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Ferguson AL, Erwin E, Sleeth J, Symonds N, Chard S, Yuma S, Oneko O, Macheku G, Andrews L, West N, Chelva M, Ginsburg O, Yeates K. An Implementation Evaluation of the Smartphone-Enhanced Visual Inspection with Acetic Acid (SEVIA) Program for Cervical Cancer Prevention in Urban and Rural Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:878. [PMID: 39063455 PMCID: PMC11277481 DOI: 10.3390/ijerph21070878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/24/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION The World Health Organization (WHO) recommends visual inspection with acetic acid (VIA) for cervical cancer screening (CCS) in lower-resource settings; however, quality varies widely, and it is difficult to maintain a well-trained cadre of providers. The Smartphone-Enhanced Visual Inspection with Acetic acid (SEVIA) program was designed to offer secure sharing of cervical images and real-time supportive supervision to health care workers, in order to improve the quality and accuracy of visual assessment of the cervix for treatment. The purpose of this evaluation was to document early learnings from patients, providers, and higher-level program stakeholders, on barriers and enablers to program implementation. METHODS From 9 September to 8 December 2016, observational activities and open-ended interviews were conducted with image reviewers (n = 5), providers (n = 17), community mobilizers (n = 14), patients (n = 21), supervisors (n = 4) and implementation partners (n = 5) involved with SEVIA. Sixty-six interviews were conducted at 14 facilities, in all five of the program regions Results SEVIA was found to be a highly regarded tool for the enhancement of CCS services in Northern Tanzania. Acceptability, adoption, appropriateness, feasibility, and coverage of the intervention were highly recognized. It appeared to be an effective means of improving good clinical practice among providers and fit seamlessly into existing roles and processes. Barriers to implementation included network connectivity issues, and community misconceptions and the adoption of CCS more generally. CONCLUSIONS SEVIA is a practical and feasible mobile health intervention and tool that is easily integrated into the National CCS program to enhance the quality of care.
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Affiliation(s)
| | - Erica Erwin
- Department of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Jessica Sleeth
- Canadian Cancer Trials Group, Kingston, ON K7L 2V5, Canada
| | - Nicola Symonds
- School of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Sidonie Chard
- Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
| | - Safina Yuma
- Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma 40478, Tanzania
| | - Olola Oneko
- Kilimanjaro Christian Medical Center, Moshi P.O. Box 3010, Tanzania
| | - Godwin Macheku
- Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma 40478, Tanzania
| | - Linda Andrews
- Pamoja Tunaweza Women’s Centre, Moshi P.O. Box 8434, Tanzania
| | - Nicola West
- Department of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Melinda Chelva
- Department of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Ophira Ginsburg
- Center for Global Health, National Cancer Institute, Bethesda, MD 20892-9760, USA
| | - Karen Yeates
- Department of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada
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Kabukye JK, Namugga J, Mpamani CJ, Katumba A, Nakatumba-Nabende J, Nabuuma H, Musoke SS, Nankya E, Soomre E, Nakisige C, Orem J. Implementing Smartphone-Based Telemedicine for Cervical Cancer Screening in Uganda: Qualitative Study of Stakeholders' Perceptions. J Med Internet Res 2023; 25:e45132. [PMID: 37782541 PMCID: PMC10580134 DOI: 10.2196/45132] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 04/03/2023] [Accepted: 07/27/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND In Uganda, cervical cancer (CaCx) is the commonest cancer, accounting for 35.7% of all cancer cases in women. The rates of human papillomavirus vaccination and CaCx screening remain low. Digital health tools and interventions have the potential to improve different aspects of CaCx screening and control in Uganda. OBJECTIVE This study aimed to describe stakeholders' perceptions of the telemedicine system we developed to improve CaCx screening in Uganda. METHODS We developed and implemented a smartphone-based telemedicine system for capturing and sharing cervical images and other clinical data, as well as an artificial intelligence model for automatic analysis of images. We conducted focus group discussions with health workers at the screening clinics (n=27) and women undergoing screening (n=15) to explore their perceptions of the system. The focus group discussions were supplemented with field observations and an evaluation survey of the health workers on system usability and the overall project. RESULTS In general, both patients and health workers had positive opinions about the system. Highlighted benefits included better cervical visualization, the ability to obtain a second opinion, improved communication between nurses and patients (to explain screening findings), improved clinical data management, performance monitoring and feedback, and modernization of screening service. However, there were also some negative perceptions. For example, some health workers felt the system is time-consuming, especially when it had just been introduced, while some patients were apprehensive about cervical image capture and sharing. Finally, commonplace challenges in digital health (eg, lack of interoperability and problems with sustainability) and challenges in cancer screening in general (eg, arduous referrals, inadequate monitoring and quality control) also resurfaced. CONCLUSIONS This study demonstrates the feasibility and value of digital health tools in CaCx screening in Uganda, particularly with regard to improving patient experience and the quality of screening services. It also provides examples of potential limitations that must be addressed for successful implementation.
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Affiliation(s)
- Johnblack K Kabukye
- SPIDER - The Swedish Program for ICT in Developing Regions, Department of Computer and Systems Sciences, Stockholm University, Stockholm, Sweden
- Uganda Cancer Institute, Kampala, Uganda
| | - Jane Namugga
- Uganda Cancer Institute, Kampala, Uganda
- Mulago Specialised Women and Neonatal Hospital, Kampala, Uganda
| | | | - Andrew Katumba
- Department of Electrical Engineering, Makerere University, Kampala, Uganda
| | | | - Hanifa Nabuuma
- Department of Electrical Engineering, Makerere University, Kampala, Uganda
| | - Stephen Senkomago Musoke
- Global Programs for Research and Training, University of California San Francisco, Kampala, Uganda
| | | | - Edna Soomre
- SPIDER - The Swedish Program for ICT in Developing Regions, Department of Computer and Systems Sciences, Stockholm University, Stockholm, Sweden
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Chongsuwat T, Wang C, Sohn Y, Klump K. Digital cervicography for cervical cancer screening in low-resource settings: A scoping review. Gynecol Oncol Rep 2023; 45:101130. [PMID: 36683777 PMCID: PMC9845952 DOI: 10.1016/j.gore.2022.101130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Digital cervicography (DC) is a method of capturing images for analysis during visual inspection with acetic acid (VIA) for cervical cancer screening. Cervical cancer is the 3rd leading cause of female cancer in the world with approximately 90 % of deaths due to cervical cancer occurring in low and middle income countries (LMICs). The need for cost-effective and sustainable methods for screening is vital in these settings. This scoping review systematically synthesizes published data illustrating the use of DC in screening programs. We aim to understand how digital cervicography is used, implemented, and impacted on programs. Methods Search of eight online databases identified 53 studies published between 1993 and 2021. Inclusion of articles were English language, cervical cancer screening program located in an LMIC, and DC as an intervention. Results All studies were cross-sectional studies (n = 53), with variation in terminology, uses, and device methods. Devices were grouped as either smartphones (n = 14), commercially available digital cameras (n = 17), or other (EVA®, n = 4; Cerviscope, n = 12; custom device, n = 4; or not specified, n = 2). Nineteen studies found acceptability and feasibility for DC in their screening programs. Various programs using DC found benefits such as task sharing, healthcare worker training, patient education and using images for review from a remote specialist or mentor. Conclusion The use of DC in LMICs is beneficial for support of healthcare workers, enhances quality improvement and demonstrates overall acceptability in screening programs. Advancing technologies for human papillomavirus (HPV) testing and cytology are common methods for cervical cancer screening, although are limited in LMICs. This scoping review demonstrates the different methods, uses, and benefit of digital cervicography in cervical cancer screening programs.
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Affiliation(s)
- Tana Chongsuwat
- University of Wisconsin School of Medicine and Public Health, 1100 Delaplaine Ct, Madison, WI 53715, United States,Corresponding author at: 1100 Delaplaine Ct, Madison, WI 53715, United States.
| | - Connor Wang
- University of Wisconsin School of Medicine and Public Health, 1100 Delaplaine Ct, Madison, WI 53715, United States
| | - Younji Sohn
- University of Oklahoma College of Medicine, 900 NE 10th St, Oklahoma City, OK 73104, United States
| | - Kathryn Klump
- University of Oklahoma College of Medicine, 900 NE 10th St, Oklahoma City, OK 73104, United States
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Hategeka C, Adu P, Desloge A, Marten R, Shao R, Tian M, Wei T, Kruk ME. Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review. PLoS Med 2022; 19:e1004055. [PMID: 35877677 PMCID: PMC9359585 DOI: 10.1371/journal.pmed.1004055] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 08/08/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs). METHODS AND FINDINGS On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework. CONCLUSIONS Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.
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Affiliation(s)
- Celestin Hategeka
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Prince Adu
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Allissa Desloge
- School of Public Health, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Robert Marten
- Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
| | | | - Maoyi Tian
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Ting Wei
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Margaret E. Kruk
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
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Dufeil E, Kenfack B, Tincho E, Fouogue J, Wisniak A, Sormani J, Vassilakos P, Petignat P. Addition of digital VIA/VILI to conventional naked-eye examination for triage of HPV-positive women: A study conducted in a low-resource setting. PLoS One 2022; 17:e0268015. [PMID: 35552564 PMCID: PMC9098068 DOI: 10.1371/journal.pone.0268015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 04/20/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND World Health Organization guidelines for cervical cancer screening recommend HPV testing followed by visual inspection with acetic acid (VIA) for triage if HPV positive. In order to improve visual assessment and identification of cervical intraepithelial neoplasia grade 2 and worse (CIN2+), providers may use visual aids such as digital cameras. OBJECTIVES To determine whether combined examination by naked-eye and digital VIA (D-VIA) and VILI (D-VILI) improves detection of CIN2+ as compared to the conventional evaluation. MATERIALS AND METHODS Women (30-49 years) living in Dschang (West Cameroon) were prospectively invited to a cervical cancer screening campaign. Primary HPV-based screening was followed by VIA/VILI and D-VIA/VILI if HPV-positive. Health care providers independently defined diagnosis (pathological or non-pathological) based on naked-eye VIA/VILI and D-VIA/VILI. Decision to treat was based on combined examination (VIA/VILI and D-VIA/VILI). Cervical biopsy and endocervical curettage were performed in all HPV-positive participants and considered as reference standard. Diagnostic performance of individual and combined naked-eye VIA/VILI and D-VIA/VILI was evaluated. A sample size of 1,500 women was calculated assuming a prevalence of 20% HPV positivity and 10% CIN2+ in HPV-positive women. RESULTS Due to the COVID-19 pandemic, the study had to terminate prematurely. A total of 1,081 women with a median age of 40 (IQR 35.5-45) were recruited. HPV positivity was 17.4% (n = 188) and 26 (14.4%) had CIN2+. Naked-eye VIA and D-VIA sensitivities were 80.8% (95% CI 60.6-93.4) and 92.0% (95% CI 74.0-99.0), and specificities were 31.2% (95% CI 24-39.1) and 31.6% (95% CI 24.4-39.6), respectively. The combination of both methods yielded a sensitivity of 92.3% (95% CI 74.9-99.1) and specificity of 23.2% (95% CI 16.8-30.7). A trend towards improved sensitivity was observed, but did not reach statistical significance. CONCLUSION Addition of D-VIA/VILI to conventional naked-eye examination may be associated with improved CIN2+ identification. Further studies including a larger sample size are needed to confirm these results.
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Affiliation(s)
- Eva Dufeil
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bruno Kenfack
- Faculty of Medicine and Pharmaceutical Science, University of Dschang, Dschang, Cameroon
- Department of Gynecology and Obstetrics, District Hospital of Dschang, Dschang, Cameroon
| | - Evelyn Tincho
- Faculty of Medicine and Pharmaceutical Science, University of Dschang, Dschang, Cameroon
- Department of Gynecology and Obstetrics, Faculty of Medicine and Biomedical Sciences, Centre Hospitalier Universitaire (CHUY), Yaoundé, Cameroon
| | - Jovanny Fouogue
- Department of Obstetrics and Gynecology, Bafoussam Regional hospital, Bafoussam, Cameroon
| | - Ania Wisniak
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
- Population Epidemiology Unit, Department of Primary Care, Geneva University Hospitals, Geneva, Switzerland
| | - Jessica Sormani
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
- School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Pierre Vassilakos
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
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Lynch KA, Atkinson TM, Omisore AD, Famurewa O, Olasehinde O, Odujoko O, Alatise OI, Egberongbe A, Kingham TP, Morris EA, Sutton E. Developing a Technology Acceptability and Usage Survey (TAUS) for mHealth Intervention Planning and Evaluation in Nigeria: Pilot Study. JMIR Form Res 2022; 6:e34035. [PMID: 35442204 PMCID: PMC9069275 DOI: 10.2196/34035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/10/2021] [Accepted: 12/29/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Technology acceptability and usage surveys (TAUS) are brief questionnaires that measure technology comfort, typical daily use, and access in a population. However, current measures are not adapted to low- and middle-income country (LMIC) contexts. OBJECTIVE The objective of this pilot study was to develop a TAUS that could be used to inform the implementation of a mobile health (mHealth) intervention in Nigeria. METHODS A literature review of validated technology comfort and usage scales was conducted to identify candidate items. The draft measure was reviewed for face validity by an expert panel comprised of clinicians and researchers with cultural, methodological, and clinical expertise. The measure was piloted by radiologists at an oncology symposium in Nigeria. RESULTS After expert review, the final measure included 18 items organized into 3 domains: (1) comfort with using mobile applications, (2) reliability of internet or electricity, and (3) attitudes toward using computers or mobile applications in clinical practice. The pilot sample (n=16) reported high levels of comfort and acceptability toward using mHealth applications in the clinical setting but faced numerous infrastructure challenges. CONCLUSIONS Pilot results indicate that the TAUS may be a feasible and appropriate measure for assessing technology usage and acceptability in LMIC clinical contexts. Dedicating a domain to technology infrastructure and access yielded valuable insights for program implementation.
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Affiliation(s)
- Kathleen A Lynch
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Thomas M Atkinson
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Adeleye D Omisore
- Department of Radiology, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Olusola Famurewa
- Department of Radiology, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | - Oluwole Odujoko
- Department of Pathology, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | | | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Elizabeth A Morris
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Elizabeth Sutton
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Smartphone-Based Visual Inspection with Acetic Acid: An Innovative Tool to Improve Cervical Cancer Screening in Low-Resource Setting. Healthcare (Basel) 2022; 10:healthcare10020391. [PMID: 35207002 PMCID: PMC8871553 DOI: 10.3390/healthcare10020391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/06/2022] [Accepted: 02/11/2022] [Indexed: 11/17/2022] Open
Abstract
Visual inspection with acetic acid (VIA) is recommended by the World Health Organization for primary cervical cancer screening or triage of human papillomavirus-positive women living in low-resource settings. Nonetheless, traditional VIA with the naked-eye is associated with large variabilities in the detection of pre-cancer and with a lack of quality control. Digital-VIA (D-VIA), using high definition cameras, allows magnification and zooming on transformation zones and suspicious cervical regions, as well as simultaneously compare native and post-VIA images in real-time. We searched MEDLINE and LILACS between January 2015 and November 2021 for relevant studies conducted in low-resource settings using a smartphone device for D-VIA. The aim of this review was to provide an evaluation on available data for smartphone use in low-resource settings in the context of D-VIA-based cervical cancer screenings. The available results to date show that the quality of D-VIA images is satisfactory and enables CIN1/CIN2+ diagnosis, and that a smartphone is a promising tool for cervical cancer screening monitoring and for on- and off-site supervision, and training. The use of artificial intelligence algorithms could soon allow automated and accurate cervical lesion detection.
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Xue Z, Angara S, Levitz D, Antani S. Analysis of digital noise and reduction methods on classifiers used in automated visual evaluation in cervical cancer screening. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2022; 11950:1195008. [PMID: 35529321 PMCID: PMC9074910 DOI: 10.1117/12.2610235] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The burden of cervical cancer disproportionately falls on low- and middle-income countries (LMICs). Automated visual evaluation (AVE) is a technology being considered as an adjunct tool for the management of HPV-positive women. AVE involves analysis of a white light illuminated cervical image using machine learning classifiers. It is of importance to analyze various impacts of different kinds of image degradations on AVE. In this paper, we report our work regarding the impact of one type of image degradation, Gaussian noise, and one of its remedies we have been exploring. The images, originated from the Natural History Study (NHS) and ASCUS-LSIL Triage Study (ALTS), were modified by the addition of white Gaussian noise at different levels. The AVE pipeline used in the experiments consists of two deep learning components: a cervix locator which uses RetinaNet (an object detection network), and a binary pathology classifier that uses the ResNeSt network. Our findings indicate that Gaussian noise, which frequently appears in low light conditions, is a key factor in degrading the AVE's performance. A blind image denoising technique which uses Variational Denoising Network (VDNet) was tested on a set of 345 digitized cervigram images (115 positives) and evaluated both visually and quantitatively. AVE performances on both the synthetically generated noisy images and the corresponding denoised images were examined and compared. In addition, the denoising technique was evaluated on several real noisy cervix images captured by a camera-based imaging device used for AVE that have no histology confirmation. The comparison between the AVE performances on images with and without denoising shows that denoising can be effective at mitigating classification performance degradation.
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Affiliation(s)
- Zhiyun Xue
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, MD 20894
| | - Sandeep Angara
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, MD 20894
| | - David Levitz
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, MD 20894
- DL Analytics, North Hollywood, CA 91602
| | - Sameer Antani
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, MD 20894
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Allanson ER, Phoolcharoen N, Salcedo MP, Fellman B, Schmeler KM. Accuracy of Smartphone Images of the Cervix After Acetic Acid Application for Diagnosing Cervical Intraepithelial Neoplasia Grade 2 or Greater in Women With Positive Cervical Screening: A Systematic Review and Meta-Analysis. JCO Glob Oncol 2021; 7:1711-1721. [PMID: 34936374 PMCID: PMC8710337 DOI: 10.1200/go.21.00168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Smartphones are used in cervical screening for visual inspection after acetic acid or Lugol's iodine (VIA/VILI) application to capture and share images to improve the sensitivity and interobserver variability of VIA/VILI. We undertook a systematic review and meta-analysis assessing the diagnostic accuracy of smartphone images of the cervix at the time of VIA/VILI (termed S-VIA) in the detection of precancerous lesions in women undergoing cervical screening. METHODS This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies from January 1, 2010, to June 30, 2020, were assessed. MEDLINE/PubMed, Embase, CINAHL, Cochrane, and LILACS were searched. Cohort and cross-sectional studies were considered. S-VIA was compared with the reference standard of histopathology. We excluded studies where additional technology was added to the smartphone including artificial intelligence, enhanced visual assessment, and other algorithms to automatically diagnose precancerous lesions. The primary outcome was the accuracy of S-VIA for the diagnosis of cervical intraepithelial neoplasia grade 2 or greater (CIN 2+). Data were extracted, and we plotted the sensitivity, specificity, negative predictive value, and positive predictive value of S-VIA using forest plots. This study was prospectively registered with The International Prospective Register of Systematic Reviews:CRD42020204024. RESULTS Six thousand three studies were screened, 71 full texts assessed, and eight studies met criteria for inclusion, with six included in the final meta-analysis. The sensitivity of S-VIA for the diagnosis of CIN 2+ was 74.56% (95% CI, 70.16 to 78.95; I2 61.30%), specificity was 61.75% (95% CI, 56.35 to 67.15; I2 95.00%), negative predictive value was 93.71% (95% CI, 92.81 to 94.61; I2 0%), and positive predictive value was 26.97% (95% CI, 24.13 to 29.81; I2 61.3%). CONCLUSION Our results suggest that S-VIA has accuracy in the detection of CIN 2+ and may provide additional support to health care providers delivering care in low-resource settings.
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Affiliation(s)
- Emma R Allanson
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Mila P Salcedo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.,The Obstetrics and Gynecology Department, Federal University of Health Sciences of Porto Alegre/Santa Casa Hospital of Porto Alegre, Porto Alegre, Brazil
| | - Bryan Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Kabukye JK, Kakungulu E, Keizer ND, Cornet R. Digital health in oncology in Africa: A scoping review and cross-sectional survey. Int J Med Inform 2021; 158:104659. [PMID: 34929545 DOI: 10.1016/j.ijmedinf.2021.104659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/09/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Low- and middle-income countries, especially in Africa, face a growing cancer burden. Adoption of digital health solutions has the potential to improve cancer care delivery and research in these countries. However, the extent of implementation and the impact of digital health interventions across the cancer continuum in Africa have not been studied. AIMS To describe the current landscape of digital health interventions in oncology in Africa. METHODS We conducted a scoping literature review and supplemented this with a survey. Following the PRISMA for Scoping Reviews guidelines, we searched literature in PubMed and Embase for keywords and synonyms for cancer, digital health, and African countries, and abstracted data using a structured form. For the survey, participants were delegates of the 2019 conference of the African Organization for Research and Training in Cancer. RESULTS The literature review identified 57 articles describing 40 digital health interventions or solutions from 17 African countries, while the survey included 111 respondents from 18 African countries, and these reported 25 different digital health systems. Six articles (10.5%) reported randomized controlled trials. The other 51 articles (89.5%) were descriptive or quasi-experimental studies. The interventions mostly targeted cancer prevention (28 articles, 49.1%) or diagnosis and treatment (23 articles, 40.4%). Four articles (7.0%) targeted survivorship and end of life, and the rest were cross-cutting. Cervical cancer was the most targeted cancer (25 articles, 43.9%). Regarding WHO classification of digital interventions, most were for providers (35 articles, 61.4%) or clients (13, 22.8%), while the others were for data services or cut across these categories. The interventions were mostly isolated pilots using basic technologies such as SMS and telephone calls for notifying patients of their appointments or results, or for cancer awareness; image capture apps for cervical cancer screening, and tele-conferencing for tele-pathology and mentorship. Generally positive results were reported, but evaluation focused on structure and process measures such as ease of use, infrastructure requirements, and acceptability of intervention; or general benefits e.g. supporting training and mentorship of providers, communication among providers and clients, and improving data collection and management. No studies evaluated individualized clinical outcomes, and there were no interventions in literature for health system managers although the systems identified in the survey had such functionality, e.g. inventory management. The survey also indicated that none of the digital health systems had all the functionalities for a comprehensive EHR, and major barriers for digital health were initial and ongoing costs, resistance from clinical staff, and lack of fit between the EHR and the clinical workflows. CONCLUSION Digital health interventions in oncology in Africa are at early maturity stages but promising. Barriers such as funding, fit between digital health tools and clinical workflows, and inertia towards technology, shall need to be addressed to allow for advancement of digital health solutions to support all parts of the cancer continuum. Future research should investigate the impact of digital health solutions on long-term cancer outcomes such as cancer mortality, morbidity and quality of life.
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Affiliation(s)
- Johnblack K Kabukye
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, Meibergdreef 15, Amsterdam, the Netherlands; Uganda Cancer Institute, Upper Mulago Hill Road, P.O. Box 3935, Kampala, Uganda.
| | - Edward Kakungulu
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, Meibergdreef 15, Amsterdam, the Netherlands
| | - Nicolette de Keizer
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, Meibergdreef 15, Amsterdam, the Netherlands
| | - Ronald Cornet
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, Meibergdreef 15, Amsterdam, the Netherlands
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11
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Champin D, Ramírez-Soto MC, Vargas-Herrera J. Use of Smartphones for the Detection of Uterine Cervical Cancer: A Systematic Review. Cancers (Basel) 2021; 13:cancers13236047. [PMID: 34885157 PMCID: PMC8656777 DOI: 10.3390/cancers13236047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 11/16/2022] Open
Abstract
Little is known regarding the usefulness of the smartphone in the detection of uterine cervical lesions or uterine cervical cancer. Therefore, we evaluated the usefulness of the smartphone in the detection of uterine cervical lesions and measured its diagnostic accuracy by comparing its findings with histological findings. We conducted a systematic review to identify studies on the usefulness of the smartphone in detecting uterine cervical lesions indexed in SCOPUS, MEDLINE/PubMed, Cochrane, OVID, Web of Science, and SciELO until November 2020. The risk of bias and applicability was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A total of 16 studies that evaluated the usefulness of the smartphone in the detection of uterine cervical lesions based on the images clicked after visual inspection with acetic acid (VIA), Lugol's iodine (VILI), or VIA/VILI combination were included in the study. Five studies estimated diagnostic sensitivity and specificity, nine described diagnostic concordance, and five described the usefulness of mobile technology. Among the five first studies, the sensitivity ranged between 66.7% (95% confidence interval (CI); 30.0-90.3%) and 94.1% (95% CI; 81.6-98.3%), and the specificity ranged between 24.0% (95% CI; 9.0-45.0%) and 85.7% (95% CI; 76.7-91.6%). The risk of bias was low (20%), and the applicability was high. In conclusion, the smartphone images clicked after a VIA were found to be more sensitive than those following the VILI method or the VIA/VILI combination and naked-eye techniques in detecting uterine cervical lesions. Thus, a smartphone may be useful in the detection of uterine cervical lesions; however, its sensitivity and specificity are still limited.
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Affiliation(s)
- Denisse Champin
- Facultad de Ciencias de la Salud, Universidad Tecnológica del Peru, Lima 15046, Peru;
| | - Max Carlos Ramírez-Soto
- Facultad de Ciencias de la Salud, Universidad Tecnológica del Peru, Lima 15046, Peru;
- Correspondence: or
| | - Javier Vargas-Herrera
- Departamento de Telemedicina, Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima 15001, Peru;
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Abstract
Cervical cancer is one of the commonest cancers afflicting women in low and middle income countries, however, both primary prevention with human papillomavirus vaccination, and secondary prevention with screening programs and treatment of preinvasive disease are possible. A coordinated approach to eliminating cervical cancer, as has been called for by the World Health Organization, requires a complex series of steps at all levels of a health system. This article outlines the current state of cervical cancer prevention in low and middle income countries, the innovations being employed to improve outcomes, and consideration of the next steps needed as we move towards global elimination.
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Affiliation(s)
- Emma R Allanson
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, Houston, Texas
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13
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Mungo C, Osongo CO, Ambaka J, Randa MA, Samba B, Ochieng CA, Barker E, Guliam A, Omoto J, Cohen CR. Feasibility and Acceptability of Smartphone-Based Cervical Cancer Screening Among HIV-Positive Women in Western Kenya. JCO Glob Oncol 2021; 7:686-693. [PMID: 33999653 PMCID: PMC8162506 DOI: 10.1200/go.21.00013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Adjunct cervical cancer screening methods are under evaluation to improve the diagnostic accuracy of human papillomavirus (HPV)-based screening in low- and middle-income countries. We evaluated the feasibility and acceptability of smartphone-based cervicography among HPV-positive women living with HIV (WLWH) in Western Kenya. METHODS HPV-positive WLWH of 25-49 years of age enrolled in a clinical trial (ClinicalTrials.gov identifier: NCT04191967) had digital images of the cervix taken using a smartphone by a nonphysician provider following visual inspection with acetic acid. All participants had colposcopy-directed biopsy before treatment. Cervical images were evaluated by three off-site colposcopists for quality, diagnostic utility, and assigned a presumed diagnosis. We determined the proportion of images rates as low, medium, or high quality, interobserver agreement using Cohen’s Kappa statistic, and the off-site colposcopist’s sensitivity and specificity for diagnosis of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) compared with histopathology. Acceptability was evaluated using a questionnaire. RESULTS One hundred sixty-four HPV-positive WLWH underwent cervicography during the study period. Mean age was 37.3 years. Images from the first 94 participants were evaluated by off-site colposcopists, with a majority (70.9%) rated as high quality. Off-site colposcopists had a sensitivity ranging from 21.4% (95% CI, 0.06 to 0.43) to 35.7% (95% CI, 0.26 to 0.46) and a specificity between 85.5% (95% CI, 0.81 to 0.90) to 94.9% (95% CI, 0.92 to 0.98) for diagnosis of CIN2+ based compared with histopathology. The majority of women, 99.4%, were comfortable having an image of their cervix taken as part of screening. CONCLUSION Cervicography by a nonphysician provider as an adjunct to HPV-based screening among WLWH in a low- and middle-income country setting is feasible and acceptable. However, low sensitivity for diagnosis of CIN2+ by off-site expert colposcopists highlights the limitations of cervicography.
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Affiliation(s)
- Chemtai Mungo
- Division of Prevention Science, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA
| | | | | | | | | | | | - Emily Barker
- Department of Obstetrics and Gynecology, Rush University School of Medicine, Chicago, IL
| | - Anagha Guliam
- Barnard College, University of Columbia, New York, NY
| | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine, Kisumu, Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
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14
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Bashingwa JJH, Shah N, Mohan D, Scott K, Chamberlain S, Mulder N, Rahul S, Arora S, Chakraborty A, Ummer O, Ved R, LeFevre AE. Examining the reach and exposure of a mobile phone-based training programme for frontline health workers (ASHAs) in 13 states across India. BMJ Glob Health 2021; 6:e005299. [PMID: 34429283 PMCID: PMC8386225 DOI: 10.1136/bmjgh-2021-005299] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/07/2021] [Indexed: 11/06/2022] Open
Abstract
Mobile phones are increasingly used to facilitate in-service training for frontline health workers (FLHWs). Mobile learning (mLearning) programmes have the potential to provide FLHWs with high quality, inexpensive, standardised learning at scale, and at the time and location of their choosing. However, further research is needed into FLHW engagement with mLearning content at scale, a factor which could influence knowledge and service delivery. Mobile Academy is an interactive voice response training course for FLHWs in India, which aims to improve interpersonal communication skills and refresh knowledge of preventative reproductive, maternal, neonatal and child health. FLHWs dial in to an audio course consisting of 11 chapters, each with a 4-question true/false quiz, resulting in a cumulative pass/fail score. In this paper, we analyse call data records from the national version of Mobile Academy to explore coverage, user engagement and completion. Over 158 596 Accredited Social Health Activists (ASHAs) initiated the national version, while 111 994 initiated the course on state-based platforms. Together, this represents 41% of the estimated total number of ASHAs registered in the government database across 13 states. Of those who initiated the national version, 81% completed it; and of those, over 99% passed. The initiation and completion rates varied by state, with Rajasthan having the highest initiation rate. Many ASHAs made multiple calls in the afternoons and evenings but called in for longer durations earlier in the day. Findings from this analysis provide important insights into the differential reach and uptake of the programme across states.
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Affiliation(s)
- Jean Juste Harrisson Bashingwa
- Computational Biology Division, Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, Cape Town, Western Cape, South Africa
| | - Neha Shah
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Nicola Mulder
- Computational Biology Division, Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, Cape Town, South Africa
| | - Sai Rahul
- BeeHyv Software Solutions Pvt. Ltd, Hyderabad, Telangana, India
| | - Salil Arora
- BBC Media Action, India, New Delhi, Delhi, India
| | | | - Osama Ummer
- BBC Media Action, India, New Delhi, Delhi, India
- Oxford Policy Management, New Delhi, Delhi, India
| | - Rajani Ved
- National Health Systems Resource Centre, New Delhi, Delhi, India
| | - Amnesty Elizabeth LeFevre
- International Health, Baltimore, Maryland, USA
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Xue Z, Guo P, Desai KT, Pal A, Ajenifuja KO, Adepiti CA, Long LR, Schiffman M, Antani S. A Deep Clustering Method For Analyzing Uterine Cervix Images Across Imaging Devices. PROCEEDINGS. IEEE INTERNATIONAL SYMPOSIUM ON COMPUTER-BASED MEDICAL SYSTEMS 2021; 2021:527-532. [PMID: 35445152 PMCID: PMC9017785 DOI: 10.1109/cbms52027.2021.00085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Visual inspection of the cervix with acetic acid (VIA), though error prone, has long been used for screening women and to guide management for cervical cancer. The automated visual evaluation (AVE) technique, in which deep learning is used to predict precancer based on a digital image of the acetowhitened cervix, has demonstrated its promise as a low-cost method to improve on human performance. However, there are several challenges in moving AVE beyond proof-of-concept and deploying it as a practical adjunct tool in visual screening. One of them is making AVE robust across images captured using different devices. We propose a new deep learning based clustering approach to investigate whether the images taken by three different devices (a common smartphone, a custom smartphone-based handheld device for cervical imaging, and a clinical colposcope equipped with SLR digital camera-based imaging capability) can be well distinguished from each other with respect to the visual appearance/content within their cervix regions. We argue that disparity in visual appearance of a cervix across devices could be a significant confounding factor in training and generalizing AVE performance. Our method consists of four components: cervix region detection, feature extraction, feature encoding, and clustering. Multiple experiments are conducted to demonstrate the effectiveness of each component and compare alternative methods in each component. Our proposed method achieves high clustering accuracy (97%) and significantly outperforms several representative deep clustering methods on our dataset. The high clustering performance indicates the images taken from these three devices are different with respect to visual appearance. Our results and analysis establish a need for developing a method that minimizes such variance among the images acquired from different devices. It also recognizes the need for large number of training images from different sources for robust device-independent AVE performance worldwide.
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Affiliation(s)
- Zhiyun Xue
- National Library of Medicine, National Institutes of Health, Bethesda, USA
| | - Peng Guo
- National Library of Medicine, National Institutes of Health, Bethesda, USA
| | - Kanan T Desai
- National Cancer Institute, National Institutes of Health, USA
| | - Anabik Pal
- National Library of Medicine, National Institutes of Health, Bethesda, USA
| | | | | | - L Rodney Long
- National Library of Medicine, National Institutes of Health, Bethesda, USA
| | - Mark Schiffman
- National Cancer Institute, National Institutes of Health, USA
| | - Sameer Antani
- National Library of Medicine, National Institutes of Health, Bethesda, USA
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16
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Rossman AH, Reid HW, Pieters MM, Mizelle C, von Isenburg M, Ramanujam N, Huchko MJ, Vasudevan L. Digital Health Strategies for Cervical Cancer Control in Low- and Middle-Income Countries: Systematic Review of Current Implementations and Gaps in Research. J Med Internet Res 2021; 23:e23350. [PMID: 34042592 PMCID: PMC8193495 DOI: 10.2196/23350] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/01/2021] [Accepted: 01/13/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Nearly 90% of deaths due to cervical cancer occur in low- and middle-income countries (LMICs). In recent years, many digital health strategies have been implemented in LMICs to ameliorate patient-, provider-, and health system-level challenges in cervical cancer control. However, there are limited efforts to systematically review the effectiveness and current landscape of digital health strategies for cervical cancer control in LMICs. OBJECTIVE We aim to conduct a systematic review of digital health strategies for cervical cancer control in LMICs to assess their effectiveness, describe the range of strategies used, and summarize challenges in their implementation. METHODS A systematic search was conducted to identify publications describing digital health strategies for cervical cancer control in LMICs from 5 academic databases and Google Scholar. The review excluded digital strategies associated with improving vaccination coverage against human papillomavirus. Titles and abstracts were screened, and full texts were reviewed for eligibility. A structured data extraction template was used to summarize the information from the included studies. The risk of bias and data reporting guidelines for mobile health were assessed for each study. A meta-analysis of effectiveness was planned along with a narrative review of digital health strategies, implementation challenges, and opportunities for future research. RESULTS In the 27 included studies, interventions for cervical cancer control focused on secondary prevention (ie, screening and treatment of precancerous lesions) and digital health strategies to facilitate patient education, digital cervicography, health worker training, and data quality. Most of the included studies were conducted in sub-Saharan Africa, with fewer studies in other LMIC settings in Asia or South America. A low risk of bias was found in 2 studies, and a moderate risk of bias was found in 4 studies, while the remaining 21 studies had a high risk of bias. A meta-analysis of effectiveness was not conducted because of insufficient studies with robust study designs and matched outcomes or interventions. CONCLUSIONS Current evidence on the effectiveness of digital health strategies for cervical cancer control is limited and, in most cases, is associated with a high risk of bias. Further studies are recommended to expand the investigation of digital health strategies for cervical cancer using robust study designs, explore other LMIC settings with a high burden of cervical cancer (eg, South America), and test a greater diversity of digital strategies.
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Affiliation(s)
- Andrea H Rossman
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, United States
| | | | | | | | | | - Nimmi Ramanujam
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, United States
- Duke Global Health Institute, Durham, NC, United States
| | - Megan J Huchko
- Duke Global Health Institute, Durham, NC, United States
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, United States
| | - Lavanya Vasudevan
- Duke Global Health Institute, Durham, NC, United States
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, United States
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Subedi R, Budukh A, Chapagain S, Gyanwali P, Gyawali B, Khadka K, Thakur C, Dahal U, Dikshit R, Jha AK, Dhimal M. Differences in cancer incidence and pattern between urban and rural Nepal: one-year experience from two population-based cancer registries. Ecancermedicalscience 2021; 15:1229. [PMID: 34158833 PMCID: PMC8183641 DOI: 10.3332/ecancer.2021.1229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/26/2022] Open
Abstract
Variations in cancer incidence, mortality and pattern exist in rural and urban areas. Understanding these differences helps in developing targeted cancer prevention and control strategies. However, no previous studies have explored the differences in cancer demographics between the rural and urban areas of Nepal. The data of Kathmandu Valley (urban area) Population-Based Cancer Registry (PBCR) and Rukum (rural area) PBCR were analysed to identify the differences in cancer pattern in rural and urban areas. The age-adjusted incidence rate (AAR) in Kathmandu was higher than that in Rukum (1.6 times among males and 1.9 times among females). The top two leading sites in males were lungs and stomach in both the regions; however, the rates were higher in Kathmandu. The incidence rate for cancer of the urinary bladder among males in Kathmandu was particularly higher - 4.4 times that of Rukum. In females, the leading site of cancer in Kathmandu was breast, which was eight times higher compared to Rukum, whereas the incidence rate of cervix cancer in Kathmandu is 30% less than in Rukum. The incidence of tobacco-related cancer was found to be higher in Kathmandu compared to Rukum. These findings reveal the need for different policy priorities for cancer control in the urban versus rural regions of Nepal, based on the different demographics of cancer in the two areas. Similar studies from other regions of Nepal are needed to develop a targeted cancer control strategy.
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Affiliation(s)
- Ranjeeta Subedi
- Nepal Health Research Council, RamshahPath, Kathmandu 44600, Nepal
| | - Atul Budukh
- Homi Bhabha National Institute, Tata Memorial Centre, Mumbai 400012, India
| | - Sandhya Chapagain
- National Academy of Medical Sciences, Bir Hospital, Kathmandu 44600, Nepal
| | - Pradip Gyanwali
- Nepal Health Research Council, RamshahPath, Kathmandu 44600, Nepal
| | - Bishal Gyawali
- Departments of Oncology and Public Health Sciences, Division of Cancer Care and Epidemiology, Queen’s University, Kingston K7L 3N6, Canada
| | - Kopila Khadka
- Nepal Health Research Council, RamshahPath, Kathmandu 44600, Nepal
| | - Chanda Thakur
- Nepal Health Research Council, RamshahPath, Kathmandu 44600, Nepal
| | - Uma Dahal
- Nepal Health Research Council, RamshahPath, Kathmandu 44600, Nepal
| | - Rajesh Dikshit
- Homi Bhabha National Institute, Tata Memorial Centre, Mumbai 400012, India
| | - Anjani Kumar Jha
- Nepal Health Research Council, RamshahPath, Kathmandu 44600, Nepal
| | - Meghnath Dhimal
- Nepal Health Research Council, RamshahPath, Kathmandu 44600, Nepal
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18
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Asgary R, Staderini N, Mthethwa-Hleta S, Lopez Saavedra PA, Garcia Abrego L, Rusch B, Marie Luce T, Rusike Pasipamire L, Ndlangamandla M, Beideck E, Kerschberger B. Evaluating smartphone strategies for reliability, reproducibility, and quality of VIA for cervical cancer screening in the Shiselweni region of Eswatini: A cohort study. PLoS Med 2020; 17:e1003378. [PMID: 33211691 PMCID: PMC7676712 DOI: 10.1371/journal.pmed.1003378] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 10/08/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Cervical cancer is among the most common preventable cancers with the highest morbidity and mortality. The World Health Organization (WHO) recommends visual inspection of the cervix with acetic acid (VIA) as cervical cancer screening strategy in resource-poor settings. However, there are barriers to the sustainability of VIA programs including declining providers' VIA competence without mentorship and quality assurances and challenges of integration into primary healthcare. This study seeks to evaluate the impact of smartphone-based strategies in improving reliability, reproducibility, and quality of VIA in humanitarian settings. METHODS AND FINDINGS We implemented smartphone-based VIA that included standard VIA training, adapted refresher, and 6-month mHealth mentorship, sequentially, in the rural Shiselweni region of Eswatini. A remote expert reviewer provided diagnostic and management feedback on patients' cervical images, which were reviewed weekly by nurses. Program's outcomes, VIA image agreement rates, and Kappa statistic were compared before, during, and after training. From September 1, 2016 to December 31, 2018, 4,247 patients underwent screening; 247 were reviewed weekly by a VIA diagnostic expert. Of the 247, 128 (49%) were HIV-positive; mean age was 30.80 years (standard deviation [SD]: 7.74 years). Initial VIA positivity of 16% (436/2,637) after standard training gradually increased to 25.1% (293/1,168), dropped to an average of 9.7% (143/1,469) with a lowest of 7% (20/284) after refresher in 2017 (p = 0.001), increased again to an average of 9.6% (240/2,488) with a highest of 17% (17/100) before the start of mentorship, and dropped to an average of 8.3% (134/1,610) in 2018 with an average of 6.3% (37/591) after the start of mentorship (p = 0.019). Overall, 88% were eligible for and 68% received cryotherapy the same day: 10 cases were clinically suspicious for cancer; however, only 5 of those cases were confirmed using punch biopsy. Agreement rates with the expert reviewer for positive and negative cases were 100% (95% confidence interval [CI]: 79.4% to 100%) and 95.7% (95% CI: 92.2% to 97.9%), respectively, with negative predictive value (NPV) (100%), positive predictive value (PPV) (63.5%), and area under the curve of receiver operating characteristics (AUC ROC) (0.978). Kappa statistic was 0.74 (95% CI; 0.58 to 0.89); 0.64 and 0.79 at 3 and 6 months, respectively. In logistic regression, HIV and age were associated with VIA positivity (adjusted Odds Ratio [aOR]: 3.53, 95% CI: 1.10 to 11.29; p = 0.033 and aOR: 1.06, 95% CI: 1.0004 to 1.13; p = 0.048, respectively). We were unable to incorporate a control arm due to logistical constraints in routine humanitarian settings. CONCLUSIONS Our findings suggest that smartphone mentorship provided experiential learning to improve nurses' competencies and VIA reliability and reproducibility, reduced false positive, and introduced peer-to-peer education and quality control services. Local collaboration; extending services to remote populations; decreasing unnecessary burden to screened women, providers, and tertiary centers; and capacity building through low-tech high-yield screening are promising strategies for scale-up of VIA programs.
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Affiliation(s)
- Ramin Asgary
- Medecins Sans Frontieres, Geneva, Switzerland
- George Washington University, Washington, District of Columbia, United States of America
- Weill Cornell Medical College, New York, New York, United States of America
- * E-mail:
| | | | | | | | | | | | | | | | | | - Elena Beideck
- Weill Cornell Medical College, New York, New York, United States of America
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Salmani H, Ahmadi M, Shahrokhi N. The Impact of Mobile Health on Cancer Screening: A Systematic Review. Cancer Inform 2020; 19:1176935120954191. [PMID: 33116352 PMCID: PMC7573752 DOI: 10.1177/1176935120954191] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/11/2020] [Indexed: 01/15/2023] Open
Abstract
Introduction: Mobile health is an emerging technology around the world that can be effective in cancer screening. This study aimed to examine the effectiveness of mobile health applications on cancer screening. Methods: We conducted a systematic literature review of studies related to the use of mobile health applications in cancer screening. We also conducted a comprehensive search of articles on cancer screening related to the use of mobile health applications in journals published between January 1, 2008, and January 31, 2019, using 5 databases: IEEE, Scopus, Web of Science, Science Direct and PubMed. Results: A total of 23 articles met the inclusion criteria and were included in the present review. All studies have identified positive effects of applications on cancer screening and clinical health outcomes. Furthermore, more than half of mobile applications had multiple functions such as providing information, planning and education. Moreover, most of the studies, which examined the satisfaction of patients and quality improvement, showed healthcare application users have significantly higher satisfaction of living and it leads to improving quality. Conclusion: This study found that the use of mobile health applications has a positive impact on health-related behaviours and outcomes. Application users were more satisfied with applying mobile health applications to manage their health condition in comparison with users who received conventional care.
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Affiliation(s)
- Hosna Salmani
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Ahmadi
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Nafiseh Shahrokhi
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Hu L, Horning MP, Banik D, Ajenifuja OK, Adepiti CA, Yeates K, Mtema Z, Wilson B, Mehanian C. Deep learning-based image evaluation for cervical precancer screening with a smartphone targeting low resource settings - Engineering approach. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:1944-1949. [PMID: 33018383 DOI: 10.1109/embc44109.2020.9175863] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cervical cancer is the fourth most common cancer among women and still one of the major causes of women's death around the world. Early screening of high grade Cervical Intraepithelial Neoplasia (CIN), precursors to cervical cancer, is vital to efforts aimed at improving survival rate and eventually eliminating cervical cancer. Visual Inspection with Acetic acid (VIA) is an assessment method which can inspect the cervix and potentially detect lesions caused by human papillomavirus (HPV), which is a major cause of cervical cancer. VIA has the potential to be an effective screening method in low resource settings when triaged with HPV test, but it has the drawback that it depends on the subjective evaluation of health workers with varying levels of training. A new deep learning algorithm called Automated Visual Evaluation (AVE) for analyzing cervigram images has been recently reported that can automatically detect cervical precancer better than human experts. In this paper, we address the question of whether mobile phone-based cervical cancer screening is feasible. We consider the capabilities of two key components of a mobile phone platform for cervical cancer screening: (1) the core AVE algorithm and (2) an image quality algorithm. We consider both accuracy and speed in our assessment. We show that the core AVE algorithm, by refactoring to a new deep learning detection framework, can run in ~30 seconds on a low-end smartphone (i.e. Samsung J8), with equivalent accuracy. We developed an image quality algorithm that can localize the cervix and assess image quality in ~1 second on a low-end smartphone, achieving an area under the ROC curve (AUC) of 0.95. Field validation of the mobile phone platform for cervical cancer screening is in progress.
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Ensemble Deep Learning for Cervix Image Selection toward Improving Reliability in Automated Cervical Precancer Screening. Diagnostics (Basel) 2020; 10:diagnostics10070451. [PMID: 32635269 PMCID: PMC7400120 DOI: 10.3390/diagnostics10070451] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/17/2020] [Accepted: 06/24/2020] [Indexed: 01/17/2023] Open
Abstract
Automated Visual Examination (AVE) is a deep learning algorithm that aims to improve the effectiveness of cervical precancer screening, particularly in low- and medium-resource regions. It was trained on data from a large longitudinal study conducted by the National Cancer Institute (NCI) and has been shown to accurately identify cervices with early stages of cervical neoplasia for clinical evaluation and treatment. The algorithm processes images of the uterine cervix taken with a digital camera and alerts the user if the woman is a candidate for further evaluation. This requires that the algorithm be presented with images of the cervix, which is the object of interest, of acceptable quality, i.e., in sharp focus, with good illumination, without shadows or other occlusions, and showing the entire squamo-columnar transformation zone. Our prior work has addressed some of these constraints to help discard images that do not meet these criteria. In this work, we present a novel algorithm that determines that the image contains the cervix to a sufficient extent. Non-cervix or other inadequate images could lead to suboptimal or wrong results. Manual removal of such images is labor intensive and time-consuming, particularly in working with large retrospective collections acquired with inadequate quality control. In this work, we present a novel ensemble deep learning method to identify cervix images and non-cervix images in a smartphone-acquired cervical image dataset. The ensemble method combined the assessment of three deep learning architectures, RetinaNet, Deep SVDD, and a customized CNN (Convolutional Neural Network), each using a different strategy to arrive at its decision, i.e., object detection, one-class classification, and binary classification. We examined the performance of each individual architecture and an ensemble of all three architectures. An average accuracy and F-1 score of 91.6% and 0.890, respectively, were achieved on a separate test dataset consisting of more than 30,000 smartphone-captured images.
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22
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Yeates K, Erwin E, Mtema Z, Magoti F, Nkumbugwa S, Yuma S, Hopman WM, Ferguson A, Oneko O, Macheku G, Mtei AF, Smith C, Andrews L, West N, Dalton M, Newcomb A, Ginsburg O. Smartphone-Enhanced Training, QA, Monitoring, and Evaluation of a Platform for Secondary Prevention of Cervical Cancer: Opportunities and Challenges to Implementation in Tanzania. JCO Glob Oncol 2020; 6:1114-1123. [PMID: 32692627 PMCID: PMC7392775 DOI: 10.1200/go.20.00124] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Until human papillomavirus (HPV)-based cervical screening is more affordable and widely available, visual inspection with acetic acid (VIA) is recommended by the WHO for screening in lower-resource settings. Visual inspection will still be required to assess the cervix for women whose screening is positive for high-risk HPV. However, the quality of VIA can vary widely, and it is difficult to maintain a well-trained cadre of providers. We developed a smartphone-enhanced VIA platform (SEVIA) for real-time secure sharing of cervical images for remote supportive supervision, data monitoring, and evaluation. METHODS We assessed programmatic outcomes so that findings could be translated into routine care in the Tanzania National Cervical Cancer Prevention Program. We compared VIA positivity rates (for HIV-positive and HIV-negative women) before and after implementation. We collected demographic, diagnostic, treatment, and loss-to-follow-up data. RESULTS From July 2016 to June 2017, 10,545 women were screened using SEVIA at 24 health facilities across 5 regions of Tanzania. In the first 6 months of implementation, screening quality increased significantly from the baseline rate in the prior year, with a well-trained cadre of more than 50 health providers who "graduated" from the supportive-supervision training model. However, losses to follow-up for women referred for further evaluation or to a higher level of care were considerable. CONCLUSION The SEVIA platform is a feasible, quality improvement, mobile health intervention that can be integrated into a national cervical screening program. Our model demonstrates potential for scalability. As HPV screening becomes more affordable, the platform can be used for visual assessment of the cervix to determine amenability for same-day ablative therapy and/or as a secondary triage step, if needed.
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Affiliation(s)
- Karen Yeates
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- New York University School of Global Public Health, New York NY
- Pamoja Tunaweza Women’s Centre, Moshi, Tanzania
| | - Erica Erwin
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- OMNI Research Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Zac Mtema
- SkyConnect Company and Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Frank Magoti
- SkyConnect Company and Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Simoni Nkumbugwa
- SkyConnect Company and Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Safina Yuma
- Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma, Tanzania
| | - Wilma M. Hopman
- Kingston General Health Research Institute; Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | | | - Olola Oneko
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | - Agnes Feksi Mtei
- Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma, Tanzania
| | | | | | - Nicola West
- Pamoja Tunaweza Women’s Centre, Moshi, Tanzania
- Queen’s University, Kingston, Ontario, Canada
| | | | - Ashley Newcomb
- Section for Global Health, Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Ophira Ginsburg
- Section for Global Health, Department of Population Health, New York University Grossman School of Medicine, New York, NY
- Perlmutter Cancer Center, New York University Langone Health, New York, NY
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23
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Weng Q, Jiang J, Haji FM, Nondo LH, Zhou H. Women's knowledge of and attitudes toward cervical cancer and cervical cancer screening in Zanzibar, Tanzania: a cross-sectional study. BMC Cancer 2020; 20:63. [PMID: 31992250 PMCID: PMC6988189 DOI: 10.1186/s12885-020-6528-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/09/2020] [Indexed: 12/09/2022] Open
Abstract
Background Cervical cancer is the most common cancer and the leading cause of cancer death among women in Tanzania. Knowledge of and willingness to receive a cervical cancer screening are important determinants of prevention. This study aimed to describe women’s awareness of cervical cancer and to explore the attitudes toward, acceptability of and barriers to cervical cancer screening (CCS) in Zanzibar. Methods A cross-sectional study was conducted from March to June 2018 involving 1483 women from 10 districts in Zanzibar who responded to questionnaires concerning their general demo-graphic characteristics, screening willingness and awareness of cervical cancer. Chi-square tests, analysis of variance (ANOVA) and stepwise multiple regression were conducted using STATA 15.1 software. Results The average total knowledge score (TKS) was 7.84 ± 5.32 on a 23-point scale. Educational level and family income were positively correlated with the TKS. Previous schistosomiasis history and family genetic disease history were strong predictors of screening willingness. Women were less likely to be screened freely if they had 7 or more deliveries and were unaware of any previous family tumor history. Age and educational level were negatively associated non-free screening willingness, while family income was positively associated; being divorced/widowed or single and being unaware of any previous family tumor history were predictors of screening reluctance, while previous disease history was a strong predictor of non-free screening willingness. Fear of screening and inconvenience were the primary concerns among the Zanzibari interviewees. Compared to the 20–49 age group, more women in the less than 20 and 50 or more age groups thought cervical cancer screening was not necessary. The highest rate of cognitive accuracy in regard to cervical cancer warning signs and risk factors was only 37.76%. Conclusions The findings revealed that knowledge of cervical cancer was poor. Educational level, family income and awareness of previous disease history were significant influencing factors of screening uptake. Specific awareness programs to increase knowledge of cervical cancer and screening willingness should be designed and implemented in the public without delay, especially for younger and elderly women.
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Affiliation(s)
- Qiao Weng
- Department of Obstetrics & Gynecology, Nanjing Drum Tower Hospital, Affiliated to Nanjing University Medical College, Nanjing, 210008, China.,Department of Obstetrics & Gynecology, Drum Tower Clinical Medical College, Nanjing Medical University, Nanjing, 210008, China
| | - Jie Jiang
- Jiangsu Province Center for Disease Prevention and Control, Nanjing, China
| | - Fatma Mrisho Haji
- Department of Obstetrics & Gynecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - Lamlet Hassan Nondo
- Department of Obstetrics & Gynecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - Huaijun Zhou
- Department of Obstetrics & Gynecology, Nanjing Drum Tower Hospital, Affiliated to Nanjing University Medical College, Nanjing, 210008, China. .,Department of Obstetrics & Gynecology, Drum Tower Clinical Medical College, Nanjing Medical University, Nanjing, 210008, China.
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24
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Runge AS, Bernstein ME, Lucas AN, Tewari KS. Cervical cancer in Tanzania: A systematic review of current challenges in six domains. Gynecol Oncol Rep 2019; 29:40-47. [PMID: 31309135 PMCID: PMC6606891 DOI: 10.1016/j.gore.2019.05.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 01/29/2023] Open
Abstract
Cervical cancer is the most common cancer in Tanzania. After excluding human immunodeficiency virus, lower respiratory infections, malaria, diarrheal diseases, and tuberculosis, cervical cancer kills more women than any other form of illness in the country. Unfortunately, Tanzania has a low doctor-to-patient ratio (1:50,000) and nearly 7000 women die each year from this disease. The clinical problem is further magnified by the country's lack of resources and prevailing poverty, sporadic cervical cancer screening, prevalence of high-risk oncogenic human papillomavirus subtypes, and relatively high rates of human immunodeficiency virus co-infection. In recent years, addressing the cervical cancer problem has become a priority for the Tanzanian government. In this systematic review of 39 peer-reviewed publications that appeared in the PubMed/MEDLINE (NCBI) database from 2013 to 2018, we synthesize the growing body of literature to capture current trends in Tanzania's evolving cervical cancer landscape. Six domains were identified, including risk factors, primary prevention, barriers to screening, treatment, healthcare worker education, and sustainability. In addition to traditional risk factors associated with sexual behavior, acetowhite changes observed during visual inspection of the cervix with acetic acid, lower education, rural setting, and HIV positivity also have a noteworthy clinical impact.
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Affiliation(s)
- Ava S. Runge
- Department of Medical Education, University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Megan E. Bernstein
- Department of Medical Education, University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Alexa N. Lucas
- Department of Medical Education, University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Krishnansu S. Tewari
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of California, Irvine Medical Center, Orange, CA, USA
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25
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Asgary R, Cole H, Adongo P, Nwameme A, Maya E, Adu-Amankwah A, Barnett H, Adanu R. Acceptability and implementation challenges of smartphone-based training of community health nurses for visual inspection with acetic acid in Ghana: mHealth and cervical cancer screening. BMJ Open 2019; 9:e030528. [PMID: 31315879 PMCID: PMC6661590 DOI: 10.1136/bmjopen-2019-030528] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To explore acceptability and feasibility of smartphone-based training of low-level to mid-level health professionals in cervical cancer screening using visual inspection with acetic acid (VIA)/cervicography. DESIGN In 2015, we applied a qualitative descriptive approach and conducted semi-structured interviews and focus groups to assess the perceptions and experiences of community health nurses (CHNs) (n=15) who performed smartphone-based VIA, patients undergoing VIA/cryotherapy (n=21) and nurse supervisor and the expert reviewer (n=2). SETTING Community health centres (CHCs) in Accra, Ghana. RESULTS The 3-month smartphone-based training and mentorship was perceived as an important and essential complementary process to further develop diagnostic and management competencies. Cervical imaging provided peer-to-peer learning opportunities, and helped better communicate the procedure to and gain trust of patients, provide targeted education, improve adherence and implement quality control. None of the patients had prior screening; they overwhelmingly accepted smartphone-based VIA, expressing no significant privacy issues. Neither group cited significant barriers to performing or receiving VIA at CHCs, the incorporation of smartphone imaging and mentorship via text messaging. CHNs were able to leverage their existing community relationships to address a lack of knowledge and misperceptions. Patients largely expressed decision-making autonomy regarding screening. Negative views and stigma were present but not significantly limiting, and the majority felt that screening strategies were acceptable and effective. CONCLUSIONS Our findings suggest the overall acceptability of this approach from the perspectives of all stakeholders with important promises for smartphone-based VIA implementation. Larger-scale health services research could further provide important lessons for addressing this burden in low-income and middle-income countries.
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Affiliation(s)
- Ramin Asgary
- Global Health, George Washington University Milken Institute of Public Health, Washington, District of Columbia, USA
- Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Helen Cole
- Environmental Science and Technology, Autonomous University of Barcelona Barcelona Catalunya Spain, Barcelona, Spain
| | - Philip Adongo
- Social and Behavioral Sciences, University of Ghana School of Public Health, Accra, Ghana
| | - Ada Nwameme
- Social and Behavioral Sciences, University of Ghana School of Public Health, Accra, Ghana
| | - Ernest Maya
- Social and Behavioral Sciences, University of Ghana School of Public Health, Accra, Ghana
- Population, Family and Reproductive Health, University of Ghana School of Public Health, Accra, Ghana
| | - Amanda Adu-Amankwah
- Population, Family and Reproductive Health, University of Ghana School of Public Health, Accra, Ghana
| | - Hannah Barnett
- Global Health, George Washington University Milken Institute of Public Health, Washington, District of Columbia, USA
| | - Richard Adanu
- Dean, University of Ghana School of Public Health, Accra, Ghana
- Obstetrics and Gynecology, Korle-Bu Teaching Hospital, Accra, Ghana
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The mTST - An mHealth approach for training and quality assurance of tuberculin skin test administration and reading. PLoS One 2019; 14:e0215240. [PMID: 30995275 PMCID: PMC6469794 DOI: 10.1371/journal.pone.0215240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/28/2019] [Indexed: 11/19/2022] Open
Abstract
Background The Tuberculin Skin Test (TST) is a relatively simple test for detecting latent tuberculosis infection (LTBI) but requires regular quality assurance to ensure proper technique for administration and reading. The objective of this study was to estimate the accuracy and reproducibility of an mhealth approach (the mTST) to measure the size of swelling immediately following TST administration (TST injection bleb) and after 48–72 hours (TST induration). Methods Five non-clinical and one clinical reviewer measured the size of TST injection blebs, and TST indurations using smartphone acquired photos of sites of TST administration and readings in patients, or saline injections in volunteers. The reference standard was the onsite measurement (measured by an experienced TB nurse) of the actual TST injection bleb, or induration. Agreement of reviewers’ measurements with the reference standard, as well as agreement within and between reviewers, was estimated using Cohen's kappa coefficient. Results Using the mTST method to assess bleb size in 64 photos of different TST injections, agreement between reviewers, and the reference standard was very good to excellent (κ ranged from 0.75 to 0.87), and within-reviewer reproducibility of readings was excellent (κ ranged from 0.86 to 0.96). Using the mTST method to assess TST induration in 72 photos, reviewers were able to detect no induration (<5mm) and induration of 15mm or greater with accuracy of 95% and 92% respectively, but accuracy was only 20% and 77% for reactions of 5-9mm and 10-14mm respectively. Conclusion The mTST approach appears to be a reliable tool to assess TST administration. The mTST approach was accurate to read indurations of 0-4mm or 15+mm, but less accurate for reactions of 5-14mm. We believe the mTST approach could be useful for training and quality assurance in locations where on-site supervision is not possible.
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27
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Stuart-Shor EM, Cunningham E, Foradori L, Hutchinson E, Makwero M, Smith J, Kasozi J, Johnston EM, Khaki A, Vandervort E, Moshi F, Kerry VB. The Global Health Service Partnership: An Academic-Clinical Partnership to Build Nursing and Medical Capacity in Africa. Front Public Health 2017; 5:174. [PMID: 28791282 PMCID: PMC5522849 DOI: 10.3389/fpubh.2017.00174] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/29/2017] [Indexed: 12/02/2022] Open
Abstract
The World Health Organization estimates a global deficit of about 12.9 million skilled health professionals (midwives, nurses, and physicians) by 2035. These shortages limit the ability of countries, particularly resource-constrained countries, to deliver basic health care, to respond to emerging and more complex needs, and to teach, graduate, and retain their future health professionals—a vicious cycle that is perpetuated and has profound implications for health security. The Global Health Service Partnership (GHSP) is a unique collaboration between the Peace Corps, President’s Emergency Plan for AIDS Relief, Seed and host-country institutions, which aims to strengthen the breadth and quality of medical and nursing education and care delivery in places with dire shortages of health professionals. Nurse and physician educators are seconded to host institutions to serve as visiting faculty alongside their local colleagues. They serve for 1 year with many staying longer. Educational and clinical best practices are shared, emphasis is placed on integration of theory and practice across the academic–clinical domains and the teaching and learning environment is expanded to include implementation science and dissemination of locally tailored and sustainable practice innovations. In the first 3 years (2013–2016) GHSP placed 97 nurse and physician educators in three countries (Malawi, Tanzania, and Uganda). These educators have taught 454 courses and workshops to 8,321 trainees, faculty members, and practicing health professionals across the curriculum and in myriad specialties. Mixed-methods evaluation included key stakeholder interviews with host institution faculty and students who indicate that the addition of GHSP enhanced clinical teaching (quality and breadth) resulting in improved clinical skills, confidence, and ability to connect theory to practice and critical thinking. The outputs and outcomes from four exemplars which focus on the translation of evidence to practice through implementation science are included. Findings from the first 3 years of GHSP suggest that an innovative, locally tailored and culturally appropriate multi-country academic–clinical partnership program that addresses national health priorities is feasible and generated new knowledge and best practices relevant to capacity building for nursing and medical education. This in turn has implications for improving the health of populations who suffer a disproportionate burden of global disease.
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Affiliation(s)
- Eileen M Stuart-Shor
- Seed Global Health, Boston, MA, United States.,Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, United States.,College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, United States
| | | | | | - Elizabeth Hutchinson
- Seed Global Health, Boston, MA, United States.,Department of Family Medicine, Swedish Family Medicine-First Hill, University of Washington, Seattle, WA, United States
| | - Martha Makwero
- Department of Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
| | - Jill Smith
- Seed Global Health, Boston, MA, United States
| | - Jane Kasozi
- School of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Esther M Johnston
- Seed Global Health, Boston, MA, United States.,Wright Center National Family Medicine Residency at HealthPoint, Auburn, WA, United States
| | - Aliasgar Khaki
- Department of Medicine, Herbert Kairuki Memorial University, College of Medicine, Dar es Salaam, Tanzania
| | - Elisa Vandervort
- School of Nursing, University of Utah, Salt Lake City, UT, United States.,Grounds for Health, Williston, VT, United States
| | - Fabiola Moshi
- School of Nursing, University of Dodoma, Dodoma, Tanzania
| | - Vanessa B Kerry
- Seed Global Health, Boston, MA, United States.,Mass General Global Health, Massachusetts General Hospital, Boston, MA, United States.,Department of Medicine, Massachusetts General Hospital, Boston, MA, United States.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
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28
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Denny L, de Sanjose S, Mutebi M, Anderson BO, Kim J, Jeronimo J, Herrero R, Yeates K, Ginsburg O, Sankaranarayanan R. Interventions to close the divide for women with breast and cervical cancer between low-income and middle-income countries and high-income countries. Lancet 2017; 389:861-870. [PMID: 27814963 DOI: 10.1016/s0140-6736(16)31795-0] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 07/11/2016] [Accepted: 07/19/2016] [Indexed: 01/06/2023]
Abstract
Breast and cervical cancers are the commonest cancers diagnosed in women living in low-income and middle-income countries (LMICs), where opportunities for prevention, early detection, or both, are few. Yet several cost-effective interventions could be used to reduce the burden of these two cancers in resource-limited environments. Population- wide vaccination against human papillomavirus (HPV) linked to cervical screening, at least once, for adult women has the potential to reduce the incidence of cervical cancer substantially. Strategies such as visual inspection with acetic acid and testing for oncogenic HPV types could make prevention of cervical cancer programmatically feasible. These two cancers need not be viewed as inevitably fatal, and can be cured, particularly if detected and treated at an early stage. Investing in the health of girls and women is an investment in the development of nations and their futures. Here we explore ways to lessen the divide between LMICs and high-income countries for breast and cervical cancers.
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Affiliation(s)
- Lynette Denny
- Department of Obstetrics and Gynaecology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
| | - Silvia de Sanjose
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Miriam Mutebi
- Department of Surgery, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa; Department of Surgery, Aga Khan University, Nairobi, Kenya
| | - Benjamin O Anderson
- Department of Surgery and Global Health Medicine, University of Washington, Division of Public Health Sciences, Seattle, WA, USA; Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jane Kim
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Jose Jeronimo
- Program for Appropriate Technology in Health (PATH), Seattle, WA, USA
| | - Rolando Herrero
- Prevention and Implementation Group, International Agency for Research on Cancer, Lyon, France
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Ophira Ginsburg
- Institute of Cancer Policy, Women's College Research Institute, Faculty of Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; WHO, Geneva, Switzerland
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