Use of mobile telemedicine for cervical cancer screening

Association between sociodemographic and clinical features, health behaviors, and health literacy of patients with prostate cancer and prostate cancer prognostic stage

Patient characteristics may influence access and acceptance of Prostate Specific Antigen test, and therefore, the timing of prostate cancer (PCa) diagnosis. A group of 361 patients from a cohort (n = 451) diagnosed with PCa in 2018-2020 at the Portuguese Institute of Oncology of Porto was evaluated before treatment, using a structured interview, the Medical Term Recognition Test, and the EORTC Quality of Life Questionnaire QLQ-PR25. PCa prognostic stages (I, II, III, IV) were attributed according to the American Joint Committee on Cancer eighth edition. Multinomial logistic regression was used to compute the odds ratio and 95% confidence interval (OR [95% CI]), considering PCa stage II, the most frequent, as reference. Older age (OR = 4.21 [2.24-7.93]), living outside the Porto Metropolitan Area while having low income (OR = 6.25 [1.53-25.62]), and erectile dysfunction (OR = 2.22 [0.99-4.99]) were associated with stage III, while urination during the night (OR = 3.02 [1.42-6.41]) was associated with stage IV. Urine leakage was less frequent in stage III (OR = 0.23 [0.08-0.68]), and living with a partner (OR = 0.41 [0.19-0.88]) and family history of cancer (OR = 0.25 [0.07-0.86]) in stage IV. Health literacy was not associated with PCa stage but lower education was less frequent in stage I (OR = 0.27 [0.11-0.69]). Patient sociodemographic and clinical characteristics should be considered as targets to improve PCa early detection and prognosis.

Implementing Smartphone-Based Telemedicine for Cervical Cancer Screening in Uganda: Qualitative Study of Stakeholders' Perceptions

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.

Recommendations for Developing a Telemedicine Strategy for Botswana: A Meta-Synthesis

Botswana is developing its eHealth capacity using a National eHealth Strategy. However, that strategy overlooks telemedicine, a potential solution for many healthcare challenges. For telemedicine to benefit Botswana, a telemedicine-specific strategy is required. While establishing a national strategy is a sovereign responsibility, guidance and recommendations can be provided. Using published resources specific to Botswana, key health-related issues were identified. These issues were matched with suitable telemedicine activities and delivery approaches. Recommendations were then derived from these for use in an effective telemedicine-specific strategy for Botswana. From 28 health-related issues, 6 were prioritised. Three telemedicine activities were identified (clinical services, education, and behaviour change), and one delivery approach was chosen (store-and-forward) because they align well with current needs, infrastructure, and mobile phone user capabilities. Since telemedicine has been proven to be effective, efficient, and cost-effective when implemented correctly, this knowledge and experience, plus a recognised strategy development framework, has led to evidence-based recommendations. Specific telemedicine options were identified as examples. As confidence grows, telemedicine options can be expanded to address additional clinical needs and explore alternative activities and delivery options. The recommendations can help the government develop a telemedicine-specific strategy that aligns with the National eHealth Strategy while actively promoting and supporting the adoption and system integration of straightforward telemedicine interventions. This foundation will facilitate the future expansion of telemedicine initiatives for the benefit of all Batswana.

Factors Influencing the Experience of Breast and Cervical Cancer Screening Among Women in Low- and Middle-Income Countries: A Systematic Review

PURPOSE

The persistent high morbidity and mortality from breast and cervical cancer in low- and middle-income countries (LMICs) may be influenced by global disparities in the uptake of screening services. This review sought to synthesize existing evidence to determine factors that influence the experience of women relating to breast and cervical screening in LMICs.

METHODS

A qualitative systematic review of the literature identified through Global Health, Embase, PsycInfo, and MEDLINE. Eligible studies included those outlining primary qualitative research or mixed-method studies with reporting of qualitative findings, detailing women's experiences of involvement with programs for breast or cervical cancer screening. Framework synthesis was used to explore and organize findings from primary qualitative studies and the Critical Appraisal Skills Programme checklist used for quality assessment.

RESULTS

Database searches yielded 7,264 studies for title and abstract screening and 90 full-text articles for screening, with qualitative data from 17 studies and a total of 722 participants included in this review. Four stages influencing experiences of women were generated across both breast and cervical cancer screening approaches, with individual (eg, knowledge of cancer), social (eg, religion, cultural beliefs), and health system (eg, accessibility) factors identified that influence women's initial and subsequent engagement.

CONCLUSION

This study synthesizes existing evidence of factors that influence engagement with breast and cervical cancer screening in LMICs. Evidence-informed recommendations are proposed that may improve the experience of cancer screening in LMICs, with further research necessary to explore their operationalization and impact on cancer care delivery.

Digital cervicography for cervical cancer screening in low-resource settings: A scoping review

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.

Advancing the Science of Implementation for Resource-Limited Settings through Bidirectional Learning Around Cervical Cancer Screening

In 2020, the highest rates of cervical cancer incidence and mortality were reported in Asian and African regions of the world. Across the globe, growing evidence confirms cancer disparities among racial and ethnic minorities, low socioeconomic status groups, sexual and gender minorities, uninsured individuals, and rural residents. Recognition of these stark disparities has led to increased global efforts for improving screening rates overall and, in medically underserved populations, highlighting the urgent need for research to inform the successful implementation of cervical cancer screening. Implementation science, defined as the study of methods to promote the integration of research evidence into health care practice, is well-suited to address this challenge. With a multilevel, implementation focus, we present key research directions that can help address cancer disparities in resource-limited settings. First, we describe several global feasibility studies that acknowledge the effectiveness of self-sampling as a strategy to improve screening coverage. Second, we highlight Project ECHO as a strategy to improve providers' knowledge through an extended virtual learning community, thereby building capacity for health care settings to deliver screening. Third, we consider community health workers, who are a cornerstone of implementing public health interventions in global communities. Finally, we see tremendous learning opportunities that use contextually relevant strategies to advance the science of community engagement and adaptations that could further enhance the uptake of screening in resource-limited settings. These opportunities provide future directions for bidirectional exchange of knowledge between local and global resource-limited settings to advance implementation science and address disparities.

Evaluation of WhatsApp as a Platform for Teledermatology in Botswana: Retrospective Review and Survey

Background

In emerging market countries in sub-Saharan Africa, access to specialty services such as dermatology is limited. Teledermatology is an innovative solution to address this issue; however, many initiatives have been tried without sustained success. Recently, WhatsApp has been used as a store-and-forward telemedicine communication platform for consultation and education in Botswana.

Objective

This study aims to describe the utilization of WhatsApp for teledermatology and the satisfaction levels of participating providers.

Methods

A 2-part pilot study was conducted. First, a retrospective review was performed of WhatsApp communications received by participating dermatologists in Gaborone, Botswana, from January 2016 to December 2019. Sender information, patient demographics and history, response time, diagnoses made, and follow-up recommendations were collected. Second, a 12-question cross-sectional survey was distributed to health care providers who utilized WhatsApp for teledermatology during this period. Descriptive statistics were then performed.

Results

There were 811 communication threads over the study period. The majority (503/811, 62%) of communications were consultations from providers inquiring about a specific patient, followed by multidisciplinary care coordination communications (90/811, 11%). Our in-depth analysis focused on the former. In 323 (64%) provider consultations, dermatologists responded within 1 hour. A diagnosis was made in 274 (55%) consultations. Dermatologists gave treatment recommendations remotely in 281 (56%) consultations and recommended an in-person dermatology visit in 163 (32%). Of the 150 health care providers surveyed, 23 (15%) responded. All respondents (100%) felt that there was a need for teledermatology and improved teledermatology education in Botswana. Moreover, 17 (74%) respondents strongly felt that the guidance received via WhatsApp was high quality, and 22 (96%) were satisfied with WhatsApp as a platform for teledermatology.

Conclusions

This retrospective review and survey demonstrated that WhatsApp is a quick, well-received, and sustainable method of communication between dermatologists and providers across Botswana. The app may offer a solution to the challenges providers face in accessing specialty referral systems, point-of-care education, and medical decision-making support for complex dermatologic cases in Botswana. The information gained from this pilot study can serve as the basis for future telemedicine studies to improve the implementation of teledermatology in Botswana and other resource-limited countries.

Cervical lesion proportion measure using a digital gridded imaging technique to assess cervical pathology in women with genital schistosomiasis

Female genital schistosomiasis (FGS) is characterized by a pattern of lesions which manifest at the cervix and the vagina, such as homogeneous and grainy sandy patches, rubbery papules in addition to neovascularization. A tool for quantification of the lesions is needed to improve FGS research and control programs. Hitherto, no tools are available to quantify clinical pathology at the cervix in a standardized and reproducible manner. This study aimed to develop and validate a cervical lesion proportion (CLP) measure for quantification of cervical pathology in FGS. A digital imaging technique was applied in which a grid containing 424 identical squares was positioned on high resolution digital images from the cervix of 70 women with FGS. CLP was measured for each image by observers counting the total number of squares containing at least one type of FGS associated lesion. For assessment of inter- and intra-observer reliability, three different observers measured CLP independently. In addition, a rubbery papule count (RPC) was determined in a similar manner. The intraclass correlation coefficient was 0.94 (excellent) for the CLP inter-rater reliability and 0.90 (good) for intra-rater reliability and the coefficients for the RPC were 0.88 and 0.80 (good), respectively. The CLP facilitated a reliable and reproducible quantification of FGS associated lesions of the cervix. In the future, grading of cervical pathology by CLP may provide insight into the natural course of schistosome egg-induced pathology of the cervix and may have a role in assessing praziquantel treatment efficacy against FGS.

Trial Registration: ClinicalTrials.gov, trial number NCT04115072; trial URL https://clinicaltrials.gov/ct2/show/NCT04115072?term=Female+genital+schistosomiasis+AND+Madagascar&draw=2&rank=1.

Female genital schistosomiasis (FGS) is characterized by development of egg-induced chronic inflammatory lesions of the cervix and the vagina. FGS causes various symptoms such vaginal discharge, genital itch, pelvic pain and post-coital bleeding, and the disease is further associated with reproductive complications such as ectopic pregnancy and infertility. Moreover, FGS is today hypothesized as a risk factor for transmission of HIV in Sub-Saharan Africa. General prevention directed against Schistosoma infection and use of praziquantel as anthelmintic drug therapy are cornerstones in the FGS control strategy. The aim of the study was to test inter- and intra-rater reliability using a cervical lesion proportion (CLP) measure in a series of digital images from women living in a Schistosoma haematobium hyperendemic area in Madagascar”. In that overall context, we have developed a digital image-based tool for quantitative assessment of FGS associated cervical lesions, which enables evaluation of treatment outcome at individual as well as community level with particular focus on resolution of cervical pathology, but also on risk of recurrence. The tool will also provide new information in understanding the natural history of FGS including development of clinical pathology.

The role of digital health in palliative care for people living with HIV in sub-Saharan Africa: A systematic review

Background

In 2018, 26.6 million people were living with HIV in sub-Saharan Africa. Palliative care services are recommended for people living with HIV at all stages from diagnosis through to end-of-life. However, the provision of palliative care in sub-Saharan Africa is limited, leading to little or no access for the majority of patients. Digital technologies in sub-Saharan Africa present an opportunity to improve access to palliative care for people living with HIV in the region. This review synthesised literature on digital health interventions for palliative care for people living with HIV in sub-Saharan Africa and assessed their effects on patient outcomes.

Methods

Literature searches were conducted in MEDLINE, Embase, PsycINFO and Global Health. Inclusion and exclusion criteria were applied. Two independent reviewers conducted study screening, data extraction and quality appraisal. A narrative synthesis was performed to draw together and report findings across heterogeneous studies. Reporting of this review follows the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist.

Results

Out of 4117 records, 25 studies were included, covering 3592 people living with HIV, across 21 countries. Studies included three randomised controlled trials, three qualitative, three pre- and post-test, two observational, two case series, six cross-sectional and six mixed methods studies. Telemedicine was the most reported digital health intervention, with 12 studies demonstrating the effectiveness of digital health interventions.

Conclusion

Emerging evidence suggests digital health interventions can be effective in facilitating patient-provider communication and health professional decision-making as a part of palliative care for people living with HIV. There is a need for further development and evaluation of digital health interventions alongside determining optimal approaches to their implementation as a part of palliative care provision in sub-Saharan Africa.

Digital health in oncology in Africa: A scoping review and cross-sectional survey

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.

Use of Smartphones for the Detection of Uterine Cervical Cancer: A Systematic Review

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.

Cervical cancer screening status and implementation challenges: Report from selected states of India

BACKGROUND

Cervical cancer contributes to 6%-29% of the cancers in India. Although the Government of India in 2010 integrated cancer screening within the National Programme for the prevention of Non-communicable Diseases, only 22% of women aged 15-45 years had undergone examination of the cervix by 2016. This prompts the question regarding the organisation of the program's implementation and service delivery and regarding challenges that may explain poor screening uptake.

METHODS

Semi-structured interviews were held with program managers and implementers in seven districts of three selected States of India. The data analysis looked at program content, the organisation of screening delivery, and the challenges to the implementation of the program, considering six theoretically derived dimensions of public health capacity: leadership and governance, organisational structure, financial resources, workforce, partnerships, and knowledge development.

RESULTS

Participants perceive the existing capacities across the six domains as insufficient to implement the CCS program nationwide. A context specific implementation, a better coordination between the program and district health facilities, timely remuneration, better maintenance of data and a strong monitoring system are possible solutions to remove health system related barriers.

CONCLUSION

The study provides evidence on the practical challenges and provides recommendations for strengthening the capacities of the health system.

Digital Health Strategies for Cervical Cancer Control in Low- and Middle-Income Countries: Systematic Review of Current Implementations and Gaps in Research

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.

Feasibility and Acceptability of Smartphone-Based Cervical Cancer Screening Among HIV-Positive Women in Western Kenya

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.

The role of telemedicine in gynecologic healthcare: A narrative review

ABSTRACT

This article offers a comprehensive narrative literature review on telemedicine use in gynecologic healthcare analyzing current telemedicine integration in the field and outlining innovative and best practices. Telemedicine use in contraceptive care, sexually transmitted infections, acute and chronic gynecologic conditions, and education are discussed. NPs are in a unique position to offer these services to patients in need of women's healthcare services. Barriers, facilitators, clinical implications, and future research are addressed.

A systematic review of handheld tools in lieu of colposcopy for cervical neoplasia and female genital schistosomiasis

Background

Visualization of the lesions in the lower genital tract is the mainstay for diagnosis of the four lesions found in female genital schistosomiasis (FGS), but colposcopes are generally not available in low‐resource settings.

Objective

We sought to review handheld devices that could potentially be used for FGS diagnosis.

Search strategy

We searched Medline and Embase 2015–2019 for handheld devices used in cervical cancer screening and FGS diagnosis.

Selection criteria

We excluded studies that did not compare the device to standard‐of‐care colposcopes or histopathology.

Main results and conclusion

In 11 studies, four handheld colposcopes, two smartphones, and one compact digital camera were evaluated. Two handheld colposcopes were found to be potentially adequate for FGS diagnosis, namely Gynocular and Mobile ODT. The smartphones and digital camera did not have sufficient magnification to diagnose grainy sandy patches, one of the FGS lesion types. Customized software should be made to support the diagnosis of both FGS and cervical neoplasia. Real‐time postgraduate training and quality control should be considered in future studies of handheld colposcopes. For patients from schistosomiasis endemic areas, we recommend that handheld devices are used for FGS. Studies are needed to determine which of the two devices is most adequate for FGS diagnosis in schistosomiasis endemic areas.

Handheld colposcopy for schistosomiasis endemic areas should be adequate for both cervical cancer and genital schistosomiasis diagnoses.

The need for a telemedicine strategy for Botswana? A scoping review and situational assessment

Background

Health, healthcare, and healthcare system problems within the developing world are well recognised. eHealth, the use of Information and Communications Technologies (ICT) for health, is frequently suggested as one means by which to ameliorate such problems. However, to identify and implement the most appropriate ehealth solutions requires development of a thoughtful and broadly evidence-informed strategy. Most published strategies focus on health informatics solutions, neglecting the potential for other aspects of ehealth (telehealth, telemedicine, elearning, and ecommerce). This study examined the setting in Botswana to determine the need for a telemedicine-specific strategy.

Methods

A situational assessment of ehealth activities in Botswana was performed through a scoping review of the scientific and grey literature using specified search terms to July 2018; an interview with an official from the major mhealth stakeholder; and benchtop review of policies and other relevant Government documents including the country’s current draft eHealth Strategy.

Results

Thirty-nine papers were reviewed. Various ehealth technologies have been applied within Botswana. These include Skype for educational activities, instant messaging (WhatsApp for telepathology; SMS for transmission of laboratory test results, patient appointment reminders, and invoicing and bill payment), and robotics for dermatopathology. In addition health informatics technologies have been used for surveillance, monitoring, and access to information by healthcare workers. The number of distinct health information systems has been reduced from 37 to 12, and 9 discrete EMRs remain active within the public health institutions. Many infrastructural issues were identified. A critical assessment of the current draft ehealth strategy document for Botswana showed limitations. Many telemedicine services have been introduced over the years (addressing cervical cancer screening, teledermatology, teleradiology, oral medicine and eye screening), but only one project was confirmed to be active and being scaled up with the intervention of the Government.

Conclusions

Botswana’s draft ‘ehealth’ strategy will not, in and of itself, nurture innovative growth in the application of telemedicine initiatives, which currently are fragmented and stalled. This lack of focus is preventing telemedicine’s recognised potential from being leveraged. A specific Telemedicine Strategy, aligned with and supportive of the pre-existing ehealth strategy, would provide the necessary focus, stimulus, and guidance.

Impact of mobile technologies on cervical cancer screening practices in Lagos, Nigeria (mHealth-Cervix): Protocol for a randomised controlled trial

Background: Incidence and mortality from cervical cancer have remained high due to many obstacles facing the implementation of organized screening programs in resource-constrained countries such as Nigeria. The application of mobile technologies (mHealth) to health services delivery has the potential to reduce inequalities, empower patients to control their health, and improve the cost-effectiveness of health care delivery.

Aim: To assess the efficacy of mobile technology intervention on Pap test screening adherence compared to a control condition and also determine the factors affecting the uptake of Pap smear screening practices among women in Lagos.

Methods: This is a multi-center randomized controlled trial that will involve women aged 25 to 65 years attending the General Outpatient clinics of the two tertiary health institutions in Lagos, Nigeria between April and December 2020. At baseline, a total of 200 National Health Insurance Scheme (NHIS) enrollees will be randomized to either a text message arm or usual care (control) arm. The primary outcome is the completion of a Pap smear within 6 months of enrolment in the study. The associations between any two groups of continuous variables will be tested using the independent sample t-test (normal distribution) or the Mann-Whitney U test (skewed data) and that of two groups of categorical variables with Chi-square X ²or Fisher's exact test where appropriate. Using binary logistic regression model, we will adjust for age and other relevant sociodemographic and clinical variables and adherence to Pap test screening. Statistical significance will be defined as P-value less than 0.05.

Discussion: The mHealth-Cervix study will evaluate the impact of mobile technologies on cervical cancer screening practices in Lagos, Nigeria as a way of contributing to the reduction in the wide disparities in cervical cancer incidence through early detection facilitated using health promotion to improve Pap smear screening adherence.

Registration: PACTR202002753354517 13/02/2020

Quantitative Screening of Cervical Cancers for Low-Resource Settings: Pilot Study of Smartphone-Based Endoscopic Visual Inspection After Acetic Acid Using Machine Learning Techniques

BACKGROUND

Approximately 90% of global cervical cancer (CC) is mostly found in low- and middle-income countries. In most cases, CC can be detected early through routine screening programs, including a cytology-based test. However, it is logistically difficult to offer this program in low-resource settings due to limited resources and infrastructure, and few trained experts. A visual inspection following the application of acetic acid (VIA) has been widely promoted and is routinely recommended as a viable form of CC screening in resource-constrained countries. Digital images of the cervix have been acquired during VIA procedure with better quality assurance and visualization, leading to higher diagnostic accuracy and reduction of the variability of detection rate. However, a colposcope is bulky, expensive, electricity-dependent, and needs routine maintenance, and to confirm the grade of abnormality through its images, a specialist must be present. Recently, smartphone-based imaging systems have made a significant impact on the practice of medicine by offering a cost-effective, rapid, and noninvasive method of evaluation. Furthermore, computer-aided analyses, including image processing-based methods and machine learning techniques, have also shown great potential for a high impact on medicinal evaluations.

OBJECTIVE

In this study, we demonstrate a new quantitative CC screening technique and implement a machine learning algorithm for smartphone-based endoscopic VIA. We also evaluated the diagnostic performance and practicability of the approach based on the results compared to the gold standard and from physicians' interpretation.

METHODS

A smartphone-based endoscope system was developed and applied to the VIA screening. A total of 20 patients were recruited for this study to evaluate the system. Overall, five were healthy, and 15 were patients who had shown a low to high grade of cervical intraepithelial neoplasia (CIN) from both colposcopy and cytology tests. Endoscopic VIA images were obtained before a loop electrosurgical excision procedure for patients with abnormal tissues, and their histology tissues were collected. Endoscopic VIA images were assessed by four expert physicians relative to the gold standard of histopathology. Also, VIA features were extracted from multiple steps of image processing techniques to find the differences between abnormal (CIN2+) and normal (≤CIN1). By using the extracted features, the performance of different machine learning classifiers, such as k-nearest neighbors (KNN), support vector machine, and decision tree (DT), were compared to find the best algorithm for VIA. After determining the best performing classifying model, it was used to evaluate the screening performance of VIA.

RESULTS

An average accuracy of 78%, with a Cohen kappa of 0.571, was observed for the evaluation of the system by four physicians. Through image processing, 240 sliced images were obtained from the cervicogram at each clock position, and five features of VIA were extracted. Among the three models, KNN showed the best performance for finding VIA within holdout 10-fold cross-validation, with an accuracy of 78.3%, area under the curve of 0.807, a specificity of 80.3%, and a sensitivity of 75.0%, respectively. The trained model performed using an unprovided data set resulted in an accuracy of 80.8%, specificity of 84.1%, and sensitivity of 71.9%. Predictions were visualized with intuitive color labels, indicating the normal/abnormal tissue using a circular clock-type segmentation. Calculating the overlapped abnormal tissues between the gold standard and predicted value, the KNN model overperformed the average assessments of physicians for finding VIA.

CONCLUSIONS

We explored the potential of the smartphone-based endoscopic VIA as an evaluation technique and used the cervicogram to evaluate normal/abnormal tissue using machine learning techniques. The results of this study demonstrate its potential as a screening tool in low-resource settings.

Assessing Nurses' Adherence to the See-and-Treat Guidelines of Botswana's National Cervical Cancer Prevention Programme

The see-and-treat approach for cervical cancer screening [visual inspection with acetic acid (VIA) followed by immediate cryotherapy] was first pilot tested in Botswana in 2009. Botswana's Ministry of Health and the Botswana-UPenn Partnership collaborated to expand see-and-treat to five additional sites throughout the country in 2014. The purpose of this study was to evaluate whether nurses' adherence to guideline-based screening was maintained during scale-up. Therefore, we compared nurses' adherence between the pilot and scaled-up sites and determined main drivers of nonadherence across all sites. We conducted a retrospective review of 6,644 medical charts from Botswana's National Cervical Cancer Prevention Programme between February 2014 and October 2015. Using multivariable regression modeled with generalized estimating equations, we determined whether nurses' adherence to the see-and-treat guideline differed between the pilot and scale-up sites after controlling for significant covariates. Overall, adherence to the guideline was high (88.4%). Although the scaled-up sites had higher adherence compared with the pilot site (90.9% vs. 80.2%, respectively), the difference between sites was not statistically significant in the multivariable model (P = 0.221). Of the nonadherent clinical encounters, the three most frequent visit types were VIA not performed (178, 23.3%), VIA negative: HIV unknown (163, 21.3%), and VIA negative: HIV negative (144, 18.9%). The most common reason for nonadherence was misspecification of follow-up times. Despite known challenges of scaling-up health innovations in resource-limited settings, our study shows that nurses maintained guideline-adherent care in Botswana's national see-and-treat program. The successful scale-up may have been attributable to the program's intensive quality assurance monitoring.

Andriod Device-Based Cervical Cancer Screening for Resource-Poor Settings

Visual inspection with acetic acid (VIA) is an effective, affordable and simple test for cervical cancer screening in resource-poor settings. But considerable expertise is needed to differentiate cancerous lesions from normal lesions, which is lacking in developing countries. Many studies have attempted automation of cervical cancer detection from cervix images acquired during the VIA process. These studies used images acquired through colposcopy or cervicography. However, colposcopy is expensive and hence is not feasible as a screening tool in resource-poor settings. Cervicography uses a digital camera to acquire cervix images which are subsequently sent to experts for evaluation. Hence, cervicography does not provide a real-time decision of whether the cervix is normal or not, during the VIA examination. In case the cervix is found to be abnormal, the patient may be referred to a hospital for further evaluation using Pap smear and/or biopsy. An android device with an inbuilt app to acquire images and provide instant results would be an obvious choice in resource-poor settings. In this paper, we propose an algorithm for analysis of cervix images acquired using an android device, which can be used for the development of decision support system to provide instant decision during cervical cancer screening. This algorithm offers an accuracy of 97.94%, a sensitivity of 99.05% and specificity of 97.16%.

m-Health for Early Detection of Oral Cancer in Low- and Middle-Income Countries

Background: Up to 86% of oral cancer (OC) patients present at the late stage where survival is dismal. Limited access to specialist diagnosis is a significant factor for late presentation. The increasing use of smartphones presents an opportunity to use digital technology to facilitate early detection of OC. Aim: To evaluate the feasibility of using Mobile Mouth Screening Anywhere (MeMoSA^®) to facilitate early detection of OC. Methods: A mobile phone app named MeMoSA was developed and the feasibility of integrating this for documentation of oral lesions, and communication between dentists and specialists for management decisions were evaluated. The experience of dentists and specialists in using MeMoSA was determined using qualitative questionnaires. Results: Communication between specialist and dentists using MeMoSA stratified cases and streamlined referral of patients. Twelve of 48 patients were found to have oral lesions or signs suspicious of cancer and 3 required referrals. The patient's compliance for referral was tracked with MeMoSA. All dentists agreed that MeMoSA could facilitate early detection of OC and believed that MeMoSA could assist in the identification of oral mucosal lesions through direct communication with specialists and continuous learning in the recognition of high-risk lesions. Conclusions: MeMoSA has the potential to be used to promote equitable health care and streamline patient management that could result in early detection of OC.

Framework to Advance Oncology-Related Telehealth

Purpose

As telehealth is increasingly used across the clinical care spectrum to provide patient-centered care, it is important to have robust measures to assess its impact on patient outcomes and care processes. The National Quality Forum (NQF) developed a Telehealth Framework to organize measures and inform target areas for measure development that includes the following four domains: access to care, financial impact or cost, experience, and effectiveness. Our goal is to identify and categorize within the NQF domains currently existing measures of telehealth applicable to oncology to detect priority areas for future research and measure development.

Methods

We reviewed telehealth-related measures applied to oncology care reported in systematic reviews and identified NQF-endorsed quality measures related to oncology care potentially amenable to telehealth. We organized identified measures by the NQF domains to inform suggestions for advancing the care of patients with cancer through telehealth.

Results

We identified 12 systematic reviews representing 183 studies reporting telehealth-related oncology research. Most studied outcomes related to diagnosis and treatment or user experience and symptom monitoring. Clinical effectiveness measures were most frequently reported (38%), and most were psychosocial. Patient, family, and/or caregiver experience was the next most frequently reported measure. There were only a few other cancer-related clinical effectiveness measures (eg, morbidity). Most NQF-endorsed oncology measures amenable to telehealth applied to the domains of access to care and effectiveness, with a lack of measures informing financial impact or cost and experience.

Conclusion

Overall, there has been a lack of quality measures to assess use of telehealth for the care of oncology patients. Future work should focus on developing measures within each of the NQF-identified domains, with special attention to the financial impact or cost domain.

Coinfections and comorbidities in African health systems: At the interface of infectious and noninfectious diseases

There is a disease epidemiological transition occurring in Africa, with increasing incidence of noninfectious diseases, superimposed on a health system historically geared more toward the management of communicable diseases. The persistence and sometimes emergence of new pathogens allows for the occurrence of coinfections and comorbidities due to both infectious and noninfectious diseases. There is therefore a need to rethink and restructure African health systems to successfully address this transition. The historical focus of more health resources on infectious diseases requires revision. We hypothesise that the growing burden of noninfectious diseases may be linked directly and indirectly to or further exacerbated by the existence of neglected tropical diseases (NTDs) and other infectious diseases within the population. Herein, we discuss the health burden of coinfections and comorbidities and the challenges to implementing effective and sustainable healthcare in Africa. We also discuss how existing NTD and infectious disease intervention programs in Africa can be leveraged for noninfectious disease intervention. Furthermore, we explore the potential for new technologies-including artificial intelligence and multiplex approaches-for diagnosis and management of chronic diseases for improved health provision in Africa.

From HIV prevention to non-communicable disease health promotion efforts in sub-Saharan Africa: A Narrative Review

OBJECTIVE

To synthesize published literature on noncommunicable disease (NCD) behavior change communication (BCC) interventions in sub-Saharan Africa (SSA) among persons living with HIV (PLHIV) and in the general population to inform efforts to adopt similar HIV and NCD BCC intervention activities.

METHODS

We conducted a literature review of NCD BCC interventions and included 20 SSA-based studies. Inclusion criteria entailed describing a BCC intervention targeting any four priority NCDs (cardiovascular disease, type 2 diabetes, cervical cancer, and depression) or both HIV and any of the NCDs. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was used to assess potential public health impact of these studies. We also solicited expert opinions from 10 key informants on the topic of HIV/NCD health promotion in five SSA countries.

RESULTS

The BCC interventions reviewed targeted multiple parts of the HIV and NCD continuum at both individual and community levels. Various strategies (i.e. health education, social marketing, motivational interviewing, mobile health, and peer support) were employed. However, few studies addressed more than one dimension of the RE-AIM framework. Opinions solicited from the key informants supported the feasibility of integrating HIV and NCD BCC interventions in SSA potentially improving access, service provision and service demand, especially for marginalized and vulnerable populations.

CONCLUSION

Although HIV/NCD integration can improve effectiveness of preventive services at individual and community levels, potential public health impact of such approaches remain unknown as reach, adoptability, and sustainability of both integrated and nonintegrated NCD BCC approaches published to date have not been well characterized.

Mobile health solutions in developing countries: a stakeholder perspective

Infrastructural deficiencies, limited access to medical care, and shortage of health care workers are just a few of the barriers to health care in developing countries. mHealth has the potential to overcome at least some of these challenges. To address this, a stakeholder perspective is adopted and an analysis of existing research is undertaken to look at mHealth delivery in developing countries. This study focuses on four key stakeholder groups i.e., health care workers, patients, system developers, and facilitators. A systematic review identifies 108 peer-reviewed articles, which are analysed to determine the extent these articles investigate the different types of stakeholder interactions, and to identify high-level themes emerging within these interactions. This analysis illustrates two key gaps. First, while interactions involving health care workers and/or patients have received significant attention, little research has looked at the role of patient-to-patient interactions. Second, the interactions between system developers and the other stakeholder groups are strikingly under-represented.

Implementation strategies to improve cervical cancer prevention in sub-Saharan Africa: a systematic review

Background

Developed countries, such as the USA, have achieved significant decreases in cervical cancer burden since the introduction of Pap smear-based programs in the 1960s. Due to implementation barriers and limited resources, many countries in sub-Saharan Africa (SSA) have been unable to attain such reductions. The purpose of this review is to evaluate implementation strategies used to improve the uptake and sustainability of cervical cancer prevention programs in SSA.

Methods

A reviewer (LJ) independently searched PubMed, Ovid/MEDLINE, Scopus, and Web of Science databases for relevant articles with the following search limits: English language, peer reviewed, and published between 1996 and 2017. The 4575 search results were screened for eligibility (CJ, LJ) to identify original research that empirically evaluated or tested implementation strategies to improve cervical cancer prevention in SSA. Fifty-three articles met criteria for inclusion in the final review. AA, CJ, and LJ abstracted the included articles for implementation-related content and evaluated them for risk of bias according to study design with the National Heart, Lung, and Blood Institute’s (NHLBI) Quality Assessment Tools. Results were reported according to PRISMA guidelines.

Results

The 53 included studies are well represented among all sub-Saharan regions: South (n = 16, 30.2%), West (n = 16, 30.2%), East (n = 14, 26.4%), and Middle (n = 7, 13.2%). There are 34 cross-sectional studies (64.2%), 10 pre-posttests (18.9%), 8 randomized control trials (15.1%), and one nonrandomized control trial (1.9%). Most studies are “fair” quality (n = 22, 41.5%). Visual inspection with acetic acid (VIA) (n = 19, 35.8%) was used as the main prevention method more frequently than HPV DNA/mRNA testing (n = 15, 28.3%), Pap smear (n = 13, 24.5%), and HPV vaccine (n = 9, 17.0%). Effectiveness of strategies to improve program implementation was measured using implementation outcomes of penetration (n = 33, 62.3%), acceptability (n = 15, 28.3%), fidelity (n = 14, 26.4%), feasibility (n = 8, 15.1%), adoption (n = 6, 11.3%), sustainability (n = 2, 3.8%), and cost (n = 1, 1.9%). Education strategies (n = 38, 71.7%) were used most often but have shown limited effectiveness.

Conclusion

This systematic review highlights the need to diversify strategies that are used to improve implementation for cervical cancer prevention programs. While education is important, implementation science literature reveals that education is not as effective in generating change. There is a need for additional organizational support to further incentivize and sustain improvements in implementation.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0718-9) contains supplementary material, which is available to authorized users.

Development of mobile technologies for the prevention of cervical cancer in Santiago, Chile study protocol: a randomized controlled trial

BACKGROUND

In Chile, more than 500 women die every year from cervical cancer, and a majority of Chilean women are not up-to-date with their Papanicolau (Pap) test. Mobile health has great potential in many health areas, particularly in health promotion and prevention. There are no randomized controlled trials in Latin America assessing its use in cervical cancer screening. The 'Development of Mobile Technologies for the Prevention of Cervical Cancer in Santiago, Chile' study aims to determine the efficacy of a text-message intervention on Pap test adherence among Chilean women in the metropolitan region of Santiago.

METHODS/DESIGN

This study is a parallel randomized-controlled trial of 400 Chilean women aged 25-64 who are non-adherent with current recommendations for Pap test screening. Participants will be randomly assigned to (1) a control arm (usual care) or (2) an intervention arm, where text and voice messages containing information and encouragement to undergo screening will be sent to the women. The primary endpoint is completion of a Pap test within 6 months of baseline assessment, as determined by medical record review at community-based clinics. Medical record reviewers will be blinded to randomization arms. The secondary endpoint is an evaluation of the implementation and usability of the text message intervention as a strategy to improve screening adherence.

DISCUSSION

This intervention using mobile technology intends to raise cervical cancer screening adherence and compliance among a Chilean population of low and middle-low socioeconomic status. If successful, this strategy may reduce the incidence of cervical cancer.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02376023 Registered 2/17/2015. First participant enrolled Feb 22nd 2016.

A Mobile Health Data Collection System for Remote Areas to Monitor Women Participating in a Cervical Cancer Screening Campaign

BACKGROUND

Barriers to efficient cervical cancer screening in low- and medium-income countries include the lack of systematic monitoring of the participants' data. The aim of this study was to assess the feasibility of a mobile health (m-Health) data collection system to facilitate monitoring of women participating to cervical cancer screening campaign.

METHODS

Women aged 30-65 years, participating in a cervical cancer screening campaign in Ambanja, Madagascar, were invited to participate in the study. Cervical Cancer Prevention System, an m-Health application, allows the registration of clinical data, while women are undergoing cervical cancer screening. All data registered in the smartphone were transmitted onto a secure, Web-based platform through the use of an Internet connection. Healthcare providers had access to the central database and could use it for the follow-up visits. Quality of data was assessed by computing the percentage of key data missing.

RESULTS

A total of 151 women were recruited in the study. Mean age of participants was 41.8 years. The percentage of missing data for the key variables was less than 0.02%, corresponding to one woman's medical history data, which was not sent to the central database. Technical problems, including transmission of photos, human papillomavirus test results, and pelvic examination data, have subsequently been solved through a system update.

CONCLUSION

The quality of the data was satisfactory and allowed monitoring of cervical cancer screening data of participants. Larger studies evaluating the efficacy of the system for the women's follow-up are needed in order to confirm its efficiency on a long-term scale.

Cervical cancer screening in low-resource settings: a smartphone image application as an alternative to colposcopy

BACKGROUND

Visual inspection after application of acetic acid (VIA) and Lugol's iodine (VILI) is a cervical cancer (CC) screening approach that has recently been adopted in low- and middle-income countries (LMIC). Innovative technologies allow the acquisition of consecutive cervical images of VIA and VILI using a smartphone application. The aim of this study was to evaluate the quality of smartphone images in order to assess the feasibility and usability of a mobile application for CC screening in LMIC.

METHODS

Between May and November 2015, women aged 30-65 years were recruited in a CC screening campaign in Madagascar. Human papillomavirus-positive women were invited to undergo VIA/VILI assessment. Pictures of their cervix were taken using a Samsung Galaxy S5 with an application called "Exam", which was designed to obtain high-quality images and to classify them in the following sequence: native, VIA, VILI and posttreatment. Experts in colposcopy were asked to evaluate if the quality of the pictures was sufficient to establish the diagnosis and to assess sharpness, focus and zoom.

RESULTS

The application use was simple and intuitive, and 208 pictures were automatically classified and recorded in the patient's file. The quality was judged as adequate for diagnosis in 93.3% of cases. The interobserver agreement was κ =0.45 (0.23-0.58), corresponding to a moderate agreement on the common scale of kappa values.

CONCLUSION

This smartphone application allows the acquisition of good quality images for VIA/VILI diagnosis. The classification of images in a patient database makes them accessible to on- and off-site experts, and allows continuous clinical education. Smartphone applications may offer an alternative to colposcopy for CC screening in LMIC.

Mobile health application for remote oral cancer surveillance

BACKGROUND

To determine the effectiveness of a mobile phone-based remote oral cancer surveillance program (Oncogrid) connecting primary care dental practitioners and frontline health care workers (FHW) with oral cancer specialists.

METHODS

The study population (N = 3,440) included a targeted cohort (n = 2,000) and an opportunistic cohort (n = 1,440) screened by FHW and dental professionals, respectively. The authors compared the screening efficacy in both groups, with specialist diagnosis considered the reference standard. The outcomes measured were lesion detection and capture of interpretable images of the oral cavity.

RESULTS

In the targeted cohort, among 51 of 81 (61%) interpretable images, 23 of 51 (45%) of the lesions were confirmed by specialists, while the opportunistic cohort showed 100% concordance with the specialists (106 of 106). Sixty-two of 129 (48%) of the recommended patients underwent biopsy; 1 of 23 (4%) were in the targeted cohort, and 61 of 106 (57%) were in the opportunistic cohort. Ninety percent of the lesions were confirmed to be malignant or potentially malignant.

CONCLUSIONS

The mobile health-based approach adopted in this study aided remote early detection of oral cancer by primary care dental practitioners in a resource-constrained setting. Further optimization of this program is required to adopt the system for FHW. Evaluation of its efficacy in a larger population is also warranted.

PRACTICAL IMPLICATIONS

The increased efficiency of early detection by dentists, when assisted by a remote mobile health-based approach, is a step toward a more effective oral cancer screening program.

Noncommunicable Diseases In East Africa: Assessing The Gaps In Care And Identifying Opportunities For Improvement

The prevalence of noncommunicable diseases in East Africa is rising rapidly. Although the epidemiologic, demographic, and nutritional transitions are well under way in low-income countries, investment and attention in these countries remain focused largely on communicable diseases. We discuss existing infrastructure in communicable disease management as well as linkages between noncommunicable and communicable diseases in East Africa. We describe gaps in noncommunicable disease management within the health systems in this region. We also discuss deficiencies in addressing noncommunicable diseases from basic science research and medical training to health services delivery, public health initiatives, and access to essential medications in East Africa. Finally, we highlight the role of collaboration among East African governments and civil society in addressing noncommunicable diseases, and we advocate for a robust primary health care system that focuses on the social determinants of health.

A systematic review of randomized controlled trials of mHealth interventions against non-communicable diseases in developing countries

Background

The reasons of deaths in developing countries are shifting from communicable diseases towards non-communicable diseases (NCDs). At the same time the number of health care interventions using mobile phones (mHealth interventions) is growing rapidly. We review studies assessing the health-related impacts of mHealth on NCDs in low- and middle-income countries (LAMICs).

Methods

A systematic literature search of three major databases was performed in order to identify randomized controlled trials (RCTs) of mHealth interventions. Identified studies were reviewed concerning key characteristics of the trial and the intervention; and the relationship between intervention characteristics and outcomes was qualitatively assessed.

Results

The search algorithms retrieved 994 titles. 8 RCTs were included in the review, including a total of 4375 participants. Trials took place mostly in urban areas, tested different interventions (ranging from health promotion over appointment reminders and medication adjustments to clinical decision support systems), and included patients with different diseases (diabetes, asthma, hypertension). Except for one study all showed rather positive effects of mHealth interventions on reported outcome measures.

Furthermore, our results suggest that particular types of mHealth interventions that were found to have positive effects on patients with communicable diseases and for improving maternal care are likely to be effective also for NCDs.

Conclusions

Despite rather positive results of included RCTs, a firm conclusion about the effectiveness of mHealth interventions against NCDs is not yet possible because of the limited number of studies, the heterogeneity of evaluated mHealth interventions and the wide variety of reported outcome measures. More research is needed to better understand the specific effects of different types of mHealth interventions on different types of patients with NCDs in LaMICs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3226-3) contains supplementary material, which is available to authorized users.

Cervical Cancer Screening in Cameroon: Interobserver Agreement on the Interpretation of Digital Cervicography Results

OBJECTIVE

The World Health Organization recommends visual inspection with acetic acid (VIA) for cervical cancer screening in resource-limited settings. In Cameroon, we use digital cervicography (DC) to capture images of the cervix after VIA. This study evaluated interobserver agreement of DC results, compared DC with histopathologic results, and examined interobserver agreement among screening methods.

METHOD

Three observers, blinded to each other's interpretations, evaluated 540 DC photographs as follows: (1) negative/positive for acetowhite lesions or cancer and (2) assigned a presumptive diagnosis of histopathologic lesion grade in the 91 cases that had a histopathologic diagnosis. Observer A was the actual screening nurse; B, a reproductive health nurse; C, a gynecologic oncologist; and D, the histopathologic diagnosis. We compared inter-rater agreement of DC impressions among observers A, B, and C, and with D, with Cohen kappas.

RESULTS

For interpretations of DC, (negative/positive) strengths of agreement of paired observers were the following: A/B, moderate [K, 0.54; 95% confidence interval (CI), 0.47-0.61], A/C, fair (K, 0.37; 95% CI, 0.29-0.44), and B/C, moderate (K, 0.45; 95% CI, 0.37-0.53). For presumptive pathologic grading, strengths of agreement for weighted Ks were as follows: A/B, moderate (K, 0.42; 95% CI, 0.28-0.56); A/C, fair (K, 0.33; 95% CI, 0.20-0.46); B/C, fair (K, 0.54; 95% CI, 0.40-0.67); A/D, moderate (K, 0.59; 95% CI, 0.45-0.74); B/D, moderate (K, 0.58; 95% CI, 0.46-0.70); and C/D, moderate (K, 0.50; 95% CI, 0.37-0.63).

CONCLUSIONS

Interobserver agreement of DC interpretations was mostly moderate among the 3 observers, between them and histopathology, and comparable to that of other visual-based screening methods, i.e., VIA, cytology, or colposcopy.

Use of Smartphones as Adjuvant Tools for Cervical Cancer Screening in Low-Resource Settings

OBJECTIVES

Our aim was to evaluate the feasibility and performance of smartphone digital images for the detection of cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) as an adjunct to a conventional visual inspection approach with acetic acid (VIA) and Lugol's iodine (VILI), in comparison with detection by histopathologic examination.

METHODS

Three hundred women were primarily screened for human papillomavirus (HPV) using self-collected vaginal specimens. Human papillomavirus-positive women were then invited for VIA and VILI, which were interpreted as (i) nonpathological, (ii) pathological or, (iii) inconclusive. Cervical smearing, endocervical brushing, and cervical biopsies were performed. Digital images of the cervix were taken with a smartphone and evaluated offsite by experienced health care providers. Sensitivity and specificity for CIN2+ were compared between on-site and off-site observers, using histopathological diagnosis as the criterion standard.

RESULTS

Eighty-eight HPV-positive women were screened for cervical cancer. Overall, 7 cases of CIN2+ (8.0%) were diagnosed using biopsy specimens. The on-site physician obtained a sensitivity of 28.6% (95% confidence interval [95% CI], 3.7-71) and a specificity of 87.2% (95% CI, 77.7- 93.7). The off-site physicians obtained a sensitivity ranging between 42.9% (95% CI, 9.9-81.6; p = 1) and 85.7% (95% CI, 42.1-99.6; p = .13) and a specificity between 48.1% (95% CI, 36.5- 59.7; p < .001) and 79.2% (95% CI, 68.5-87.6; p = .10). Comparison between observers did not reach significance. Observers assessed 95.6% of all images as very good or acceptable for interpretation purpose.

CONCLUSION

Smartphone images may be a useful adjunct to conventional VIA and VILI for the detection of CIN2+ and improve cervical cancer screening in low-resource settings.

Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective

BACKGROUND

Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa.

METHODS

We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories.

RESULTS

A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts.

CONCLUSIONS

Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.

Adoption of Information and Communication Technologies for Early Detection of Breast and Cervical Cancers in Low- and Middle-Income Countries

PURPOSE

In response to the growing burden of breast and cervical cancers, low- and middle-income countries (LMICs) are beginning to implement national cancer prevention programs. We reviewed the literature on information and communication technology (ICT) applications in the prevention of breast and cervical cancers in LMICs to examine their potential to enhance cancer prevention efforts.

METHODS

Ten databases of peer-reviewed and gray literature were searched using an automated strategy for English-language articles on the use of mobile health (mHealth) and telemedicine in breast and cervical cancer prevention (screening and early detection) published between 2005 and 2015. Articles that described the rationale for using these ICTs and/or implementation experiences (successes, challenges, and outcomes) were reviewed. Bibliographies of articles that matched the eligibility criteria were reviewed to identify additional relevant references.

RESULTS

Of the initial 285 citations identified, eight met the inclusion criteria. Of these, four used primary data, two were overviews of ICT applications, and two were commentaries. Articles described the potential for mHealth and telemedicine to address both demand- and supply-side challenges to cancer prevention, such as awareness, access, and cost, in LMICs. However, there was a dearth of evidence to support these hypotheses.

CONCLUSION

This review indicates that there are few publications that reflect specifically on the role of mHealth and telemedicine in cancer prevention and even fewer that describe or evaluate interventions. Although articles suggest that mHealth and telemedicine can enhance the implementation and use of cancer prevention interventions, more evidence is needed.

Characteristics of Blood Vessels in Female Genital Schistosomiasis: Paving the Way for Objective Diagnostics at the Point of Care

BACKGROUND

The mucosal changes associated with female genital schistosomiasis (FGS) encompass abnormal blood vessels. These have been described as circular, reticular, branched, convoluted and having uneven calibre. However, these characteristics are subjective descriptions and it has not been explored which of them are specific to FGS.

METHODS

In colposcopic images of young women from a schistosomiasis endemic area, we performed computerised morphologic analyses of the cervical vasculature appearing on the mucosal surface. Study participants where the cervix was classified as normal served as negative controls, women with clinically diagnosed FGS and presence of typical abnormal blood vessels visible on the cervical surface served as positive cases. We also included women with cervical inflammatory conditions for reasons other than schistosomiasis. By automating morphological analyses, we explored circular configurations, vascular density, fractal dimensions and fractal lacunarity as parameters of interest.

RESULTS

We found that the blood vessels typical of FGS are characterised by the presence of circular configurations (p < 0.001), increased vascular density (p = 0.015) and increased local connected fractal dimensions (p = 0.071). Using these features, we were able to correctly classify 78% of the FGS-positive cases with an accuracy of 80%.

CONCLUSIONS

The blood vessels typical of FGS have circular configurations, increased vascular density and increased local connected fractal dimensions. These specific morphological features could be used diagnostically. Combined with colourimetric analyses, this represents a step towards making a diagnostic tool for FGS based on computerised image analysis.

Smartphone Use for Cervical Cancer Screening in Low-Resource Countries: A Pilot Study Conducted in Madagascar

Background

Visual inspection of the cervix after application of 5% acetic acid (VIA) is a screening technique for cervical cancer used widely in low and middle-income countries (LMIC). To improve VIA screening performance, digital images after acid acetic application (D-VIA) are taken. The aim of this study was to evaluate the use of a smartphone for on- and off-site D-VIA diagnosis.

Materials and Methods

Women aged 30–65 years, living in the city of Ambanja, Madagascar, were recruited through a cervical cancer screening campaign. Each performed a human papillomavirus (HPV) self-sample as a primary screen. Women testing positive for HPV were referred for VIA followed by D-VIA, cervical biopsy and endocervical curettage according to routine protocol. In addition, the same day, the D-VIA was emailed to a tertiary care center for immediate assessment. Results were scored as either D-VIA normal or D-VIA abnormal, requiring immediate therapy or referral to a tertiary center. Each of the three off-site physicians were blinded to the result reported by the one on-site physician and each gave their individual assessment followed by a consensus diagnosis. Statistical analyses were conducted using STATA software.

Results

Of the 332 women recruited, 137 (41.2%) were HPV-positive and recalled for VIA triage; compliance with this invitation was 69.3% (n = 95). Cervical intraepithelial neoplasia was detected in 17.7% and 21.7% of digital images by on-site and off-site physicians, respectively. The on-site physician had a sensitivity of 66.7% (95%CI: 30.0–90.3) and a specificity of 85.7% (95%CI: 76.7–91.6); the off-site physician consensus sensitivity was 66.7% (95%CI: 30.0–90.3) with a specificity of 82.3% (95%CI: 72.4–89.1).

Conclusion

This pilot study supports the use of telemedicine for off-site diagnosis of cervical intraepithelial neoplasia, with diagnostic performance similar to those achieved on-site. Further studies need to determine if smartphones can improve cervical cancer screening efficiency in LMIC.

The first step toward diagnosing female genital schistosomiasis by computer image analysis

Schistosoma haematobium causes female genital schistosomiasis (FGS), which is a poverty-related disease in sub-Saharan Africa. Furthermore, it is co-endemic with human immunodeficiency virus (HIV), and biopsies from genital lesions may expose the individual to increased risk of HIV infection. However, microscopy of urine and hematuria are nonspecific and insensitive predictors of FGS and gynecological investigation requires extensive training. Safe and affordable diagnostic methods are needed. We explore a novel method of diagnosing FGS using computer color analysis of colposcopic images. In a cross-sectional study on young women in an endemic area, we found strong associations between the output from the computer color analysis and both clinical diagnosis (odds ratio [OR] = 5.97, P < 0.001) and urine microscopy for schistosomiasis (OR = 3.52, P = 0.004). Finally, using latent class statistics, we estimate that the computer color analysis yields a sensitivity of 80.5% and a specificity of 66.2% for the diagnosis of FGS.

mHealth Education Applications Along the Cancer Continuum

The majority of adults worldwide own a mobile phone, including those in under-resourced communities. Mobile health (mhealth) education technologies present a promising mechanism for improving cancer prevention, treatment, and follow-up. The purpose of this study was to summarize the literature related to mobile phone (mhealth) applications for patient education specific to cancer and identify current recommendations from randomized studies. In particular, we were interested in identifying mobile phone applications along the cancer continuum, from cancer prevention to survivorship. The authors identified 28 articles reporting on mobile applications for patients related to cancer. Articles were identified in all categories along the cancer continuum, including health professional involvement in application development. Of these, six involved direct patient education, and eight focused on improving patient/professional communication and patient self-management. However, only six of the studies were randomized interventions. The potential for mobile applications to help overcome the "health care gap" has not yet been realized in the studies from the USA that were reviewed for this paper. However, early recommendations are emerging that support the use of mHealth communications to change behaviors for cancer prevention, early detection, and symptom management and improved patient-provider communication. Recommendations include short messages, use of multiple modalities as patient characteristics dictate comfort with mHealth communication, and the inclusion of patients and health professionals to develop and test applications. Tailoring mHealth to particular cultures, languages, and ethnic groups may also represent a unique possibility to provide accessible information and education at minimal cost for under-resourced communities and individuals.

Colourimetric image analysis as a diagnostic tool in female genital schistosomiasis

Female genital schistosomiasis (FGS) is a highly prevalent waterborne disease in some of the poorest areas of sub-Saharan Africa. Reliable and affordable diagnostics are unavailable. We explored colourimetric image analysis to identify the characteristic, yellow lesions caused by FGS. We found that the method may yield a sensitivity of 83% and a specificity of 73% in colposcopic images. The accuracy was also explored in images of simulated inferior quality, to assess the possibility of implementing such a method in simple, electronic devices. This represents the first step towards developing a safe and affordable aid in clinical diagnosis, allowing for a point-of-care approach.

Scaling up a Mobile Telemedicine Solution in Botswana: Keys to Sustainability

Effective health care delivery is significantly compromised in an environment where resources, both human and technical, are limited. Botswana's health care system is one of the many in the African continent with few specialized medical doctors, thereby posing a barrier to patients' access to health care services. In addition, the traditional landline and non-robust Information Technology (IT) network infrastructure characterized by slow bandwidth still dominates the health care system in Botswana. Upgrading of the landline IT infrastructure to meet today's health care demands is a tedious, long, and expensive process. Despite these challenges, there still lies hope in health care delivery utilizing wireless telecommunication services. Botswana has recently experienced tremendous growth in the mobile telecommunication industry coupled with an increase in the number of individually owned mobile devices. This growth inspired the Botswana-UPenn Partnership (BUP) to collaborate with local partners to explore using mobile devices as tools to improve access to specialized health care delivery. Pilot studies were conducted across four medical specialties, including radiology, oral medicine, dermatology, and cervical cancer screening. Findings from the studies became vital evidence in support of the first scale-up project of a mobile telemedicine solution in Botswana, also known as "Kgonafalo." Some technical and social challenges were encountered during the initial studies, such as malfunctioning of mobile devices, accidental damage of devices, and cultural misalignment between IT and healthcare providers. These challenges brought about lessons learnt, including a strong need for unwavering senior management support, establishment of solid local public-private partnerships, and efficient project sustainability plans. Sustainability milestones included the development and signing of a Memorandum of Understanding (MOU) between the Botswana government and a private telecommunications partner, the publication and awarding of the government tender to a local IT company, and the development and signing of a Memorandum of Agreement between the Ministry of Health Clinical Services department and the local tender winner. The initial system scale-up is scheduled to occur in 2014 and to ensure the project's sustainability, the system is aligned with the national eHealth strategy and local ownership of the project remains at the forefront (1).

Cervical cancer screening in sub-Saharan Africa: a randomized trial of VIA versus cytology for triage of HPV-positive women

Developing countries are interested in using human papillomavirus (HPV) testing as a primary screening test for cervical cancer prevention programs. The low specificity of the HPV assay requires triage testing of HPV-positive women. The aim of the study is to compare visual inspection with acetic acid (VIA) and cytology as triage testing methods in HPV-positive women to detect cervical intraepithelial neoplasia or Grade 2 or higher (CIN2+). The study was conducted in two Cameroonian towns (Yaoundé and Edea) and included 846 eligible women aged 25 to 65 years. All participants performed self-HPV testing. HPV-positive women (n = 259) were randomly assigned to be tested either by VIA (VIA group) or cytology (cytology group). HPV-positive women had both cervical biopsy and endocervical curettage to detect biopsy-confirmed CIN2+. All statistical tests were two-sided. The prevalence of HPV was 38.5%, and the mean age of HPV-positive women was 41.5 ± 10.1 years. One hundred ninety-eight women (97 in the VIA group and 99 in the cytology) were randomly assigned to one of the two testing arms. The sensitivity of VIA was 25.0% (95% CI, 7.1-59.1%), and the sensitivity of cytology was 90.0% (59.6-98.2%). The specificity was 74.2% (95% CI, 64.2-82.1%) for VIA and 85.2% (76.3-91.2%) for cytology. ROC area for cytology was 0.910 against the 0.496 area for VIA. In this trial, VIA was inferior to cytology as a triage test among HPV-positive women. Further investigations are needed to determine the optimal triage method for HPV-positive women.

Assessing the impact of mHealth interventions in low- and middle-income countries--what has been shown to work?

BACKGROUND

Low-cost mobile devices, such as mobile phones, tablets, and personal digital assistants, which can access voice and data services, have revolutionised access to information and communication technology worldwide. These devices have a major impact on many aspects of people's lives, from business and education to health. This paper reviews the current evidence on the specific impacts of mobile technologies on tangible health outcomes (mHealth) in low- and middle-income countries (LMICs), from the perspectives of various stakeholders.

DESIGN

Comprehensive literature searches were undertaken using key medical subject heading search terms on PubMed, Google Scholar, and grey literature sources. Analysis of 676 publications retrieved from the search was undertaken based on key inclusion criteria, resulting in a set of 76 papers for detailed review. The impacts of mHealth interventions reported in these papers were categorised into common mHealth applications.

RESULTS

There is a growing evidence base for the efficacy of mHealth interventions in LMICs, particularly in improving treatment adherence, appointment compliance, data gathering, and developing support networks for health workers. However, the quantity and quality of the evidence is still limited in many respects.

CONCLUSIONS

Over all application areas, there remains a need to take small pilot studies to full scale, enabling more rigorous experimental and quasi-experimental studies to be undertaken in order to strengthen the evidence base.

HIV, tuberculosis, and noncommunicable diseases: what is known about the costs, effects, and cost-effectiveness of integrated care?

Unprecedented investments in health systems in low- and middle-income countries (LMICs) have resulted in more than 8 million individuals on antiretroviral therapy. Such individuals experience dramatically increased survival but are increasingly at risk of developing common noncommunicable diseases (NCDs). Integrating clinical care for HIV, other infectious diseases, and NCDs could make health services more effective and provide greater value. Cost-effectiveness analysis is a method to evaluate the clinical benefits and costs associated with different health care interventions and offers guidance for prioritization of investments and scale-up, especially as resources are increasingly constrained. We first examine tuberculosis and HIV as 1 example of integrated care already successfully implemented in several LMICs; we then review the published literature regarding cervical cancer and depression as 2 examples of NCDs for which integrating care with HIV services could offer excellent value. Direct evidence of the benefits of integrated services generally remains scarce; however, data suggest that improved effectiveness and reduced costs may be attained by integrating additional services with existing HIV clinical care. Further investigation into clinical outcomes and costs of care for NCDs among people living with HIV in LMICs will help to prioritize specific health care services by contributing to an understanding of the affordability and implementation of an integrated approach.