility, access to knowledge and information, relative advantage, women's needs, and relative priority. However, some potential barriers were also identified including: complexity, leadership engagement, external policies, economic cost, women needs and maintenance. Stakeholders conditioned the strategy's sustainability to the political commitment of national and provincial health authorities to prioritize cervical cancer prevention, and to the establishment of the ATICA strategy as a programmatic line of work by health authorities. They also highlighted the need to ensure, above all, that there was staff to take Pap tests and carry out the HPV-lab work, and to guarantee a constant provision of HPV-tests.

CONCLUSION

Health decision-makers and health-care providers had a positive perception regarding implementation of the multicomponent mHealth intervention designed to increase adherence to triage among women with HPV self-collected tests. This increases the potential for a successful scaling-up of the intervention, with great implications not only for Argentina but also for middle and low-income countries considering using mHealth interventions to enhance the cervical screening/follow-up/treatment process.