Feasibility of implementing cervical cancer screening program using smartphone imaging as a training aid for nurses in rural India

Sharma, Deborshi; Rohilla, Latika; Bagga, Rashmi; Srinivasan, Radhika; Jindal, Har Ashish; Sharma, Nikita; Kankaria, Ankita; Jamir, Limalemla; Suri, Vanita; Singh, Rakesh Kumar; Duggal, Mona

doi:10.1111/phn.12517

Cited by 17 publications

(33 citation statements)

References 16 publications

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“…Many sub-Saharan countries have already implemented a healthcare system in which community health workers and nurses deliver primary care. With inexpensive smartphones equipped with quality digital cameras, cervicography no longer requires complex and expensive equipment [15][16][17]22]. To improve the sustainability, transportability, and scalability of the intervention effect, the program nurses served as trainers and provided mentorship to MoH nurses in a total of 30 facilities.…”

Section: Policy Implicationsmentioning

confidence: 99%

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Evaluating smartphone strategies for reliability, reproducibility, and quality of VIA for cervical cancer screening in the Shiselweni region of Eswatini: A cohort study

et al. 2020

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Background Cervical cancer is among the most common preventable cancers with the highest morbidity and mortality. The World Health Organization (WHO) recommends visual inspection of the cervix with acetic acid (VIA) as cervical cancer screening strategy in resource-poor settings. However, there are barriers to the sustainability of VIA programs including declining providers’ VIA competence without mentorship and quality assurances and challenges of integration into primary healthcare. This study seeks to evaluate the impact of smartphone-based strategies in improving reliability, reproducibility, and quality of VIA in humanitarian settings. Methods and findings We implemented smartphone-based VIA that included standard VIA training, adapted refresher, and 6-month mHealth mentorship, sequentially, in the rural Shiselweni region of Eswatini. A remote expert reviewer provided diagnostic and management feedback on patients’ cervical images, which were reviewed weekly by nurses. Program’s outcomes, VIA image agreement rates, and Kappa statistic were compared before, during, and after training. From September 1, 2016 to December 31, 2018, 4,247 patients underwent screening; 247 were reviewed weekly by a VIA diagnostic expert. Of the 247, 128 (49%) were HIV–positive; mean age was 30.80 years (standard deviation [SD]: 7.74 years). Initial VIA positivity of 16% (436/2,637) after standard training gradually increased to 25.1% (293/1,168), dropped to an average of 9.7% (143/1,469) with a lowest of 7% (20/284) after refresher in 2017 (p = 0.001), increased again to an average of 9.6% (240/2,488) with a highest of 17% (17/100) before the start of mentorship, and dropped to an average of 8.3% (134/1,610) in 2018 with an average of 6.3% (37/591) after the start of mentorship (p = 0.019). Overall, 88% were eligible for and 68% received cryotherapy the same day: 10 cases were clinically suspicious for cancer; however, only 5 of those cases were confirmed using punch biopsy. Agreement rates with the expert reviewer for positive and negative cases were 100% (95% confidence interval [CI]: 79.4% to 100%) and 95.7% (95% CI: 92.2% to 97.9%), respectively, with negative predictive value (NPV) (100%), positive predictive value (PPV) (63.5%), and area under the curve of receiver operating characteristics (AUC ROC) (0.978). Kappa statistic was 0.74 (95% CI; 0.58 to 0.89); 0.64 and 0.79 at 3 and 6 months, respectively. In logistic regression, HIV and age were associated with VIA positivity (adjusted Odds Ratio [aOR]: 3.53, 95% CI: 1.10 to 11.29; p = 0.033 and aOR: 1.06, 95% CI: 1.0004 to 1.13; p = 0.048, respectively). We were unable to incorporate a control arm due to logistical constraints in routine humanitarian settings. Conclusions Our findings suggest that smartphone mentorship provided experiential learning to improve nurses’ competencies and VIA reliability and reproducibility, reduced false positive, and introduced peer-to-peer education and quality control services. Local collaboration; extending services to remote populations; decreasing unnecessary burden to screened women, providers, and tertiary centers; and capacity building through low-tech high-yield screening are promising strategies for scale-up of VIA programs.

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Section: Policy Implicationsmentioning

confidence: 99%

“…Smartphone cameras provide a reliable alternative option. Although some pilot research projects have tested this approach [15,16,22], it has not yet been evaluated in routine settings.…”

Section: Introductionmentioning

confidence: 99%

Evaluating smartphone strategies for reliability, reproducibility, and quality of VIA for cervical cancer screening in the Shiselweni region of Eswatini: A cohort study

et al. 2020

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“…The review focused on LMICs: 19 studies were conducted in sub-Saharan Africa [ 30 , 31 , 34 - 39 , 42 - 46 , 50 , 52 , 54 - 56 , 59 ], 7 in Asia [ 32 , 33 , 40 , 47 - 49 , 51 , 53 , 58 ], and 1 in South America [ 41 ].…”

Section: Resultsmentioning

confidence: 99%

“…Women randomized to one of the study arms received e-vouchers through their mobile phone, which covered the costs of a return trip to the health facility. In total, 15 studies used smartphones for facilitating digital cervicography and visualizing the cervix during VIA at the point of care [ 30 , 31 , 35 , 36 , 42 - 46 , 50 , 51 , 53 - 57 ]. In total, 7 studies included visual inspection with Lugol iodine images in addition to VIA images [ 35 - 37 , 50 , 53 - 55 ].…”

Section: Resultsmentioning

confidence: 99%

Digital Health Strategies for Cervical Cancer Control in Low- and Middle-Income Countries: Systematic Review of Current Implementations and Gaps in Research

Rossman¹,

Reid²,

Pieters³

et al. 2021

J Med Internet Res

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Background Nearly 90% of deaths due to cervical cancer occur in low- and middle-income countries (LMICs). In recent years, many digital health strategies have been implemented in LMICs to ameliorate patient-, provider-, and health system–level challenges in cervical cancer control. However, there are limited efforts to systematically review the effectiveness and current landscape of digital health strategies for cervical cancer control in LMICs. Objective We aim to conduct a systematic review of digital health strategies for cervical cancer control in LMICs to assess their effectiveness, describe the range of strategies used, and summarize challenges in their implementation. Methods A systematic search was conducted to identify publications describing digital health strategies for cervical cancer control in LMICs from 5 academic databases and Google Scholar. The review excluded digital strategies associated with improving vaccination coverage against human papillomavirus. Titles and abstracts were screened, and full texts were reviewed for eligibility. A structured data extraction template was used to summarize the information from the included studies. The risk of bias and data reporting guidelines for mobile health were assessed for each study. A meta-analysis of effectiveness was planned along with a narrative review of digital health strategies, implementation challenges, and opportunities for future research. Results In the 27 included studies, interventions for cervical cancer control focused on secondary prevention (ie, screening and treatment of precancerous lesions) and digital health strategies to facilitate patient education, digital cervicography, health worker training, and data quality. Most of the included studies were conducted in sub-Saharan Africa, with fewer studies in other LMIC settings in Asia or South America. A low risk of bias was found in 2 studies, and a moderate risk of bias was found in 4 studies, while the remaining 21 studies had a high risk of bias. A meta-analysis of effectiveness was not conducted because of insufficient studies with robust study designs and matched outcomes or interventions. Conclusions Current evidence on the effectiveness of digital health strategies for cervical cancer control is limited and, in most cases, is associated with a high risk of bias. Further studies are recommended to expand the investigation of digital health strategies for cervical cancer using robust study designs, explore other LMIC settings with a high burden of cervical cancer (eg, South America), and test a greater diversity of digital strategies.

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“…Primary outcome is attendance rate for follow-up. Other examples of web-based screening of cervical cancer in low- and medium-income countries come from Madagascar [53] and rural Indian zones [54]. Such a procedure could help prevent these frequent cancers by eliminating the lengthy travel necessary for examinations, and it was for this reason that a similar program of telecolposcopy was set up at eight spoke sites across Arkansas [55].…”

Section: Potential Impacts Of E-health In Oncologymentioning

confidence: 99%

Outpatient Cancer Care Delivery in the Context of E-Oncology: A French Perspective on “Cancer outside the Hospital Walls”

Bertucci

Corroller

Monneur-Miramon

et al. 2019

Cancers

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In oncology, the treatment of patients outside of hospitals has become imperative due to an increasing number of patients who are older and live longer, along with issues such as medical desertification, oncologist hyperspecialization, and difficulties in financing mounting health expenditures. Treatments have become less “invasive”, with greater precision and efficiency. Patients can therefore receive most of their care outside of hospitals. The development of e-health can address these new imperatives. In this letter, we describe the different e-health tools and their potential clinical impacts in oncology, as already reported at every level of care, including education, prevention, diagnosis, treatment, and monitoring. A few randomized studies have yet demonstrated the clinical benefit. We also comment on issues and limits of “cancer outside the hospital walls” from the point of view of patients, health care professionals, health facilities, and public authorities. Care providers in hospitals and communities will have to adapt to these changes within well-coordinated networks in order to better meet patient expectations regarding increasing education and personalizing management. Ultimately, controlled studies should aim to definitively demonstrate areas of interest, benefits, and incentives, for not only patients, but also caregivers (formal and informal) and health care providers, health care facilities, and the nation.

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Feasibility of implementing cervical cancer screening program using smartphone imaging as a training aid for nurses in rural India

Abstract: Appropriately trained nurses can reliably conduct screening. Real-time expert feedback might improve reporting. Rigorous awareness activities and on-site treatment can reduce drop-outs. The medical institute's involvement and administrative will were instrumental.

Cited by 17 publications

References 16 publications

Evaluating smartphone strategies for reliability, reproducibility, and quality of VIA for cervical cancer screening in the Shiselweni region of Eswatini: A cohort study

Evaluating smartphone strategies for reliability, reproducibility, and quality of VIA for cervical cancer screening in the Shiselweni region of Eswatini: A cohort study

Digital Health Strategies for Cervical Cancer Control in Low- and Middle-Income Countries: Systematic Review of Current Implementations and Gaps in Research

Outpatient Cancer Care Delivery in the Context of E-Oncology: A French Perspective on “Cancer outside the Hospital Walls”

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