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Cervical Cancer Prevention in Low Resource Setting – A Pilot Implementation Study in Nepal

The goal of the proposed project is to evaluate the implementation of self HPV sample collection to screen and treat cervical cancer in a low-resource setting. Cervical cancer is the second most common cause of cancer death in women worldwide, with 85% of cases and cervical cancer deaths occurring in low-and middle-income countries (LMICs). Cervical cancer is preventable with good-quality screening and vaccination against Human Papillomavirus (HPV), the cause of almost all cervical cancer cases.

Self-Sampling is cost-effective in low-resource settings and is recommended as a primary screening test in LMICs. Despite being a cost-effective option there is limited understanding and huge gaps in implementing large-scale self-HPV testing screening programs. Therefore, Dhulikhel Hospital in collaboration with the Yale Center for Methods in Implementation and Prevention Science (CMIPS) and Institute for Implementation Science and Health (IISH) proposed implementing and evaluating a population-based cervical cancer screening program with initial HPV screening with self-sample collection followed by colposcopy test and treatment.

Objective

It has two major aims. Aim 1. To evaluate the implementation of a self HPV sample collection screening and treatment among women 30-60 years old in semi-urban Nepal. It measured acceptability, feasibility, fidelity, cost and sustainability. Aim 2: To explore acceptability, facilitators, and barriers to the self HPV sample collection and treatment intervention implemented from the provider’s and client’s perspective

Study Procedure

The study was conducted in the following sequential procedures.

  1. Recruitment: The research assistant obtained a list of women 30 to 60 years old women and contacted them by telephone to screen eligible women. They contacted eligible women by telephone and informed them about the study objectives, risks, and benefits of the study and received verbal informed consent for recruitment.  Each woman who is recruited in the study is asked for any other women in her family or neighborhood who may be eligible for the study through a snowball approach
  2. Baseline data collection: At baseline, the trained research assistants interviewed the participants using a standardized electronic questionnaire on the kobo toolbox. The questionnaire assessed

(1) socioeconomic characteristics include age, sex, ethnicity, religion, marital status, annual income, and education.

(2) Reproductive health history (age at menarche, age at marriage, age at first sexual intercourse, age at first pregnancy, gravida, parity, sexually transmitted infection, HPV vaccination).

 (3) Lifestyles (Alcohol consumption and smoking, Physical activity, Diet) 

3. Sample collection: Research Assistant visited women in person and informed them about the study objectives, study risk and benefits, confidentiality, and HPV self-sample collection procedure. They provided participants with an information sheet in the Nepali language on HPV self-sample collection procedure. They received informed written consent from participants and oriented a step-wise procedure for HPV self-sample collection.

4. End-line data collection: After sample collection from women, research assistants interviewed them regarding HPV self-sample acceptability: their experience to understand the procedure and perform accordingly, and their spousal and family support.

Outcome

Quantitative findings showed total 1844 women provided baseline information out of which 1194 provided samples.  There was a high level of acceptability of self-sampling among the participants. Ninety eight percent of participants find it easy to understand the use of a brush and around 96% find it easy in using it. Sixty nine percent of participants reported preference for self-sampling over clinician sampling due to less shame and embarrassment, practicality, less pain and discomfort and its possibility of collection at home.

Qualitative findings showed following barriers and facilitators of HPV self-sampling from client and providers level. The client level facilitators were: (a) knowledge on benefits of screening; (b) self-sampling opportunity; (c) positive word-of-mouth impressions from peers; and (d) privacy during screening. The provider-level facilitators were: (a) mass screening camps; (b) information and awareness channel through community health volunteers; and (c) availability of equipment and supplies for screening. The client-level barriers were: (a) inadequate motivation due to absence of symptoms; (b) busy work schedule; (c) fear of positive test results and its consequences; (d) fear of harm during procedure; and (e) lack of confidence in the health system. The provider-level barriers were: (a) high cost of care HPV supplies; (b) logistical challenges to collect samples in the community; (c) low cancer awareness in the community; and (d) cervical cancer screening not listed as the government’s priority program.

Team Members

Principal Investigators: Archana Shrestha, Sunila Shakya, and Donna Spiegelman,

Co-Investigators: Sangini Seth, Ramesh Kumar Makaju, Shrinkhala Shrestha 

Project Coordinator: Bandana Paneru and Dikshya Kalfe

Research Assistants: Soniya Makaju and Aerona Karmacharya

Supported by: Yale Center for Methods in Implementation and Prevention Science (CMIPS)