Abstract:

Background: Self-collection has been proposed as a strategy to increase cervical screening coverage among hard-to-reach women. However, evaluations of the implementation of this strategy on a large scale are scarce. This paper describes the process and measurement of the scaling-up of self-collection offered by community health workers during home visits as a strategy to reach under-screened women aged 30+ with public health coverage, defined as the target women. Methods: We used an adaptation of the Health System Framework to analyze key drivers of scaling-up. A content analysis approach was used to collect and analyze information from different sources. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) model was used to evaluate the impact of the strategy. Results: HPV self-collection was scaled-up in the province of Jujuy in 2014 after a RCT (Self-collection Modality Trial, initials EMA in Spanish) was carried out locally in 2012 and demonstrated effectiveness of the strategy to increase screening uptake. Facilitators of scaling-up were the organizational capacity of the provincial health system, sustainable funding for HPV testing, and local consensus about the value of the technology. Reach: In 2014, 9% (2983/33,245) of target women were screened through self-collection in the Jujuy public health sector. Effectiveness: In 2014, 17% (n = 5657/33,245) of target women were screened with any HPV test (self-collected and clinician-collected tests) vs. 11.7% (4579/38,981) in 2013, the pre-scaling-up period (p < 0.0001). Implementation: Training about the strategy was provided to 84.2% (n = 609/723) of total community health workers (CHWs). Of 414 HPV+ women, 77.5% (n = 320) had follow-up procedures. Of 113 women with positive triage, 66.4% (n = 75) had colposcopic diagnosis. Treatment was provided to 80.7% of CIN2+ women (n = 21/26). Adoption: Of trained CHWs, 69.3% (n = 422/609) had at least one woman with self-collection; 85.2% (n = 315/368) of CHWs who responded to an evaluation survey were satisfied with self-collection strategy. Maintenance: During 2015, 100.0% (723/723) CHWs were operational and 63.8% (461/723) had at least one woman with self-collection. Conclusions: The strategy was successfully scaled-up, with a high level of adoption among CHWs, which resulted in increased screening among socially vulnerable under-screened women.

Author affiliation: Arrossi, Silvina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Centro de Estudios de Estado y Sociedad; Argentina

Author affiliation: Paolino, Melisa Delia. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Ministerio de Salud. Instituto Nacional del Cáncer; Argentina

Author affiliation: Thouyaret, Laura. Ministerio de Salud. Instituto Nacional del Cáncer; Argentina

Author affiliation: Laudi, Rosa. Ministerio de Salud. Instituto Nacional del Cáncer; Argentina

Author affiliation: Campanera, Alicia. Provincia de Jujuy. Ministerio de Salud; Argentina

Abstract:

The aim of this article is to present results of programmatic introduction of HPV testing with cytologic triage among women 30 years and older in the province of Jujuy, Argentina, including description of the planning phase and results of program performance during the first year. We describe the project implementation process, and calculate key performance indicators using SITAM, the national screening information system. We also compare disease detection rates of HPV testing in 2012 with cytology as performed during the previous year. HPV testing with cytology triage was introduced through a consensus-building process. Key activities included establishment of algorithms and guidelines, creating the HPV laboratory, training of health professionals, information campaigns for women and designing the referral network. By the end of 2012, 100% (n = 270) of public health care centers were offering HPV testing and 22,834 women had been HPV tested, 98.5% (n = 22,515) were 30+. HPV positivity among women over 30 was 12.7%, 807 women were HPV+ and had abnormal cytology, and 281 CIN2+ were identified. CIN2+ detection rates was 1.25 in 2012 and 0.62 in 2011 when the program was cytology based (p = 0.0002). This project showed that effective introduction of HPV testing in programmatic contexts of low-middle income settings is feasible and detects more disease than cytology.

Author affiliation: Arrossi, Silvina. Centro de Estudios de Estado y Sociedad; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

Author affiliation: Thouyaret, Laura. Instituto Nacional del Cáncer. Programa Nacional de Prevención de Cáncer Cervicouterino; Argentina. Provincia de Buenos Aires. Ministerio de Salud; Argentina

Author affiliation: Laudi, Rosa. Provincia de Buenos Aires. Ministerio de Salud; Argentina. Instituto Nacional del Cáncer. Programa Nacional de Prevención de Cáncer Cervicouterino; Argentina

Author affiliation: Marín, Oscar. Provincia de Buenos Aires. Ministerio de Salud; Argentina. Provincia de Jujuy. Hospital Pablo Soria; Argentina

Author affiliation: Ramírez, Josefina. Provincia de Jujuy. Ministerio de Salud; Argentina

Author affiliation: Paolino, Melisa Delia. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Provincia de Buenos Aires. Ministerio de Salud; Argentina. Instituto Nacional del Cáncer. Programa Nacional de Prevención de Cáncer Cervicouterino; Argentina

Author affiliation: Herrero, Rolando. International Agency for Research on Cancer; Francia

Author affiliation: Campanera, Alicia. Provincia de Buenos Aires. Ministerio de Salud; Argentina