A process evaluation of integrated service delivery of self-collected HPV-based cervical cancer screening using RE-AIM in the ASPIRE Mayuge pragmatic randomized trial

BackgroundIn many low-resourced settings, self-collected HPV-based cervical cancer screening (SCS) is being rolled out through task shifting to community health workers (CHWs). Process evaluations are needed to ensure SCS programs are effective and translate to community-based contexts. MethodsThe Advances in Screening and Prevention in Reproductive Cancers (ASPIRE) study in Mayuge, Uganda was a two-arm, pragmatic randomized trial comparing two SCS implementation strategies facilitated by CHWs: Door-to-door and Community health day recruitment. This adjunct study uses the RE-AIM evaluation framework to assess the Reach, Efficacy, Adoption, Implementation and Maintenance of each implementation strategy in a subpopulation using process data collected throughout the trial. ResultsOf the trial population (n=2019), 781 women participated in both the baseline and exit surveys (door-to-door: n=406; community health day: n=375) and are included in this analysis. Both implementation strategies demonstrated high Reach, Efficacy, Adoption, Implementation and Maintenance. Trial consent rate was high and 100% of consenting participants in both arms participated in SCS (Reach). Follow-up rates among HPV positive participants were also high in both arms (door-to-door: 84% and community health day: 74%) (Efficacy). The intervention employed 61 CHWs, 7 nurses, 3 health facilities and other local staff within the health system to implement the intervention (Adoption). The community health day arm received HPV screening results and visual inspection with acetic acid (VIA) quicker than the door-to-door arm, but reported higher dissatisfaction with wait times (Implementation). While women had knowledge of cervical cancer symptoms and prevention measures at six-months post-intervention, no one in either arm recalled that cervical cancer could be asymptomatic (Maintenance). ConclusionBoth SCS implementation strategies performed well, demonstrating high Reach, Efficacy, Adoption, Implementation and Maintenance throughout participating communities. Implementing pragmatic approaches including task-shifting to CHWs can reduce health worker burden and improve screening access in low-resourced, community-based settings.