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Oommen AM, Isaac R, Paul B, Weller D, Finkel ML, Thomas A, Ram TS, H. R. P, Cherian AG, Thomas V, Sadan V, Siva R, Rose A, Marcus TA, Jeyapaul S, K. SR, Malini T, N. S, Jebaraj P, John NO, Ramesh C, Raj C. JJ, Kumar S. R, B. V. B, Dorathy P. I, Murali V, N. P, K. K, Ranjani D. P. Strategies for primary HPV test-based cervical cancer screening programme in resource-limited settings in India: Results from a quasi-experimental pragmatic implementation trial. PLoS One 2024; 19:e0301385. [PMID: 38578742 PMCID: PMC10997089 DOI: 10.1371/journal.pone.0301385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 03/11/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND In order for low and middle income countries (LMIC) to transition to Human Papilloma Virus (HPV) test based cervical cancer screening, a greater understanding of how to implement these evidence based interventions (EBI) among vulnerable populations is needed. This paper documents outcomes of an implementation research on HPV screening among women from tribal, rural, urban slum settings in India. METHODS A mixed-method, pragmatic, quasi-experimental trial design was used. HPV screening on self-collected cervical samples was offered to women aged 30-60 years. Implementation strategies were 1) Assessment of contextual factors using both qualitative and quantitative methods like key informant interviews (KII), focus group discussions (FGDs), pre-post population sample surveys, capacity assessment of participating departments 2) enhancing provider capacity through training workshops, access to HPV testing facility, colposcopy, thermal ablation/cryotherapy at the primary health care centers 3) community engagement, counselling for self-sampling and triage process by frontline health care workers (HCWs). Outcomes were assessed using the RE-AIM (Reach, Effectiveness, adoption, implementation, maintenance) framework. RESULTS Screening rate in 8 months' of study was 31.0%, 26.7%, 32.9%, prevalence of oncogenic HPV was 12.1%, 3.1%, 5.5%, compliance to triage was 53.6%, 45.5%, 84.6% in tribal, urban slum, rural sites respectively. Pre-cancer among triage compliant HPV positive women was 13.6% in tribal, 4% in rural and 0% among urban slum women. Unique challenges faced in the tribal setting led to programme adaptations like increasing honoraria of community health workers for late-evening work and recalling HPV positive women for colposcopy by nurses, thermal ablation by gynaecologist at the outreach camp site. CONCLUSIONS Self-collection of samples combined with HCW led community engagement activities, flexible triage processes and strengthening of health system showed an acceptable screening rate and better compliance to triage, highlighting the importance of identifying the barriers and developing strategies suitable for the setting. TRIAL REGISTRATION CTRI/2021/09/036130.
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Affiliation(s)
- Anu Mary Oommen
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Rita Isaac
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Biswajit Paul
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - David Weller
- University of Edinburgh, Edinburgh, United Kingdom
| | - Madelon L. Finkel
- Weill Cornell Medical College, New York, New York, United States of America
| | - Anitha Thomas
- Department of Gynaecologic Oncology, Christian Medical College Vellore, Tamil Nadu, India
| | - Thomas Samuel Ram
- Department of Radiation Oncology, Christian Medical College Vellore, Tamil Nadu, India
| | - Prashanth H. R.
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Anne George Cherian
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Vinotha Thomas
- Department of Gynaecologic Oncology, Christian Medical College Vellore, Tamil Nadu, India
| | - Vathsala Sadan
- College of Nursing Community Health, Christian Medical College Vellore, Tamil Nadu, India
| | - Rajeswari Siva
- College of Nursing Community Health, Christian Medical College Vellore, Tamil Nadu, India
| | - Anuradha Rose
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Tobey Ann Marcus
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Shalini Jeyapaul
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | | | - Tabeetha Malini
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Surenthiran N.
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Paul Jebaraj
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Neenu Oliver John
- Department of Radiation Oncology, Christian Medical College Vellore, Tamil Nadu, India
| | - Charles Ramesh
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | | | - Rakesh Kumar S.
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Balaji B. V.
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Irene Dorathy P.
- College of Nursing Community Health, Christian Medical College Vellore, Tamil Nadu, India
| | - Valliammal Murali
- RUHSA Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Prema N.
- College of Nursing Community Health, Christian Medical College Vellore, Tamil Nadu, India
| | - Kavitha K.
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
| | - Priya Ranjani D.
- Community Health Department, Christian Medical College Vellore, Tamil Nadu, India
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