Training, Supervision, and Competence Assessment of Cameroonian Health Care Providers Using HPV Self-Sampling, Triage by Visual Inspection, and Treatment by Thermal Ablation in a Single Visit.

Background: Developing human resource capacity and efficient deployment of skilled personnel are essential for cervical cancer screening program implementation in resource-limited countries. Our aim was to provide a context-specific training framework, supervision, and effectiveness evaluation of health care providers in a cervical cancer screening program. Methods: A 5-year cervical cancer screening program was implemented in Dschang, West Cameroon. Women were invited to perform human papillomavirus self-sampling (Self-HPV), followed by triage using visual inspection with acetic acid (VIA) and thermal ablation if needed. Health care providers were trained in four key learning phases to perform counseling, screening, and treatment process in a single visit. Training included (i) a 3-day basic course, (ii) 3-day advanced practical training, (iii) 2 weeks of supervision, and (iv) bi-monthly supervision by a mentor. The diagnostic performance of health care providers was compared between two time periods, period I (September 2018 to April 2019) and period II (May 2019 to January 2020), for an overall 17-month study period. Results: Fourteen health care providers were recruited for the training course and 12 of them completed the training objectives. Follow-up and evaluations were conducted for three health care providers working in the screening unit at Dschang District Hospital. During the study period, 1,609 women performed Self-HPV, among which 759 were screened during period I and 850 during period II. HPV positivity was 18.2 and 17.1%, and VIA positivity was 45.7 and 71.0% in period I and II, respectively. VIA sensitivity was 60.0% (95% confidence interval [CI] 26.2-87.8) and 80.8% (95% CI 60.6-93.4) in period I and II, respectively (p = 0.390). VIA specificity decreased between period I (57.4, 95% CI 48.1-66.3) and II (30.8, 95% CI 22.6-40.0) (p < 0.001). Health care providers demonstrated substantial agreement with their mentor in their diagnoses during both periods (period I: Cohen's kappa coefficient [k] = 0.73, 95% CI 0.62-0.85, and period II: k = 0.62 0.47-0.76; p = 0.0549). Discussion: Training, supervision, and a focus on effectiveness in cervical cancer screening are interventions that contribute to improving frontline provider competencies and maintaining a high quality of health care service delivery.

Acceptability and safety of thermal ablation to prevent cervical cancer in sub-Saharan Africa.

BACKGROUND: The World Health Organization recommends thermal ablation as an alternative to cryotherapy to treat women with precancerous lesions in low-resource settings. However, limited data are available on women's experience and adverse events (AEs) of the procedure in the context of Sub-Saharan Africa. The objective of this study was to evaluate the acceptability and safety of thermal ablation in women screened positive for precancerous cervical lesions. METHODS: Asymptomatic women aged 30-49 years old living in the Dschang Health District were invited to participate in a cervical cancer screening campaign termed "3 T-Approach" (for Test-Triage and Treat). Recruited women were asked to perform HPV self-sampling followed by triage with visual assessment and treatment with thermal ablation if required. After treatment and 4-6 weeks later, interviews were conducted to assess women's experience on anxiety, discomfort, and pain during thermal ablation. AEs were recorded on pre-defined electronic forms 4-6 weeks after treatment to assess the procedure's safety. RESULTS: Between September 2018 and December 2020, 399 HPV-positive women (18.7% of women screened) were recruited, 236 (59.1%) had a positive visual assessment, 234 were treated by thermal ablation and 198 (84.6%) received therapy in the same visit. Treatment was not considered as painful (score ≤ 4/10) by 209 (90.9%) patients while 5 (2.5%) reported high pain (score 8-10/10). During post-treatment interviews 4-6 weeks later, most reported AEs were graded mild or moderate (grade I-II). The most frequent symptoms reported as mild AEs (grade 1-2) were vaginal watery discharge (75.5%), vaginal bloody-stained discharge (21.5%) and malodourous discharge (14.5%). None of the participants experienced serious AEs (grade 3-4) or AEs requiring admission to hospital or emergency consultation. The vast majority of women (99.6%) would agree to repeat the procedure if necessary and (99.6%) would recommend it to friends or family. CONCLUSION: Thermal ablation is widely accepted by women and appears as a safe procedure. It may contribute to improving the link between screening and treatment in a single visit and to optimizing cervical cancer control in low-resource settings. TRIAL REGISTRATION: The study was registered on clinicaltrials.gov ( NCT03757299 ) in November 2018 (28/11/2018).