Contributing authors

Serra Lem Asangbeh^1,2,3, Katayoun Taghavi⁴, Maša Davidović^2,3,5, Julia Bohlius^2,3,4

• ¹Graduate School Cellular and Biomedical Sciences, University of Bern, Switzerland

• ² Swiss Tropical and Public Health Institute, Allschwil, Switzerland

• ³University of Basel, Basel, Switzerland

• ⁴Institute of Social and Preventive Medicine, Bern, Switzerland

• ⁵ Graduate School of Health Sciences, University of Bern, Switzerland

Corresponding author: Serra L. Asangbeh, Email: [email protected]

Abstract

Introduction

Inequities and inequalities in cervical cancer (CC) incidence and mortality persist between high- and low-income countries. In several countries with high human Immunodeficiency virus (HIV) prevalence, prevention strategies and particularly screening, have been integrated in antiretroviral treatment (ART) programmes. However, these programmes are undermined by a lack of functional monitoring systems for women screened for precancerous cervical lesions or diagnosed with invasive CC.

Health policies provide a blueprint for programme implementation, tailored to the health needs of the population. For these programmes to be effective, monitoring and evaluation frameworks with clearly defined indicators and targets that track programme performance and ultimately outcomes of women screened are needed.

Objective

This scoping review will identify and assess consistency of indicators and targets for CC prevention and control programmes in countries with the highest HIV prevalence. We will use the WHO toolkit for CC prevention and control programmes and the WHO draft global strategy to eliminate CC as a public health problem as reference documents to check policy alignment with global indicators and targets.

Methods

We will use the enhanced version of Arksey and O’Malley’s methodological to conduct this review. Reporting will be guided by the Preferred Reporting Items for Systematic Reviews and Meta Analyses extension for scoping reviews (PRISMA-ScR).

We will conduct a search for policies, strategies, plans for cervical cancer, cancer and non-communicable diseases control on https://www.iccp-portal.org/map. We will also conduct a search for documents not registered on this website on MEDLINE (via Ovid and Pubmed), Google Scholar, and national data repositories of participating countries (when available). We will also consult experts in participating countries for other relevant information.

Results and dissemination

We will present results of this review at conferences and submit for publication in a peer-reviewed journal. The current study will contribute towards the development of a CC prevention and care cascade in SSA.

Introduction

Cervical cancer (CC) incidence and mortality rates are projected to rise in the next decade¹. The greatest burden is borne by Sub-saharan Africa, exacerbated by the high Human Immunodeficiency Virus (HIV) prevalence in this region. Women living with HIV (WLHIV) are more prone to persistent human papillomavirus (HPV) infection, precancerous lesion development and rapid progression to invasive CC².

In high-income countries, effective screening programmes have reduced CC incidence by about 80% in over three decades.^3,4 However, many low and middle-income countries, have yet to witness this reduction, due to competing health priorities, resource challenges and a general lack of monitoring and evaluation systems for existing programmes. Several countries, South of the Sahara have integrated cervical screening into existing antiretroviral therapy (ART) services, a strategy which has been shown to be feasible and acceptable and an effective way to improve access to cervical screening⁵. Such a model maximizes the many contacts women have with the health system (antenatal clinics, Family Planning units, vaccination units, ART clinics), thus improving coverage and potentially, follow-up of screened women.

In order to assess effectiveness of these programmes, there is need for a monitoring and evaluation system with indicators that measure progress towards achieving the set goals. Such monitoring frameworks are crucial in identifying gaps and taking timely corrective measures to optimize gains for efforts. World Health Organisation (WHO) recommends ‘a functioning monitoring system to track HPV vaccination, screening and follow-up treatment’ as an essential requirement for a comprehensive CC prevention and control program⁶. Developing indicators and tools to monitor and assess programme performance is an essential part of the planning phase for the implementation of quality control for a CC control program⁷. Assessing the impact of prevention efforts furnished by countries requires a comprehensive monitoring and evaluation framework, which includes indicators that monitor service delivery and progress towards defined targets.

Objective

The purpose of this scoping review is to identify indicators and targets for CC prevention and control programmes in countries with the highest HIV burden while assessing consistency with recommended global indicators and targets.

Methods and design

We will use the revised Arksey and O’Malley scoping review methodological framework⁸ for the current study. It is a six-item framework, which guides scoping review conduct. It provides recommendations and further clarification for all items. The Preferred Reporting Items for Systematic Reviews and Meta Analyses extension for scoping reviews (PRISMA-ScR)⁹ will guide reporting of this review.

PRISMA-ScR is a 22-item checklist for reporting scoping reviews adapted from the PRISMA checklist. This tool excludes 5 items (13, 15, 16, 22, 23) from the 27- item PRISMA checklist not relevant for scoping reviews. Two of the 22 items are optional: critical appraisal of individual sources of evidence and critical appraisal within sources of evidence.

Inclusion Criteria

1. We will include the most recent versions of policy documents that contain aspects of CC prevention and control in countries with HIV prevalence greater than or equal to 10%. This arbitrary cut-off corresponds to nine countries in Southern Africa: Swaziland, Lesotho, Botswana, South Africa, Namibia, Zimbabwe, Zambia, Mozambique and Malawi. Standalone CC prevention and control documents will take precedence over general plans for cancer control or non-communicable diseases control. There will be no language restrictions.

Exclusion criteria

We will exclude general cancer control plans where a recent standalone CC prevention and control document is available.

Methodological framework

Identifying the research question

The WHO toolkit for CC prevention and control programmes, and the draft global strategy to eliminate CC as a public health problem provides the basis for our inquiry. The toolkit defines a wide range of indicators disaggregated by different variables including HIV status and recommends key indicators to be included in monitoring and evaluation systems for global monitoring of cervical cancer prevention and control programmes. The global strategy defines global targets to be met by programmes in order to achieve CC elimination within a century. As described by Levac et al³, we will link the purpose of our study with our research questions. (include the scope of inquiry, the definition of the concept, target population and outcomes of interest in the definition of our research questions).

Questions- Objectives

1. What performance and result indicators are recommended for CC prevention in countries with the highest HIV prevalence?

   1. How are these indicators defined? (numerators and denominators?)

   2. How do these indicators and their definitions align with the core indicators recommended by WHO for programme monitoring?

2. What targets are defined for HPV vaccination, cervical screening and treatment of precancerous lesions and invasive cancer?

3. What are the tools available for programme monitoring and evaluation?

Identifying relevant documents and policies

We will use the portal of the International Cancer Control Partnership that provides resources for cancer control planners. It contains a comprehensive but non-exhaustive list of cancer control plans). Two researchers will identify policy documents relevant to CC prevention and control through website searches on https://www.iccp-portal.org/map (which contains a comprehensive but non-exhaustive list of cancer control plans). Country experts will also be consulted for unpublished documents.

We will also conduct a search to identify other policy documents for CC prevention and control for these specific countries on MEDLINE (via Ovid and Pubmed), Google Scholar, and national data repositories (when available). Our search terms will constitute a combination of Medical Subject Headings (MeSH) terms and key words including but not limited to: Human papillomavirus vaccination AND Cervical cancer screening AND Cervix screening AND screening for precancerous lesions AND Cervical cancer prevention AND Cervical cancer control AND cancer control AND cancer prevention and control AND non-communicable diseases control policy OR plan OR strategy OR guideline AND Botswana OR Namibia OR Malawi OR South Africa OR Mozambique OR South Africa OR Zambia OR Zimbabwe.

Our search strategy will also be guided by the suggested list of documents for a desk review in the toolkit for CC prevention and control, such as: strategic health plan, cancer screening policy or strategic plan, national cancer prevention and control policy, HPV vaccination policy or strategic plan, national cervical cancer treatment policy or strategic plan, policy relevant to any aspect of cervical cancer screening, national clinical practice guidelines for cervical cancer screening, clinical practice guidelines for cervical cancer screening specific to HIV infected women, national clinical practice guidelines for the management of invasive cervical cancer, policies and clinical practice guidelines used for cervical cancer screening and treatment of invasive cancer.

Document selection

Two reviewers will independently conduct the guideline search and save them in a Mendeley library. They will screen for eligibility of policy documents focusing on titles, executive summaries and overviews. They will further assess the full texts of the documents and retain eligible ones where inclusion information is not captured in the title, executive summary nor overview. The team has met to discuss study inclusion criteria.

Charting the data

A standardized data extraction sheet will be used to extract data from included documents. Data items to be collected will include country, title of the plan, period of validity, information on human papillomavirus vaccination, cervical screening methods and strategies, treatment methods, indicators and targets for monitoring HPV vaccination, screening and treatment.

Two researchers will independently extract data and both extractions will be compared. A third researcher will resolve discrepancies that may arise in the review process. All identified indicators will be summarized in the final narrative, separating HIV-specific indicators.

Collating, summarizing and reporting results

We will report results using descriptive numerical summaries and themes that provide clarity on indicators for monitoring and targets. Indicators will be reported according to stage of the continuum: HPV vaccination, screening, treatment and care. Indicators specific to the HIV population will be reported separately under the same categories. We will classify identified indicators to reflect different stages in the continuum of care.

Consultation (optional)

We have already consulted some CC prevention and control experts in some participating countries for relevant policy documents.

Potential amendments

Any amendments to the present protocol during the review process will be reported.

Conclusion

This review will summarise indicators and targets for CC prevention and control programmes in sub Saharan African countries with the highest HIV prevalence. We will report indicators under CC prevention and care, highlighting indicators specific to the HIV population. We will also extract definitions of recommended indicators in policy documents and assess consistency across countries and with WHO recommended global indicators and targets. This review will also inform the development of a CC prevention and care cascade in SSA and will form one chapter of a PhD thesis.

Ethics and dissemination

No ethics approval is recommended for this study. This narrative review will inform a cervical cancer prevention and care cascade for low- and middle-income countries under development.

References

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