Carolyn Nakisige

The social and economic impacts of cervical cancer on women and children in low‐ and middle‐income countries: A systematic review

AbstractBackgroundThere is limited knowledge on the social and economic impacts of a diagnosis of cervical cancer on women and children in low‐ and middle‐income countries (LMICs).ObjectivesTo determine the social and economic impacts associated with cervical cancer among women and children living in LMICs.Search strategyThe MEDLINE, PsychInfo, CINAHL, Pais International, and CAB Global Health databases were systematically searched to retrieve studies up to June 2021.Selection criteriaStudies were included if they reported on either the social or economic impacts of women or children in a LMIC.Data collection and analysisData was independently extracted by two co‐authors. The authors performed a quality assessment on all included articles.Main resultsIn all, 53 studies were included in the final review. Social impacts identified included social support, education, and independence. Economic impacts included employment and financial security. No study reported the economic impact on children. Studies that utilized quantitative methods typically reported more positive results than those that utilized qualitative methods.ConclusionsAdditional mixed‐methods research is needed to further understand the social support needs of women with cervical cancer. Furthermore, research is needed on the impact of a mother's diagnosis of cervical cancer on her children.

Implementing Smartphone-Based Telemedicine for Cervical Cancer Screening in Uganda: Qualitative Study of Stakeholders’ Perceptions

Background In Uganda, cervical cancer (CaCx) is the commonest cancer, accounting for 35.7% of all cancer cases in women. The rates of human papillomavirus vaccination and CaCx screening remain low. Digital health tools and interventions have the potential to improve different aspects of CaCx screening and control in Uganda. Objective This study aimed to describe stakeholders’ perceptions of the telemedicine system we developed to improve CaCx screening in Uganda. Methods We developed and implemented a smartphone-based telemedicine system for capturing and sharing cervical images and other clinical data, as well as an artificial intelligence model for automatic analysis of images. We conducted focus group discussions with health workers at the screening clinics (n=27) and women undergoing screening (n=15) to explore their perceptions of the system. The focus group discussions were supplemented with field observations and an evaluation survey of the health workers on system usability and the overall project. Results In general, both patients and health workers had positive opinions about the system. Highlighted benefits included better cervical visualization, the ability to obtain a second opinion, improved communication between nurses and patients (to explain screening findings), improved clinical data management, performance monitoring and feedback, and modernization of screening service. However, there were also some negative perceptions. For example, some health workers felt the system is time-consuming, especially when it had just been introduced, while some patients were apprehensive about cervical image capture and sharing. Finally, commonplace challenges in digital health (eg, lack of interoperability and problems with sustainability) and challenges in cancer screening in general (eg, arduous referrals, inadequate monitoring and quality control) also resurfaced. Conclusions This study demonstrates the feasibility and value of digital health tools in CaCx screening in Uganda, particularly with regard to improving patient experience and the quality of screening services. It also provides examples of potential limitations that must be addressed for successful implementation.

Artificial intelligence and visual inspection in cervical cancer screening

Visual inspection with acetic acid is limited by subjectivity and a lack of skilled human resource. A decision support system based on artificial intelligence could address these limitations. We conducted a diagnostic study to assess the diagnostic performance using visual inspection with acetic acid under magnification of healthcare workers, experts, and an artificial intelligence algorithm. A total of 22 healthcare workers, 9 gynecologists/experts in visual inspection with acetic acid, and the algorithm assessed a set of 83 images from existing datasets with expert consensus as the reference. Their diagnostic performance was determined by analyzing sensitivity, specificity, and area under the curve, and intra- and inter-observer agreement was measured using Fleiss kappa values. Sensitivity, specificity, and area under the curve were, respectively, 80.4%, 80.5%, and 0.80 (95% CI 0.70 to 0.90) for the healthcare workers, 81.6%, 93.5%, and 0.93 (95% CI 0.87 to 1.00) for the experts, and 80.0%, 83.3%, and 0.84 (95% CI 0.75 to 0.93) for the algorithm. Kappa values for the healthcare workers, experts, and algorithm were 0.45, 0.68, and 0.63, respectively. This study enabled simultaneous assessment and demonstrated that expert consensus can be an alternative to histopathology to establish a reference standard for further training of healthcare workers and the artificial intelligence algorithm to improve diagnostic accuracy.

High-risk human papillomavirus testing for underscreened populations: cost-effectiveness and affordability in three country settings

The high-risk human papillomavirus (hrHPV)-based screening recommended by the World Health Organization is expected to lead to worldwide reduction of the cervical cancer burden, but the countries burdened most by cervical cancer also struggle with the costs of transitioning to this approach. Country-specific evaluations are needed to inform policymakers on implementation of hrHPV-based screening for their setting. Following initial implementation in Uganda, Bangladesh and Slovakia focused on underscreened women in the PRESCRIP-TEC project, we investigated the potential cost-effectiveness and affordability of hrHPV-based screening strategies. Country-specific model-based cost-effectiveness and budget impact analyses were conducted for the three countries, comparing the PRESCRIP-TEC strategy with the existing screening strategy in each setting. Data from initial project implementation informed the relevant model parameters. The PRESCRIP-TEC strategy resulted in disability-adjusted life year (DALY) gains in all three countries. The cervical cancer incidence rate was reduced by a third for Uganda, 15% for Bangladesh and 11% for Slovakia. The incremental cost-effectiveness ratios were UGX 0.56 million per DALY for Uganda (I$ 475), BDT 76 thousand per DALY for Bangladesh (I$ 1698) and EUR 1782 (I$ 3637) per DALY for Slovakia. Substantial additional funding will be required to enable implementation, particularly in relation to the initial start-up costs. The provided estimates can serve to inform policymakers and researchers in the context of implementing hrHPV-based screening in diverse settings.

Validation of Artificial Intelligence as Decision Support System in VIA (PRESCRIP-TEC)

The research project is a component of another research project that applies the protocol of the World Health Organization for screening of cervical cancer, with testing of high-risk Human Papilloma Virus (hrHPV) as first screening. In the screen, triage and treat approach women who tested positive for hrHPV are undergoing Visual Inspection of the cervix with Acetic Acid (VIA). This procedure is applied in Uganda, India and Bangladesh. However the quality of VIA by lower-trained staff is variable because Low and Middle Income Countries face limited numbers of qualified health care professionals. Artificial intelligence (AI) might be a solution to improve consistency of VIA assessment. This research validates an AI decision support system (AI-DSS) under field conditions.