PurposeAlmost nine of 10 deaths resulting from cervical cancer occur in low-income countries. Visual inspection under acetic acid (VIA) is an evidence-based, cost-effective approach to cervical cancer screening (CCS), but challenges to effective implementation include health provider training costs, provider turnover, and skills retention. We hypothesized that a smartphone camera and use of cervical image transfer for real-time mentorship by experts located distantly across a closed user group through a commercially available smartphone application would be both feasible and effective in enhancing VIA skills among CCS providers in Tanzania.MethodsWe trained five nonphysician providers in semirural Tanzania to perform VIA enhanced by smartphone cervicography with real-time trainee support from regional experts. Deidentified images were sent through a free smartphone application on the available mobile telephone networks. Our primary outcomes were feasibility of using a smartphone camera to perform smartphone-enhanced VIA and level of agreement in diagnosis between the trainee and expert reviewer over time.ResultsTrainees screened 1,072 eligible women using our methodology. Within 1 month of training, the agreement rate between trainees and expert reviewers was 96.8%. Providers received a response from expert reviewers within 1 to 5 minutes 48.4% of the time, and more than 60% of the time, feedback was provided by regional expert reviewers in less than 10 minutes.ConclusionOur method was found to be feasible and effective in increasing health care workers’ skills and accuracy. This method holds promise for improved quality of VIA-based CCS programs among health care providers in low-income countries.

The authors develop a hybrid model of health care use that blends features of the traditional AdayAndersen behavioral model with the socioecological modeling perspective. They use the model to conceptualize the various levels of influence expected from socioecological variables in individuals' mammography use decisions, build contextual variables from fine-grained data into four different types of geographic areas, and then use two-and three-level modeling of personal and area-level contextual factors to explain observed behavior. The central focus is on whether differentiating the conceptualized levels of influence seems to materially affect regression findings. The test could conceivably be confounded by the modifiable areal unit problem, but little evidence for this is found. Findings for California women suggest that distinctions do matter in how the levels of influence are defined for local neighborhood contextual factors. Studies using only county-level contextual factors will miss some meaningful associations related to interpersonal/proximate-level factors. Keywordsaccess to care; mammography use; modifiable areal unit problem; multilevel model; socioecological model; breast cancer screening There are many different ways to combine microdata into variables describing small areas, and how this is done may affect statistical properties of the variables (Ali et al., 2005;Tatalovich, Wilson, Milam, Jerrett, & McConnell, 2006). Greenland (2002) and Pickett and Pearl (2000) discussed what this might mean for multilevel analyses. Empirical small area analyses (with areal-level aggregates for both the dependent and the explanatory variables) have found inconsistencies across models using different areal aggregations, which has been named the modifiable areal unit problem, or MAUP (Cockings & Martin, 2005;Fotheringham & Wong, 1991). To our knowledge, there have been no published studies with empirical assessments of MAUP in multilevel regression models, which is a major contribution of this article.To test for MAUP in multilevel models requires careful conceptualization of the relevant zones of influence for contextual variables (i.e., the appropriate level of aggregation for use in the analysis). A strong conceptual model is needed to guide the assessment because coefficient estimates can change for other reasons besides MAUP. These include differences in the relevance of the zones of influence defined (Pickett & Pearl, 2000), differences in statistical properties of the constructed variables because of MAUP (Greenland, 2002), or omission of important variables (Dietz, 2002 To identify all important variables and their relevant zones of influence, we developed a hybrid conceptual model that blends the best features of traditional behavioral models of access and use with socioecological models of health outcomes. This model situates the individual decision maker, distinguished by enabling-predisposing need characteristics, into an ecological context that has different zones of influence (fundamental-dista...

PURPOSE Until human papillomavirus (HPV)–based cervical screening is more affordable and widely available, visual inspection with acetic acid (VIA) is recommended by the WHO for screening in lower-resource settings. Visual inspection will still be required to assess the cervix for women whose screening is positive for high-risk HPV. However, the quality of VIA can vary widely, and it is difficult to maintain a well-trained cadre of providers. We developed a smartphone-enhanced VIA platform (SEVIA) for real-time secure sharing of cervical images for remote supportive supervision, data monitoring, and evaluation. METHODS We assessed programmatic outcomes so that findings could be translated into routine care in the Tanzania National Cervical Cancer Prevention Program. We compared VIA positivity rates (for HIV-positive and HIV-negative women) before and after implementation. We collected demographic, diagnostic, treatment, and loss-to-follow-up data. RESULTS From July 2016 to June 2017, 10,545 women were screened using SEVIA at 24 health facilities across 5 regions of Tanzania. In the first 6 months of implementation, screening quality increased significantly from the baseline rate in the prior year, with a well-trained cadre of more than 50 health providers who “graduated” from the supportive-supervision training model. However, losses to follow-up for women referred for further evaluation or to a higher level of care were considerable. CONCLUSION The SEVIA platform is a feasible, quality improvement, mobile health intervention that can be integrated into a national cervical screening program. Our model demonstrates potential for scalability. As HPV screening becomes more affordable, the platform can be used for visual assessment of the cervix to determine amenability for same-day ablative therapy and/or as a secondary triage step, if needed.

PBS demonstrated the optimal combination of recruitment success, efficiency, cost, and population representativeness and serves as a model for the assembly of future prospective probability-based birth cohorts.