An integrated community-clinic model of optimized implementation strategies to increase early detection of breast and cervical cancers in Kenya

项目概要/摘要 肯尼亚的乳腺癌和宫颈癌发病率很高，大多数妇女被诊断为晚期乳腺癌。 阶段性疾病实施有效的计划来筛查和早期发现这些癌症， 大大降低了高死亡率。肯尼亚一直在增加癌症筛查的可及性， 超过六分之一的合格妇女接受过乳腺癌和宫颈癌筛查。 研究的目的是评估多组分战略的有效性和成本效益 以增加乳腺癌和宫颈癌筛查的接受率。一个关键的差距， 在肯尼亚，导致筛查率下降的主要原因是缺乏社区-诊所联系。有证据表明，女性往往 不知道设施中提供的筛查服务，而且，即使在那些知道的人中， 的动机，预期或感知的耻辱，并降低自我效能进行筛查。我们将 进行一项实用的随机分组试验，以评估筛查结果，包括筛查 接受、诊断测试完成、治疗启动和实施结果，以支持量表- 起来我们将测试两个多成分的策略包：（1）癌症社区-诊所联系（C3 Link） 核心：社区卫生志愿者-为妇女和家庭成员提供集体教育， 在社区环境和实践中增加筛查的使用，以改善筛查 在诊所环境中处理和发展以CHV参与的团队护理;（2）C3 Link Plus：C3 Link 核心策略沿着一系列连续的个体策略，这些策略在3个月时强度增加 间隔;未接受筛查的妇女将首先接受一对一的教育;第二，激励 最后是解决具体障碍的导航。 我们将在肯尼亚27个社区开展这项研究，以解决以下三个具体问题： 目的：目的1：进行一项随机分组试验，以评估短期（干预实施阶段） 两套多成分战略对乳腺癌的长期影响（维持阶段） 和宫颈癌筛查结果沿着护理的连续性相比， 目标2：使用混合方法评估 并比较注重可接受性的一揽子战略的多层次执行结果， 可行性、适当性、忠诚度和可持续性;目标3：实现成本效益和回报率- 进行投资分析，以支持在肯尼亚各地扩大有效的一揽子执行战略 以及其他撒哈拉以南非洲国家。肯尼亚卫生部可以利用这项研究的结果， 设计筛选基础设施的最佳方法和投资计划， 指南建议。所吸取的经验教训可适用于撒哈拉以南非洲的其他环境。

PROJECT SUMMARY/ABSTRACT Kenya has a high incidence of breast and cervical cancers, and most women are diagnosed with late- stage disease. Implementing effective programs to screen and detect these cancers at an early stage could substantially decrease the high mortality. Kenya has been increasing access to cancer screening, but less than one-sixth of eligible women have ever received breast and cervical cancer screening. The goal of the study is to assess the effectiveness and cost-effectiveness of multicomponent strategies to increase the uptake of breast and cervical cancer screeening. A key gap that perpetuates the low screening rates in Kenya is the lack of community–clinic linkages. There is evidence that women are often unaware of the screening services offered in facilities, and, even among those who are aware, there is lack of motivation, anticipated or perceived stigma, and reduced self-efficacy to undergo screening. We will conduct a pragmatic cluster randomized trial to evaluate the screening outcomes, including screening uptake, diagnostic test completion, and treatment initiation and implementation outcomes to support scale- up. We will test two multicomponent packages of strategies: (1) Cancer Community–Clinic Linkage (C3Link) Core: Community health volunteer (CHV)-delivered group education for women and family members to increase screening uptake in the community setting and practice facilitation to improve the screening process and develop team-based care with CHV participation in the clinic setting; (2) C3Link Plus: C3Link Core strategies along with a sequential series of individual strategies that increase in intensity at 3-month intervals; women who remain unscreened will first receive one-on-one education; second, motivational interviewing; and, finally, navigation to address specific barriers. We will implement the study across 27 communities in Kenya to address the following three specific aims: Aim 1: Conduct a cluster randomized trial to assess short-term (intervention implementation phase) and longer-term impacts (maintenance phase) of the two packages of multicomponent strategies on breast and cervical cancer screening outcomes along the continuum of care compared to enhanced standard of care (communities receiving a messaging campaign only); Aim 2: Use a mixed-methods approach to assess and compare multilevel implementation outcomes of the package of strategies focusing on acceptability, feasibility, appropriateness, fidelity, and sustainability; Aim 3: Perform cost-effectiveness and return-on- investment analysis to support scale-up of an effective package of implementation strategies across Kenya and other sub-Saharan African countries. The Kenyan Ministry of Health can use the findings from this study to design optimal approaches and plan investments in screening infrastructure to scale up implementation of guideline recommendations. The lessons learned can be applied to other sub-Saharan African settings.