Cervical Cancer Elimination in Low-and-middle-income countries: The Role of Cost and Empowerment in the Implementation of Human Papillomavirus Self-Sampling

Abstract

The World Health Organization (WHO) announced an ambitious call for global cervical cancer elimination within the next century. More than 80% of cervical cancers occur in low-and-middle-income countries (LMICs), where the age-standardized mortality rates are six-times higher than in high-income countries. The goal of this dissertation is to outline a roadmap toward cervical cancer elimination in LMICs and evaluate a community-based HPV self-sampling program in Peru via micro-costing and mixed-method study of empowerment. In the first aim, we conduct a scoping review to synthesize evidence-based primary and secondary prevention strategies for cervical cancer and highlight research gaps and priorities. We find that effective prevention methods include HPV vaccination, screening using visual inspection and HPV testing and thermocoagulation, and discuss implementation challenges in LMICs. Aims 2 and 3 are nested within a community-based HPV self-sampling social entrepreneurship in Peru called the Hope Project, where volunteer women (Hope Ladies) from socioeconomically disadvantaged peri-urban area of Lima sell HPV self-sampling kits in their communities to increase cervical cancer screening coverage. In Aim 2, we conduct a micro-costing analysis from the program perspective to determine the unit costs of: (1) recruitment and training of Hope Ladies, (2) Hope Ladies distributing HPV self-sampling kits (careHPV), and (3) Hope Ladies linking screened women with appropriate follow-up care. We find that community-based HPV self-sampling appears to be a feasible way to improve cervical cancer screening in Peru. In Aim 3, we evaluate the Hope Ladies’ individual and collective relational and financial empowerment after participating in the Hope Project. We use deductive content analysis and surveys informed by empowerment frameworks (e.g., Kabeer’s conceptual model) to triangulate our qualitative and quantitative findings. We develop an implementation-science informed causal pathway for the Hope Project, where the Hope Ladies’ financial/relational empowerment function as the mechanism of action for this intervention and articulate the pre-conditions necessary to increase the screening coverage. Finally, we conclude that cervical cancer elimination in LMICs would require intersectoral collaboration to increase access to and coverage of evidence-based strategies. We call for implementation, scale-up and economic and programmatic evaluation of community-based HPV self-sampling in LMICs.