This past weekend, I attended a conference on health and high politics examining the role of politics, global partnerships, and innovation in health equity and security. Two talks at the end of the day stood out for me. The first was by Dr. Leslie Davidson, a professor of epidemiology and pediatrics at Columbia University, and the second was by Dr. Ophira Ginsburg, a medical oncologist at Women’s College Research Institute in Toronto who specializes in women’s health equity and global cancer control.
A common thread in both talks was the increasingly important role of community health workers in meeting the challenges of delivering health services to underserved populations. During Dr. Davidson’s talk, she mentioned a recently published study from Argentina demonstrating the effectiveness of using community health workers as part of an integrative program to promote cervical cancer screening. Ever intrigued, I decided to read the original paper and share it here.
In the study published in Lancet Global Health, researchers found that when community health workers offered self-collecting HPV tests to women, participation rates increased four-fold. Human papillomavirus, or HPV, DNA testing is emerging as a viable alternative to Pap smears in low-resource settings. Earlier studies have shown that HPV DNA testing is as sensitive as conventional Pap smears in detecting cervical disease. An additional benefit of HPV DNA testing is the potential for self-sampling, which allows women to collect their own vaginal swabs in the comfort of their own homes.
For their study, researchers recruited 200 community health workers who were randomly assigned to one of two groups: the intervention group offered self-collecting HPV DNA testing to the women they visited and educated them on how to do the procedure while the control group advised women to visit their local health centres for cervical screening. Over 6000 women took part in the study over a six-month period.
In the intervention group, 86% of the women visited by community health workers had an HPV test within six months of the visit. The majority of these women collected their own vaginal swabs and gave it to the community health worker or delivered it to the local clinic for testing. In the control group, only 20% of women had an HPV test during that time. Not surprisingly, more cases of HPV-positive cervical abnormalities were detected in the intervention group than in the control group, leading to more women receiving treatment earlier.
In developed nations, Pap smears are the standard of care in screening and have played a major role in driving down the number of cervical cancer-related deaths. Unfortunately, in low- and middle-income countries, many barriers prevent the widespread implementation of Pap smears as an effective screening tool. These include the need for trained personnel, high-quality lab infrastructure, and educational campaigns informing women and encouraging them to participate.
Over 85% of new cervical cancer cases and cervical cancer-related deaths occur in developing countries. This study highlights the impact of combining a new technology (HPV DNA testing) with a social innovation (routine home visits from community health workers) to achieve widespread implementation of cervical screening. It is the first study of its kind to be conducted under real-world conditions in a low-resource setting. The success of this study provides an optimistic outlook on what can realistically be achieved by integrating self-collecting HPV DNA testing with existing community health worker programs. Strategies like this have the potential to increase cervical screening coverage in low- and middle-income countries and prevent tens of thousands of unnecessary deaths.
Arrossi S, Thouyaret L, Herrero R, Campanera A, Magdaleno A, Cuberli M, Barletta P, Laudi R, Orellana L, & EMA Study team (2015). Effect of self-collection of HPV DNA offered by community health workers at home visits on uptake of screening for cervical cancer (the EMA study): a population-based cluster-randomised trial. The Lancet. Global health, 3 (2) PMID: 25617202
Ginsburg, O. (2013). Breast and cervical cancer control in low and middle-income countries: Human rights meet sound health policy Journal of Cancer Policy, 1 (3-4) DOI: 10.1016/j.jcpo.2013.07.002