‘I’m here to save my life’: a qualitative study of experiences navigating a cryotherapy referral system for human papillomavirus-positive women in western Kenya

Background: We sought to understand the beliefs, social norms and logistical factors that affect human papillomavirus (HPV)-positive women’s uptake of cryotherapy treatment as part of a two-part cervical cancer screening strategy in rural Kenya. Methods: In-depth interviews within a parent cluster-randomised trial. Setting: Government-run county hospital in western Kenya. Participants: 273 of 372 (73.4%) HPV-positive women who underwent cryotherapy Results: Many women feared that an HPV infection meant they would develop cancer. Almost all women reported initial fear of the treatment procedure, followed by a more positive experience than anticipated. Lacking funds for transportation to the treatment site was the most common barrier. Women felt that decentralised treatment would be the most important facilitator of greater access. Spousal encouragement and financial support were key facilitators of treatment access, however many women felt that other husbands in the community would not be supportive. Women described successfully acquiring treatment as empowering, and almost all would recommend seeking cryotherapy to other women who test HPV-positive. Most felt eager to share their own experiences with others to encourage treatment. Conclusions: The main facilitators of treatment access were understanding of the health risks and sense of empowerment. A decentralised treatment model or transportation support may facilitate access, along with improved health messaging about HPV infection, cancer and the treatment process. Focusing on women’s personal feelings of empowerment may further improve uptake and satisfaction. These data will be used to design a strategy to improve linkage to treatment

How Providing Cervical Cancer Screening Results via Cell Phone Affects Patient Follow-Up Rates in Western Kenya

Purpose: Human papillomavirus (HPV) testing is being more widely used in simplified cervical cancer screening protocols in low-resource settings. One challenge to successful implementation is the multiple visits necessary to provide results and follow-up. mHealth strategies may reduce visit burden by providing information through text message. Methods: As part of a cluster-randomized trial to compare HPV testing in clinics and community health campaigns in western Kenya, we carried out a mixed-methods study to assess women\u27s preferences and experiences with different strategies to receive their results. Women could opt to receive their HPV results via text message, cell phone call, home visit, or return clinic visit. We examined overall receipt of results, follow-up rates, and acceptability by notification method. Results: Among the 4,947 women who underwent HPV-based cervical cancer screening, 1,596 (32%) received results via text message, 1,181 (24%) via cell phone call, 1,563 (32%) via clinic visit, and 605 (12%) via home visit. Women opting for texts or calls were younger and had higher rates of prior cervical cancer screening, HIV testing, and modern contraceptive use (P \u3c .001 for all). Home visits were associated with a significantly higher rate of treatment acquisition (45%) than texts (38%), cell phone calls (38%), and clinic visits (23%; P \u3c .001). In a model controlling for age, prior screening, HIV testing, and contraceptive use, clinic visits remained significantly associated with decreased odds of treatment (adjusted odds ratio, 0.45; 95% CI, 0.29 to 0.69) compared with texts. Among treated women, there was no difference in time to treatment by notification method. Conclusion: Cell phone-based results notification strategies were preferred by women with greater health-seeking behavior; however, HPV-positive women who received results via home visit were more likely to pursue for treatment

Mobile Phone Ownership and Use Among Women Screening for Cervical Cancer in a Community-Based Setting in Western Kenya: Observational Study

BackgroundMobile phone ownership among women of reproductive age in western Kenya is not well described, and our understanding of its link with care-seeking behaviors is nascent. Understanding access to and use of mobile phones among this population as well as willingness to participate in mobile health interventions are important in improving and more effectively implementing mobile health strategies. ObjectiveThis study aims to describe patterns of mobile phone ownership and use among women attending cervical cancer screening and to identify key considerations for the use of SMS text message–guided linkage to treatment strategies and other programmatic implications for cervical cancer screening in Kenya. MethodsThis analysis was nested within a cluster randomized trial evaluating various strategies for human papillomavirus (HPV)–based cervical cancer screening and prevention in a rural area in western Kenya between February and November 2018. A total of 3299 women were surveyed at the time of screening and treatment. Questionnaires included items detailing demographics, health history, prior care-seeking behaviors, and patterns of mobile phone ownership and use. We used bivariate and multivariable log-binomial regression to analyze associations between independent variables and treatment uptake among women testing positive for high-risk HPV. ResultsRates of mobile phone ownership (2351/3299, 71.26%) and reported daily use (2441/3299, 73.99%) were high among women. Most women (1953/3277, 59.59%) were comfortable receiving their screening results via SMS text messages, although the most commonly preferred method of notification was via phone calls. Higher levels of education (risk ratio 1.23, 95% CI 1.02-1.50), missing work to attend screening (risk ratio 1.29, 95% CI 1.10-1.52), and previous cervical cancer screening (risk ratio 1.27, 95% CI 1.05-1.55) were significantly associated with a higher risk of attending treatment after testing high-risk HPV–positive, although the rates of overall treatment uptake remained low (278/551, 50.5%) among this population. Those who shared a mobile phone with their partner or spouse were less likely to attend treatment than those who owned a phone (adjusted risk ratio 0.69, 95% CI 0.46-1.05). Treatment uptake did not vary significantly according to the type of notification method, which were SMS text message, phone call, or home visit. ConclusionsAlthough the rates of mobile phone ownership and use among women in western Kenya are high, we found that individual preferences for communication of messages about HPV results and treatment varied and that treatment rates were low across the entire cohort, with no difference by modality (SMS text message, phone call, or home visit). Therefore, although text-based results performed as well as phone calls and home visits, our findings highlight the need for more work to tailor communication about HPV results and support women as they navigate the follow-up process

Patient factors affecting successful linkage to treatment in a cervical cancer prevention program in Kenya: A prospective cohort study.

ObjectiveTo identify patient factors associated with whether women who screened positive for high-risk human papillomavirus (hrHPV) successfully accessed treatment in a cervical cancer prevention program in Kenya.MethodsA prospective cohort study was conducted as part of a trial of implementation strategies for hrHPV-based cervical cancer screening in western Kenya from January 2018 to February 2019. In this larger trial, women underwent hrHPV testing during community health campaigns (CHCs), and hrHPV+ women were referred to government facilities for cryotherapy. For this analysis, we looked at rates of and predictors of presenting for treatment and presenting within 30 days of receiving positive hrHPV results ("timely" presentation). Data came from questionnaires completed at the time of screening and treatment. Multivariable logistic regression was used to identify factors associated with each outcome.ResultsOf the 505 hrHPV+ women, 266 (53%) presented for treatment. Cryotherapy was performed in 236 (89%) of the women who presented, while 30 (11%) were not treated: 15 (6%) due to gas outage, six (2%) due to pregnancy, five (2%) due to concern for cervical cancer, and four (2%) due to an unknown or other reason. After adjusting for other factors in the multivariable analysis, higher education level and missing work to come to the CHC were associated with presenting for treatment. Variables that were associated with increased likelihood of timely presentation were missing work to come to the CHC, absence of depressive symptoms, told by someone important to come to the CHC, and shorter distance to the treatment site.ConclusionThe majority of hrHPV+ women who did not get treated were lost at the stage of decision-making or accessing treatment, with a small number encountering barriers at the treatment sites. Patient education and financial support are potential areas for intervention to increase rates of hrHPV+ women seeking treatment

Systems-level barriers to treatment in a cervical cancer prevention program in Kenya: Several observational studies.

ObjectiveTo identify health systems-level barriers to treatment for women who screened positive for high-risk human papillomavirus (hrHPV) in a cervical cancer prevention program in Kenya.MethodsIn a trial of implementation strategies for hrHPV-based cervical cancer screening in western Kenya in 2018-2019, women underwent hrHPV testing offered through community health campaigns, and women who tested positive were referred to government health facilities for cryotherapy. The current analysis draws on treatment data from this trial, as well as two observational studies that were conducted: 1) periodic assessments of the treatment sites to ascertain availability of resources for treatment and 2) surveys with treatment providers to elicit their views on barriers to care. Bivariate analyses were performed for the site assessment data, and the provider survey data were analyzed descriptively.ResultsSeventeen site assessments were performed across three treatment sites. All three sites reported instances of supply stockouts, two sites reported treatment delays due to lack of supplies, and two sites reported treatment delays due to provider factors. Of the 16 providers surveyed, ten (67%) perceived lack of knowledge of HPV and cervical cancer as the main barrier in women's decision to get treated, and seven (47%) perceived financial barriers for transportation and childcare as the main barrier to accessing treatment. Eight (50%) endorsed that providing treatment free of cost was the greatest facilitator of treatment.ConclusionPatient education and financial support to reach treatment are potential areas for intervention to increase rates of hrHPV+ women presenting for treatment. It is also essential to eliminate barriers that prevent treatment of women who present, including ensuring adequate supplies and staff for treatment

Evaluating a community-based cervical cancer screening strategy in Western Kenya: a descriptive study

BackgroundThe incidence of cervical cancer in Kenya is among the highest in the world. Few Kenyan women are able to access screening, thus fueling the high cervical cancer burden. Self-collected human papilloma Virus (HPV) tests, administered during community-health campaigns in rural areas may be a way to expand access to screening.MethodsIn December 2015, we carried out a four-day community health campaign (CHC) to educate participants about cervical cancer prevention and offer self-administered HPV screening. Community enumeration, outreach and mobilization preceded the CHC. Samples were sent to Migori County Hospital for HPV DNA testing using careHPV Test Kits. Women were notified of results through their choice of short message service (SMS), phone call, home visit or clinic visit. HPV positive women were referred for cryotherapy following a screen-and-treat strategy.ResultsDoor-to-door enumeration identified approximately 870 eligible women in Ngodhe Community in Migori County. Among the 267 women attending the campaign, 255 women enrolled and collected samples: 243 tests were successfully resulted and 12 were indeterminate. Of the 243 resulted tests, 47 (19%) were positive for HPV, with young age being the only significant predictor of positivity. In multivariate analysis, each additional year of age conferred about a 4% decrease in the odds of testing positive (95% CI 0.1 to 7%, p = 0.046). Just over three-quarters of all women (195/255), were notified of their results. Those who were unable to be reached were more likely to prefer receiving results from clinic (54/60, 90%) and were less likely to have mobile phones (24/60, 73%). Although 76% of HPV positive women were notified of their results, just half (51%) of those testing positive presented for treatment. HPV positive women who successfully accessed the treatment facility did not differ from their non-presenting counterparts by demographics, health history, desired route of notification or access to a mobile phone.ConclusionNearly a third of eligible women in Ngodhe Community attended the CHC and were screened for cervical cancer. Nearly all women who attended the CHC underwent cervical cancer screening by self-collected HPV tests. Three-quarters of all participants received results, but just half of HPV positive participants presented for treatment in a timely fashion, suggesting that linkage to treatment remains a major challenge.Trial registrationNCT02124252 , Registered 25 April 2014

Evaluating a community-based cervical cancer screening strategy in Western Kenya: a descriptive study

Abstract Background The incidence of cervical cancer in Kenya is among the highest in the world. Few Kenyan women are able to access screening, thus fueling the high cervical cancer burden. Self-collected human papilloma Virus (HPV) tests, administered during community-health campaigns in rural areas may be a way to expand access to screening. Methods In December 2015, we carried out a four-day community health campaign (CHC) to educate participants about cervical cancer prevention and offer self-administered HPV screening. Community enumeration, outreach and mobilization preceded the CHC. Samples were sent to Migori County Hospital for HPV DNA testing using careHPV Test Kits. Women were notified of results through their choice of short message service (SMS), phone call, home visit or clinic visit. HPV positive women were referred for cryotherapy following a screen-and-treat strategy. Results Door-to-door enumeration identified approximately 870 eligible women in Ngodhe Community in Migori County. Among the 267 women attending the campaign, 255 women enrolled and collected samples: 243 tests were successfully resulted and 12 were indeterminate. Of the 243 resulted tests, 47 (19%) were positive for HPV, with young age being the only significant predictor of positivity. In multivariate analysis, each additional year of age conferred about a 4% decrease in the odds of testing positive (95% CI 0.1 to 7%, p = 0.046). Just over three-quarters of all women (195/255), were notified of their results. Those who were unable to be reached were more likely to prefer receiving results from clinic (54/60, 90%) and were less likely to have mobile phones (24/60, 73%). Although 76% of HPV positive women were notified of their results, just half (51%) of those testing positive presented for treatment. HPV positive women who successfully accessed the treatment facility did not differ from their non-presenting counterparts by demographics, health history, desired route of notification or access to a mobile phone. Conclusion Nearly a third of eligible women in Ngodhe Community attended the CHC and were screened for cervical cancer. Nearly all women who attended the CHC underwent cervical cancer screening by self-collected HPV tests. Three-quarters of all participants received results, but just half of HPV positive participants presented for treatment in a timely fashion, suggesting that linkage to treatment remains a major challenge. Trial registration NCT02124252, Registered 25 April 2014

Scaling up cervical cancer prevention in Western Kenya: Treatment access following a community‐based HPV testing approach

ObjectiveTo evaluate access to treatment after community-based HPV testing as testing within screen-and-treat programs has the potential to lower mortality from cervical cancer in low-resource settings.MethodsA prospective cohort study was conducted in western Kenya in 2018. Women aged 25-65 years underwent HPV self-testing. HPV-positive women were referred for cryotherapy. Participant data were obtained from questionnaires during screening and treatment. The proportion successfully accessing treatment and variables associated with successful treatment was determined.ResultsOf the 750 women included, 140 (18.6%) tested positive for HPV. Of them, 135 were notified of their results, of whom 77 (59.2%) sought treatment and 73 (52.1%) received cryotherapy. Women who received treatment had a shorter time from screening to result notification (median 92 days, interquartile range [IQR] 84-104) compared to those who did not (97 days, IQR 89-106; P=0.061). In adjusted analyses, women with a history of cervical cancer screening (odds ratio [OR] 11, 95% confidence interval [CI] 1.42-85.20) and those electing result notification through a home visit (OR 4, 95% CI 1.23-14.17) were significantly more likely to acquire treatment at follow-up.ConclusionLinkage to treatment after community-based HPV screening in this population was low, highlighting the need for strategies aimed at strengthening treatment linkage in similar settings

Uptake and correlates of cervical cancer screening among women attending a community-based multi-disease health campaign in Kenya.

IntroductionDespite the increased risk of cervical cancer among HIV-positive women, many HIV-care programs do not offer integrated cervical cancer screening. Incorporating self-collected Human Papillomavirus (HPV) testing into HIV programs is a potential strategy to identify women at higher risk for cervical cancer while leveraging the staffing, infrastructure and referral systems for existing services. Community-based HIV and HPV testing has been effective and efficient when offered in single-disease settings.MethodsThis cross-sectional study was conducted within a community outreach and multi-disease screening campaigns organized by the Family AIDS Care and Education Services in Kisumu County, Kenya. In addition to HIV testing, the campaigns provided screening for TB, malaria, hypertension, diabetes, and referrals for voluntary medical male circumcision. After these services, women aged 25-65 were offered self-collected HPV testing. Rates and predictors of cervical cancer screening uptake and of HPV positivity were analyzed using tabular analysis and Fisher's Exact Test. Logistic regression was performed to explore multivariate associations with screening uptake.ResultsAmong the 2016 women of screening age who attended the outreach campaigns, 749 women (35.6%) were screened, and 134 women (18.7%) were HPV-positive. In bivariate analysis, women who had no children (p < 0.01), who were not pregnant (p < 0.01), who were using contraceptives (p < 0.01), who had sex without using condoms (p < 0.05), and who were encouraged by a family member other than their spouse (p < 0.01), were more likely to undergo screening. On multivariable analysis, characteristics associated with higher screening uptake included: women aged 45-54 (OR 1.62, 95% CI 1.05-2.52) compared to women aged 25-34; no children (OR 1.65, 95% CI 1.06-2.56); and family support other than their spouse (OR 1.53, 95% CI 1.09-2.16). Women who were pregnant were 0.44 times (95% CI 0.25-0.76) less likely to get screened. Bivariate analyses with participant characteristics and HPV positivity found that women who screened HPV-positive were more likely to be HIV-positive (p < 0.001) and single (p < 0.001).ConclusionsThe low screening uptake may be attributed to implementation challenges including long waiting times for service at the campaign and delays in procuring HPV test kits. However, given the potential benefits of integrating HPV testing into HIV outreach campaigns, these challenges should be examined to develop more effective multi-disease outreach interventions