Integration of cervical cancer screening into healthcare facilities in low- and middle-income countries: a scoping review protocol

Abstract

Background

Cervical cancer is the fourth most common malignancy in women, with 90% of deaths in low- and middle-income countries. Integrating cervical cancer screening services into healthcare facilities is crucial for overcoming the disease. Thus, this review aims to map existing evidence and identify barriers and facilitators in low- and middle-income countries.

Methods

The scoping review will employ a five-step framework as proposed by Arksey and O’Malley. These are (1) formulating the research questions, (2) identifying relevant studies, (3) selecting eligible studies, (4) charting the data, and (5) collating, summarising and reporting the results. Five databases (MEDLINE, Maternity and Infant Care, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science) will be systematically searched. Grey literature will also be searched. Data will be extracted, charted, synthesised and summarised.

Ethics and dissemination

This review does not require ethics approval. Findings will be disseminated through peer-reviewed publications, policy briefs and conference presentations.

STRENGTHS AND LIMITATIONS OF THE STUDY.

• The review will involve a rigorous search and screening process aimed at maximising comprehensiveness while minimising bias.

• The protocol followed a well-established methodological framework, ensuring the production of a high-quality review.

• The study will examine the risk of bias in the individual study using a relevant tool.

• The review will be limited to publications in selected languages, potentially biasing studies published in other languages.

Introduction

Cervical cancer is the fourth most common malignancy among women globally.^{1 2} There were reportedly 604 127 new cervical cancer cases in 2020 worldwide and, the age-standardised incidence rates were highest in eastern Africa, followed by Southern Africa and Middle Africa.³ About 90% of the projected 342 000 deaths from cervical cancer in 2020 occurred in low-income and middle-income nations.^{3 4}

Cervical cancer is preventable and curable, as long as it is detected early and managed effectively.⁵ Quick and accurate cervical cancer screening programmes are critical so that every woman with cervical disease gets the treatment she needs, and avoidable deaths are prevented.⁶ However, the screening coverage of eligible women in most low- and middle-income countries (LMICs) is on average 19%, compared with 63% in high-income countries.⁷ A wide range of barriers, such as lack of knowledge and awareness of cervical cancer, cultural/traditional and religious factors, and health system barriers to screening, were identified across most LMICs.⁸

Integrating the available cervical cancer screening service into the primary care packages in healthcare facilities is one of the solutions recommended by the WHO⁹ to overcome the burden related to cervical cancer in LMICs.¹⁰ Therefore, the availability of integrated screening services in healthcare facilities can be used as an opportunity for those women who visit the facilities for different reasons as well as to achieve the 2030 cancer elimination goal (90-70-90 strategy) by the WHO. These are 90% of women should get vaccinated, 70% of age-eligible women should get screened and 90% of women who are diagnosed positive for screening should get treatment in 2030.¹¹ Integrated service delivery offers various potential benefits such as improved quality of care, improved efficiency in service provision, increased uptake of a range of sexual and reproductive health services, cost-effective use of resources and increased client satisfaction.^{12 13}

Even though several studies^14–19 were conducted on cervical cancer screening uptake among women in LMICs, to the best knowledge of the investigators, the availability of comprehensive evidence on integration of cervical cancer screening into healthcare facilities of LMICs is very limited. Therefore, the aim of this scoping review is (1) to summarise the existing evidence on the integration of cervical cancer screening into healthcare facilities and (2) to identify barriers and facilitators associated with the integration of cervical cancer screening programmes in LMICs.

Methods

Protocol design

This review will be guided by the scoping review framework proposed by Arksey and O’Malley.²⁰ The framework consists of five steps such as (1) formulating the research questions, (2) identifying relevant studies, (3) selecting eligible studies, (4) charting the data and (5) collating, summarising and reporting the results as described below.

Formulating the research questions

Our research questions were developed and refined through an iterative process and consultations held by the multidisciplinary research team. The following questions will be addressed by this scoping review: (1) what is the existing evidence on the integration of cervical cancer screening programmes into healthcare facilities in LMICs? and (2) what are the barriers and facilitators associated with the cervical cancer screening integration programmes in LMICs?

Identifying relevant studies

The search strategy will include terms that covere healthcare facilities, integration of cervical cancer screening and LMICs (online supplemental material 1). The search strategy will be piloted to ensure the appropriateness of proposed keywords and databases. Both peer-reviewed and non-peer-reviewed literature published since 2000 will be retrieved, which was a starting point for the implementation of Millennium Development Goals (MDGs) that included achieving universal access to reproductive health by 2015.²¹

A comprehensive literature search will be conducted on the following five electronic databases such as MEDLINE, Maternity and Infant Care, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science. The reference lists of published articles will be scrutinised for additional relevant publications. A manual searches of the articles’ reference lists will also be conducted to identify additional potentially eligible studies not found in the databases.

Selecting eligible studies

Inclusion criteria

The eligibility criteria were set based on population, concepts and contexts (PCC) framework described by Joanna Briggs Institute (JBI) which was proposed by Peters et al,²² shown in table 1. Regarding the study type, we plan to include all primary studies published in a peer-reviewed journal that is accessible online and through interlibrary requests. Such studies could include randomised trials, observational studies, cross-sectional studies, case studies and laboratory studies. Articles with non-English language and non-journal articles will be excluded.

Table 1.

Inclusion criteria using the population, concepts and contexts (PCC) framework

Criteria	Description
P-Population	Specialised hospitals General hospitals Primary hospitals Central hospitals Health centres Clinics Primary care clinics Primary care services (MCH, HIV service, TB service, NCDs clinic, Outpatient clinic, Reproductive health services, FP, routine genecology service)
C-Concept	Cervical cancer screening integration Barriers and facilitators of cervical cancer screening integration
C-Context	Studies: Conducted in low- and middle-income countries30 Published since 2000 Written in English All primary studies (quantitative, qualitative and mixed-method published articles Quantitative (cross-sectional/observational), Qualitative (phenomenology, case study) and Mixed-method published articles

FP, Family Planning; MCH, Maternal and child health; NCDs clinic, Noncommunicable diseases clinic; TB service, Tuberculosis management service.

All eligible articles will be uploaded into Endnote 20 reference management software,²³ and duplicates will be identified and removed. Title and abstract screening and full-text reviews will be done independently by two researchers (RNK and DMS) using Covidence. A third reviewer will be employed if there are significant discrepancies that cannot be resolved by discussion and consensus. Then, reference lists of potentially relevant publications will be manually searched. When the full text of potentially relevant publications could not be located, two attempts will be made to contact the author(s) via email to request a copy.

Charting the data

A spreadsheet of key factors will be developed to extract relevant data from each included study. Two authors (RNK and DMS) will test and refine the data extraction tool using 10 eligible studies before its use. The extracted data will include key variables such as (1) author(s), (2) publication journal and year, (3) aim(s) or research question, (4) study setting, (5) study design, (6) data source, (7) data collection methods, (8) data analysis, (9) participant characteristics, (10) key findings and (11) limitations.

Collating, summarising and reporting the results

Findings of the scoping review will be presented using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA–ScR) guidelines.²⁴ A PRISMA flow diagram will be used to demonstrate the literature study selection process and search results. A descriptive numerical summary will be used to present the characteristics of the included studies. A qualitative thematic synthesis will also be conducted. The results will be classified under the main conceptual categories, such as ‘integration of cervical cancer screening’ and ‘facilitators and barriers to the integration programme’. Under each category, we will further provide data on the article’s characteristics, including but not limited to the total number of studies, types of study design, source of data, year of publications and key findings. Tables and figures will be used to present the results in line with the aims of the scope of the review. The implication of the results will be elaborated in light of research and practice to help us identify gaps in cervical cancer screening in LMICs.

Quality assessment

JBI quality appraisal tools^25–29 will be used to assess the methodological quality of research publications by evaluating the extent to which they addressed the possibility of bias in areas of study design, conduct and analysis (online supplemental material 2). The magnitude of studies with a total score indicating poor quality will be discussed. Two researchers (RNK and DMS) will independently assess each included paper, and any uncertainty regarding the quality of publications will be resolved through discussion. Although a formal assessment of the methodological quality of the included studies will be performed, articles with poor quality will not be excluded.

Ethics and dissemination

Since the scoping review methods involve reviewing and collecting data from publicly available materials, this study will not require ethics approval. Findings will be disseminated through a peer-reviewed publication and policy briefs, and the research team will present the findings to key health system stakeholders in LMICs.

Data availability statement

All the relevant data are within the manuscript itself.

Ethics statements

Patient consent for publication

Not applicable.