Strategies for primary HPV test-based cervical cancer screening programme in resource-limited settings in India: Results from a quasi-experimental pragmatic implementation trial
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Background: In order for low and middle income countries (LMIC) to transition to Human Papilloma Virus (HPV) test based cervical cancer screening, a greater understanding of how to implement these evidence based interventions (EBI) among vulnerable populations is needed. This paper documents outcomes of an implementation research on HPV screening among women from tribal, rural, urban slum settings in India. Methods: A mixed-method, pragmatic, quasi-experimental trial design was used. HPV screening on self-collected cervical samples was offered to women aged 30–60 years. Implementation strategies were 1) Assessment of contextual factors using both qualitative and quantitative methods like key informant interviews (KII), focus group discussions (FGDs), pre-post population sample surveys, capacity assessment of participating departments 2) enhancing provider capacity through training workshops, access to HPV testing facility, colposcopy, thermal ablation/cryotherapy at the primary health care centers 3) community engagement, counselling for self-sampling and triage process by frontline health care workers (HCWs). Outcomes were assessed using the RE-AIM (Reach, Effectiveness, adoption, implementation, maintenance) framework. Results: Screening rate in 8 months’ of study was 31.0%, 26.7%, 32.9%, prevalence of oncogenic HPV was 12.1%, 3.1%, 5.5%, compliance to triage was 53.6%, 45.5%, 84.6% in tribal, urban slum, rural sites respectively. Pre-cancer among triage compliant HPV positive women was 13.6% in tribal, 4% in rural and 0% among urban slum women. Unique challenges faced in the tribal setting led to programme adaptations like increasing honoraria of community health workers for late-evening work and recalling HPV positive women for colposcopy by nurses, thermal ablation by gynaecologist at the outreach camp site. Conclusions: Self-collection of samples combined with HCW led community engagement activities, flexible triage processes and strengthening of health system showed an acceptable screening rate and better compliance to triage, highlighting the importance of identifying the barriers and developing strategies suitable for the setting. Trial registration: CTRI/2021/09/036130.
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Home or community-based screening has been evaluated in many countries and is now part of screening policy and routine practice in many countries, and this has led to improved screening rates among unscreened women.
“This has led to improved screening rates among unscreened women.8 9 16 18 48”
From Protocol for a cervical screening implementation trial comparing two approaches for delivering HPV self-collection in low-resource settings in India: a type 3 hybrid cluster randomised controlled trial (SHE-CAN) (2025) · cites this paper as [16]
The Discussion reports about 30% screening uptake in eight months with the self-sampling programme, compared with 6–8% annually under the existing visual-inspection programme at the rural site. Results show that most participants had not been screened in the previous three years, but the paper does not establish an improvement specifically among never-screened women or isolate the effect of home- or community-based screening from the programme’s other components. (LLM, conf=0.82)
Experimental — accuracy not yet measuredVulnerable groups such as tribal populations have shown a higher prevalence of HPV infection and face significant challenges to screening and follow-up.
“Vulnerable groups such as tribal populations have shown a higher prevalence of HPV infection and also face significant challenges to screening and follow-up.16 19”
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- Authors
- Oommen, A. M., Isaac, R., Paul, B., Weller, D., Finkel, M. L., Thomas, A., Ram, T. S., H. R., P., Cherian, A. G., Thomas, V., Sadan, V., Siva, R., Rose, A., Marcus, T. A., Jeyapaul, S., K., S. R., Malini, T., N., S., Jebaraj, P., John, N. O., Ramesh, C., Raj C., J. J., Kumar S., R., B. V., B., Dorathy P., I., Murali, V., N., P., K., K., & Ranjani D., P.
- Affiliations
- Christian Medical College, Vellore (IN)
- University of Edinburgh (GB)
- Weill Cornell Medicine (US)
- Corresponding author
- Isaac, Rita
- ORCID
- Venue
- PLOS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2024-04-05
- Volume
- 19
- Issue
- 4
- Pages
- e0301385
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC10997089
- OpenAlex
- W4393995202
- Cited by
- 18
- References
- 20
- Citations by year
- 2026: 9 · 2025: 5 · 2024: 4
- FWCI
- 5.49
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS ONE (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Prevent Cancer Foundation (16/136/109)
- Topics
- Health Sciences › Medicine › Epidemiology › Cervical Cancer and HPV Research
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Women's cancer prevention and management
- Keywords
- HPV-based cervical cancer screening, self-collected cervical samples, implementation strategies, resource-limited settings, tribal women, rural women, community health workers, colposcopy, thermal ablation, cryotherapy, RE-AIM framework, India
- MeSH terms
- Resource-Limited Settings, Uterine Cervical Dysplasia, Uterine Cervical Neoplasms, Colposcopy, Female, Humans, India, Mass Screening, Pregnancy, Papillomaviridae, Papillomavirus Infections, Early Detection of Cancer
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