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

Abstract

BackgroundDeveloping 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.MethodsA 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.ResultsFourteen 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).DiscussionTraining, 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.

Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen‐positive women: results from the ESTAMPA study

“…As observed by others, 27 our results suggest that adopting proficiency schemes based on training and supervision is desirable to improve VIA. Consequently, alternatives such as computer tools based on remote support from external experts and/or artificial intelligence algorithms (AI) that can offer permanent supervision and training 30,37-40 may be useful.…”

“…However, the variability of VIA is so high that the range of sensitivity in primary screening overlaps with the range in triage. Although women's characteristics may explain differences in VIA results, 33,34 the experience level of VIA examiners, training and supervision, and quality assurance may largely explain the variability of this visual technique 6,27,35,36 . In ESTAMPA, the majority of VIAs (98%) were performed by eight examiners, and despite the lower number, performance of VIA varied widely between them.…”

“…Several studies have evidenced high variability of VIA to detect high‐grade cervical lesions with sensitivities ranging between 17%‐96% in primary screening, 4 , 6 , 13 , 14 , 15 , 16 , 17 and between 25%–92% in HPV‐positive women. 13 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 Only five studies in HPV‐positive women, characterised by including intensive training, report sensitivities ≥80%. 20 , 23 , 24 , 27 , 30 VIA positivity, which is a useful indicator in triage scenarios, has also shown to be highly variable.…”

“… 13 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 Only five studies in HPV‐positive women, characterised by including intensive training, report sensitivities ≥80%. 20 , 23 , 24 , 27 , 30 VIA positivity, which is a useful indicator in triage scenarios, has also shown to be highly variable. 5 It is worth noting that in the context of triage, knowledge of HPV status may increase the positivity rate of observer‐depended techniques, as reported for cytology, increasing the sensitivity.…”

“…Although women's characteristics may explain differences in VIA results, 33 , 34 the experience level of VIA examiners, training and supervision, and quality assurance may largely explain the variability of this visual technique. 6 , 27 , 35 , 36 In ESTAMPA, the majority of VIAs (98%) were performed by eight examiners, and despite the lower number, performance of VIA varied widely between them. A research nurse who was also a VIA trainer, accounted for 37% (n = 1177) of all VIAs, becoming the most experienced examiner.…”