Cervical cancer is a preventable and treatable disease when identified early.1 Cervical cancer in low- and middle- income countries (LMICs) accounts for about 85% of the global burden of cervical cancer.1 We define LMICs based on the 2020 World Bank classification of income economies.2 The high burden of cervical cancer in LMICs could be reduced through a comprehensive approach that involves prevention, early diagnosis, and effective screening and treatment programs.3 However, access to these programs in LMICs is limited by many challenges such as lack of policies and programs for cervical cancer, lack of resource allocation, lack of access and availability of quality cervical cancer prevention services, and inadequate manpower in LMICs.4 The World Health Organization (WHO) in response to these challenges published guidance in 2013, recommending that in settings where access to HPV vaccination and screening using cytology and colposcopy are not available, alternative evidence-based cervical screening methods such as HPV testing and visual inspection with acetic acid (VIA) by trained healthcare workers could be used to screen women.5
A number of LMICs such as Zambia, Bangladesh, Guatemala, Honduras, and Nicaragua have scaled up cervical screening to population level using these approaches.6 However, several challenges remain for expansion of screening, such as training and maintaining the cadre of healthcare personnel who can sustain screening and treatment, ensuring adequate follow-up for screen-positive women, and overcoming the lack of government commitment due to competing priorities with infectious and other non-communicable diseases.6 Women’s lack of knowledge of cervical cancer and screening, and socio-cultural barriers may also affect acceptability and uptake of screening services. Therefore, further, alternative strategies for improving uptake and implementation of cervical cancer screening in LMICs are required. One additional strategy is the use of community-based resources (CBRs) as described previously in low-income settings,7–9 and involvement of non-business and non-governmental civil society organizations including key individuals in the community.10,11 Involvement of the community can promote trust and improve acceptance of screening and cultural permissibility within the community.10–12
Recently, systematic reviews by Driscoll13 and O’Donovan12 have shown that community health workers (CHWs) could help in reducing barriers and increase acceptance of cervical screening in LMICs. However, no review to date has been published examining the broader involvement of community-based resources including key stakeholders – for example health champions, traditional leaders, chief’s wives, etc. in the community in cervical screening in LMICs settings.
The review objectives are to assess: i) the role of community-based resources (CBRs) such as community health workers (CHWs) and community-based civil society organizations (CBOs) including key stakeholders – for example health champions, traditional leaders, chief’s wives, etc. in the community in cervical screening in LMICs settings; and summarize the key findings where effectiveness of interventions utilizing CBRs is reported; and ii) to compare roles of CBRs across geographical regions.
Scoping review framework
We will adapt the methodological guideline articulated in Arksey and O’Malley’s framework14 and further enhanced by Levac15 and Daudt16 for conducting and reporting this scoping review. The framework involves the following stages: i) identifying the research question ii) identifying relevant studies iii) study selection iv) charting the data, and v) collating, summarizing, and reporting the results.
Identifying the research question
The research questions are: 1) What are the roles of CBRs in cervical cancer screening in LMICs? and 2) Are there differences in the roles of CBRs in cervical screening across geographical regions?
Identifying relevant studies
We will search for published literature in English language between January 2016 and June 2020 for current and up to date information in the following 3 electronic databases: MEDLINE, CINAHL and Global Health based on their ability to capture the bulk of relevant LMICs literature. We will use keywords for exploring the above databases: cervical cancer, screening, community health workers, community-based organisations, civil society organizations, HIV, and low- and middle-income countries. Medical Subject Heading [MeSH] and free text terms will also be developed and combined to identify published studies. Truncation commands (using root words to capture alternative word endings), proximity operators (for words within a chosen distance of each other) and Boolean logic operators (OR and AND) will be used, and to ensure highest yield, pilot trial with search terms will be carried out and refined. More papers will be located through handsearching of citations and reference list tracking and contacts with authors for further information. A broad range of search terms based on descriptions from previous papers by Adamu7 and O’ Donovan17 to capture all relevant literature.
We searched International Prospective Register of Systematic Reviews (PROSPERO), Cochrane Library, PubMed, and Google scholar and no published or scheduled review on our topic was identified. Search strategy for MEDLINE via OVID is shown in Table 1: the search strategy will be adapted for other databases.
Relevant titles and abstracts identified from databases search will be uploaded and saved in EndNote X9 Library. After screening for duplicates, the remaining titles and abstracts will be independently screened by two reviewers based on the review’s eligibility criteria (see Table 2) developed according to the research questions. Thereafter, full-text copies will be downloaded, and the 2 reviewers will further screen the studies for eligibility of inclusion into the review and disagreements will be resolved by discussion, and 10% of the selected studies will be checked by 3rd reviewer for consistency. Reasons for exclusion of studies screened in full text will be documented.
PRISMA flow chart diagram18 will be used to summarize the study selection.
PICOS (Population, Intervention, Comparison, Outcome and Study design) framework will guide the selection of eligibility criteria.
Charting the data
Results from included studies will be extracted using a data extraction form (Online Supplementary Document, Table S1). The form will be piloted and updated and include the following items: study author, date, and study design; study population and country; name of CBRs; role of CBRs and screening modality; and key outcomes and comments.
Collating, summarizing, and reporting of the results.
The extracted data will be summarized and presented in line with the broader aims of the scoping review. We recognize that there will be reasonable variation in the roles, and outcome measures used in the included studies, but only limited synthesis (description and comparison).
The extracted data will be reported via tables of summary of roles of CBRs based on LMICs regions according to World Bank groupings19 (see Online Supplementary Document, Table S2 and Table S3 for CHWs and CBOs, respectively) including comments on any intervention effects.
Learning from previous scoping and rapid reviews, a scoping review unlike conventional systematic reviews place less emphasis on the methodological quality appraisal of included studies.12,20–22 Therefore, we will not subject included studies to quality assessment.
This will be the first review to explore the broader and unique contribution of the diverse communities in LMICs in cervical cancer screening. The review will summarise the current evidence on the roles of CBRs in cervical screening in LMICs from the international literature; comparison of these roles across geographical areas will be also be described.
Our search will be limited to published studies from January 2016 to June 2020 to map the landscape of current evidence without the constraints of rigorous analysis and synthesis of review findings; as such, we will restrict our search to 3 databases namely: MEDLINE, Global Health and CINAHL without considering the literature from non-peer reviewed and grey databases. Nevertheless, we are aware that limiting our search to peer reviewed English language publications within the last 5 years in 3 databases risks missing some papers.
Findings from this review will identify potential gaps in evidence and any differences in the roles of CBRs between countries in SSA and other LMICs.
DA was funded by Commonwealth Scholarship Commission. NR was supported by the Rotary International Global Fellowship from the Rotary Foundation. The Commission and Rotary Foundation had no role in preparation, funding, and decision to publish this paper.
DA, DW and CC conceived this scoping review protocol.
DA drafted the manuscript, which was assessed and refined by NR, CC and DW.
NR is the second reviewer.
All authors approved the final version of the manuscript.
DA is the guarantor.
All authors have completed the Unified Competing Interest form available at http://www.icmje.org/conflicts-of-interest/ in line with the Journal of Global Health editorial policy and declare no conflicts of interest.
Usher Institute, University of Edinburgh
Medical Quad, Teviot Place, Edinburgh, EH8 9AG, United Kingdom.
Email: [email protected]