The global WHO strategy for cervical cancer elimination recommends that each country should meet by 2030 the 90-70-90 targets. (6) Achieving and sustaining the second target (70% of participation rate with a high-performance test) will be one of the most challenging issue for many LMCs countries. For example, in Cameroon, participation is very low, it is estimated that cervical cancer screening participation rate in a woman’s lifetime is less than 10%. (22) This condition is one of the main reasons for the high cervical cancer incidence and death among middle-aged women in the country. (8) Our aim was to explore the effectiveness and costs of two different recruitment strategies in encouraging women to have a screening test.
Media-based information for public education about health-related issue are frequently used in many national campaigns in Cameroon.(23–25) However, according to the 2018 Demographic and Health Survey in Cameroon, within West Region, 38.1% of women were not exposed to any television, radio, or newspapers, 56.5% of women watch television and 22.4% listen to radio at least once a week. (22) This aspect is crucial for any decision making related to information spreading. Considering this data, radio broadcasting in our context is not the most efficient strategy compared to television-based intervention which also may be more expensive. Data is still limited about the impact of encouraging behavior changes in favor of effective health service and cost per person screened.
Efficiency results for screening coverage must consider that CIC and oral communication within the community co-existed with CHW-led intervention during the second period under study and that several women recruited by CHW could have been screened without mentioning the CHW referral, which would lead to their misclassification. Community spread communication co-existed with CHW-led intervention and has probably also increased our recruitment in each group, thus CHW's impact could be greater than we assumed. At the screening center, warm welcome can lead to a positive experience and favor recruitment.
Involvement of CHW for health education and promotion around cervical cancer in the community constitute an important step to increase participation in program. CHW intervention contribute to optimize the participation as they use their cultural knowledge and ensure that message are delivered in a culturally appropriate fashion according to women’s preferences and needs in rural areas who are rarely or never screened, which differ from those of women living closer to the city. (16, 26) As shown in Tables 1 and 2, women recruited by CHW tended to be less educated, have more children, use fewer condoms, and consume more tobacco. Participant knowledge about cervical cancer may not be the same as women living closer to the hospital. Studies have suggested that higher cervical cancer awareness is found among women within an urban environment due to internet and media access. (27) It has been established that a lack of information and awareness about screening centers’ location, costs, available time, and geographical condition are the main barriers to CC screening. (28–31)
In our study, CIC were used to convey an invitation to get screened. However, other studies have utilized media as an educational tool that appeared as effective as CHW intervention to recognize the importance of CC screening, although lay health workers were more effective to change screening behaviors through encouragement and logistical support. (32, 33)
CIC appear to be most suitable for women living close to the city center, while CHW improve recruitment coverage in rural areas. CHW not only enhanced recruitment outside urban areas, but they were also able to engage with and invite more women from a different socio-demographic population to be screened, including in zone 1. To avoid a Bottleneck effect due to limited capacities at the screening center, one strategy could be to start by using CIC, before gradually implementing CHW intervention.
A probable reason for a higher history of previous cervical cancer screening among participants from zone 1 in the CIC group is an increase of awareness and a built trust throughout a previous screening campaign in Dschang, in addition to the twenty years of collaboration of our research team in Cameroon. (11)
Transportation and childcare were previously reported as screening barriers. (26) Our screening recruitment heavily depended on rain seasons as roads were impracticable. Moreover, financial transport aid was an essential aspect of our strategy as women living in rural areas had to travel for many hours. CHW intervention helped to decrease these barriers as they recruited hard-to-reach women with multiple children and informed them about the financial subsidies for transportation.
The cost per screened women and CIN2 + diagnosed was higher in the CHW group. However, the media campaign was most efficient in zone 1. The higher recruitment of women in rural areas by CHW highlights the importance of training, preparing, and deploying CHWs to screen hard-to-reach women, especially considering that almost 45% of the Cameroon population lives in a rural area. (34) Undetected cervical lesions potentially leading to cervical cancer also increase overall costs not only for the healthcare system but can cause direct and indirect costs for the woman and her family such as cancer management cost, or loss of income due to disease, disability or even death.
In Uganda, if the population screening coverage was increased, then a self-HPV community campaign was found more cost-effective than provider collection. (35) When possible, CHW selection should be based on abilities and long term motivation, and their work should be adequately compensated to avoid having inactive workers that need to be replaced by newly trained personnel, which increases the screening cost. (15, 36) Training in October 2019 was more expensive in total than the first session in June 2019; however, the investment is similar if we consider the expense per CHW trained. Improving CHW knowledge is a key factor to a successful recruitment intervention, (18) as was shown with the October session based on a multi-modal training, which was followed by an increase of screened women.
Strategies with multiple visits to get screened, treated, and follow-up can decrease screening effectiveness and can increase the overall cost of cancer prevention per woman due to loss to follow-up (14, 37). In our setting, the 3T strategy led only to a 1.1% loss to follow-up and will probably increase program effectiveness as barriers for Cameroonian women include “low health literacy, poverty, lack of resources, and geographical conditions”. (10) However, additional after-treatment visits may increase the need for CHW, as studies have shown that in-person follow-up could be a cost-effective approach to keep women in the screening process. (14) In this study, we only focused on the cost of screening recruitment; however, further studies will be needed to assess the full financial and social burden and cost-benefit analysis of an HPV “screen and treat” program in Dschang. In Sub-Saharan Africa, most women dying from cervical cancer are around fifty years old and DALYs caused by CC were estimated as 641 years per 100’000 women. (11, 38)
The large sample size and heterogeneity of the population regarding social and demographic characteristics are the major strengths of this study. Real-world conditions and thus the amount paid for equipment, supplies, and labor do not reflect theoretical costs. Health area attribution discordances and village overlap between two health areas/zones could have led to misclassification and inexact cost and recruitment rate estimates, in addition to some miscommunication that led to incorrect patient reimbursement cost. Moreover, measuring the success rate of CHW intervention could have allowed a more detailed analysis of the cost of CHW service. Indeed, the ratio of CHW-approached to screened women is currently unknown. Since recruitment strategies were not led simultaneously, CHW intervention might have enroll less participants as some women had already been informed through CIC. Another limitation is that some women recruited by CHW might have eventually attended screening without CHW intervention, at least we advanced their screening participation.