Role of community-based resources in cervical cancer screening uptake in low- and middle-income countries: a scoping review protocol

Role of community-based resources in cervical cancer screening uptake in lowand middle-income countries: a scoping review protocol Danladi Adamu 1 a , Nicole M Robertson 2 , David Weller 3 , Christine Campbell 3 1 Usher Institute, Teviot Place, University of Edinburgh, EH8 9AG, UK; College of Medical Sciences, Gombe State University, Nigeria, 2 Usher Institute, Teviot Place, University of Edinburgh, EH8 9AG, UK; University of Kentucky College of Medicine, Lexington, Kentucky, USA, 3 Usher Institute, Teviot Place, University of Edinburgh, EH8 9AG, UK


Background Background
Poor cervical cancer screening coverage and utilization by women in low-and middle-income countries (LMICs) are linked to health system factors such as lack of access and availability of quality health care, inadequate workforce capacity, and socio-cultural and behavioral barriers. To improve women's participation in cervical screening, strategies such as involvement of community resources have been recommended. The aim of this review is to understand the current roles 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.

Methods and analysis Methods and analysis
We will conduct a scoping review of MEDLINE, CINAHL and Global Health databases from January 2016 to June 2020 for published peer-reviewed literature from LMICs including reference list tracking and handsearching of studies with community focus published in English describing interventions provided by CBRs in cervical screening uptake.

Ethics and dissemination Ethics and dissemination
Ethical approval is not required. Findings from this review will be summarised for conferences and published in peer-reviewed journals for widespread dissemination. Study will identify possible gaps in the evidence and differences in the role of CBRs between sub-Saharan Africa (SSA) and other LMIC regions and inform recommendations and implementation of future cervical screening research, policy, and practice.
Cervical cancer is a preventable and treatable disease when identified early. 1 Cervical cancer in low-and middleincome 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 treat-ment, 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 nonbusiness 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 RATIONALE Recently, systematic reviews by Driscoll 13 and O'Donovan 12 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.

OBJECTIVES
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 framework 14 and further enhanced by Levac 15 and Daudt 16 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. 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, communitybased 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 Adamu 7 and O' Donovan 17 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.

STUDY SELECTION
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, fulltext 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 3 rd reviewer for consistency. Reasons for exclusion of studies screened in full text will be documented.
PRISMA flow chart diagram 18 will be used to summarize the study selection.
ELIGIBILITY CRITERIA 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 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. Role of community-based resources in cervical cancer screening uptake in low-and middle-income countries: a scoping... • Services offered by CBRs with or without health care workers in cervical screening in LMIC setting. • Services offered by CBRs with focus on both cervical screening and other aspects of cervical cancer e.g. HPV vaccination. We will only extract and report findings for cervical screening. • Services offered by CBRs within and outside of LMICs. We will only extract and report findings for LMICs.

Journal of Global Health Reports
• Services offered by CBRs in cervical screening outside LMIC setting. • Services offered by health care workers without CBRs in cervical screening. • Services offered by CBRs on other aspects of cervical cancer, not related to cervical screening e.g. HPV vaccination.
• Studies with or without control group, and the control groups are women who either receive no intervention, another intervention other than that of intervention group, or routine standard screening.
• Role(s) played by CBRs in cervical screening uptake among women with and without HIV. • Evidence of uptake or non-uptake of cervical screening. 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 groupings 19 (see Online Supplementary Document 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.

DISCUSSION
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 Role of community-based resources in cervical cancer screening uptake in low-and middle-income countries: a scoping...
Journal of Global Health Reports evidence and any differences in the roles of CBRs between countries in SSA and other LMICs.