10.5061/DRYAD.THT76HDXF
Olwanda, Easter
0000-0002-3158-9415
Kenya Medical Research Institute
Khan, James
University of California, San Francisco
Choi, Yujung
Duke University
Islam, Jessica
0000-0002-3690-3848
University of North Carolina
Huchko, Megan
Duke University
Comparison of the costs of HPV testing through Community health campaigns
versus Home-based testing in rural western Kenya: A micro-costing study
Dryad
dataset
2020
FOS: Health sciences
National Cancer Institute
https://ror.org/040gcmg81
R01-CA188428
2020-09-30T00:00:00Z
2020-09-30T00:00:00Z
en
29250047 bytes
5
CC0 1.0 Universal (CC0 1.0) Public Domain Dedication
Objectives: To estimate the cost of HPV-based screening through Community
health campaigns (CHCs) and home-based testing. Setting: Community health
campaigns (CHCs) and home-based testing in six communities in rural
western Kenya. Participants: CHCs and home-based screening reached 2297
and 1002 women aged 25 to 65 years respectively. Outcome measures: Outcome
measures were overall cost per woman screened achieved through the CHCs
and home-based testing, and the cost per woman for each activity
comprising the screening intervention. Results: The mean cost per woman
screened through CHCs and home-based testing were similar, at $37.7 (range
$26.4 - $52.0) and $37.1 (range $27.6 - $54.0), respectively. For CHCs,
personnel represented 49% of overall cost, supplies 25%, services 5%, and
capital goods 23%. For home-based testing, these were: personnel 73%,
supplies 25%, services 1%, and capital goods 2%. A greater number of
participants was associated with a lower cost per participant.
Conclusions: The mean cost per woman screened is comparable for CHC and
home-based testing, with differences in type of input. The CHCs generally
reached more eligible women in the 6 communities, whereas home-based
strategies more efficiently reached populations with low screening rates.
This micro-costing study was part of a two-phase cluster-randomized trial
in Nyanza, Kenya to determine the uptake rates of implementation
strategies for HPV self-testing. Between February and October 2018, six
rural communities were offered HPV screening through Community Health
Campaigns (CHCs). We defined a community as one or two sub-locations
within a defined administrative boundary. Each community had a total
population size of between 4500 to 9500 and had either a level II, III or
IV Ministry of Health facility. Though each community had between 10-12
villages, we only measured costs at the community level. Women aged
between 25 and 65 years who did not screen at the CHCs (46.4% of the
target populations) were offered home-based screening in November 2018.
The implementation strategy for both CHCs and home-based testing
consisted, in different intensities, of outreach and mobilization,
screening, and notification of results. In all communities, we informed
all the eligible women about CHC based screening first through community
outreach. We then conducted a second outreach for the home-based testing
to reach the women who did not screen at the CHCs. We offered HPV-testing
through self-collection to women from both CHCs and home-based testing.
Outreach for the CHCs were conducted for two weeks before the screening
services were available and involved door-to-door mobilization and
meetings with key stakeholders. Resources used were the study vehicle,
fuel, and personnel, including two research assistants, ten community
health volunteers (CHVs), one study coordinator, one study driver, and one
study administrator. Resources used were similar across the six
communities, except for two (Olasi and Osingo) where the study vehicle
broke down, requiring transport reimbursement for the research assistants.
For home-based testing, outreach and mobilization took place concurrently
with screening. At least ten CHVs from each community, accompanied by the
research assistants, identified the homes of eligible women who did not
screen at the CHCs and offered them the HPV self-collection kits to be
completed at home. Activities dedicated to screening included
registration, group education, informed consent, and HPV self-collection.
A multi-disciplinary team that included experts in cervical cancer
prevention, health care providers with knowledge of community strategies,
and CHVs with experience delivering health education in Kenya
conceptualized and designed an education module. The education module was
delivered before screening for both the CHCs and homes to educate the
women on anatomy, definitions of cervical cancer and HPV, how screening
works, how to conduct self-HPV testing, result interpretation and the
available treatments. A positive test result meant having a type of
high-risk HPV that is linked to cervical cancer. We strongly emphasized
early treatment to prevent that progression to cervical cancer in the
future. Follow-up test was recommended in a year or three years for HIV
positive and negative women respectively, to see if the infection had
cleared or to check for signs of cervical cancer. The HPV screening
campaigns lasted ten days per community for the CHCs and four days per
community for home-based testing. The CareHPV™ testing system used was not
a point-of-care test therefore the collected specimens were transported
daily from the CHCs and homes to the study laboratory at Migori County
Hospital for processing. The tests were run in batches of 90, with a
turnover time of approximately 1–2 weeks for the women from both sites to
know their results. Options for notification of results included: home
visits, text messaging, and phone calls. However, there were
implementation differences between the two strategies during notification.
At the CHCs, both HPV-positive and negative women who opted for home
visits were notified by the research assistants over ten days per
community. The study vehicle was used for transport during notification in
four of the six communities. For women screened at home, the CHVs
conducted home visits for HPV negative women while the assistant study
coordinator conducted home visits for the HPV-positive women using the
study motorbike. The hrHPV positivity rate in this population was 17%. A
total of 505 women tested positive for hrHPV. hrHPV-positive women from
both the CHCs and home-based testing were referred to one of four
government health facilities based on proximity to their community for a
visual exam with acetic acid and treatment with cryotherapy/LEEP per the
WHO guidelines. The government health facilities were Migori County
Referral Hospital, Macalder Sub-County Hospital, Ogwedhi Health Centre and
Karungu Sub-County Hospital. Timely and effective linkage to
cryotherapy/LEEP treatment for both screening strategies was achieved by
decentralization of treatment centers, making follow up phone calls and
sending text message reminders to the hrHPV women who had received their
HPV test result but had not yet accessed treatment within one month. These
strategies were developed in collaboration with the Ministry of Health and
based on feedback from health-care providers and participants in the
ongoing study. Costing methods We applied micro-costing methods from the
provider’s perspective to estimate the delivery cost of HPV screening in
CHCs and home-based testing. We adopted an economic perspective, whereby
all resources were costed at full value even if donated or subsidized. We
enumerated the resources used, multiplied by the price paid or market
quotes, and summed to estimate the total cost in each community, and
finally divided by the total number of screening participants to arrive at
unit costs per woman screened. All costs are reported in U.S. dollars,
converted from Kenyan shillings at a commercial exchange rate of 101.7
Kenyan shillings per U.S. dollar (17 January 2018). We classified
resources into four main input categories: personnel, recurrent supplies,
services, and capital goods. We estimated personnel compensation from
project financial records. For staff with multiple responsibilities, we
obtained information on the time dedicated to the interventions via
interviews (e.g., for outreach and notification activities), supplemented
by time and motion data (collected during screening activities). When the
two methods covered the same issue, e.g. hours per week on different
tasks, we relied on time and motion data, which was collected in
real-time. Recurrent supplies refer to items consumed within one year as
well as longer-lived resources of low value. These included careHPVTM
(QIAGEN Inc., Gaithersburg, MD; USA) collection media, test kits and
brushes, pipette tips, motor vehicle fuel, and staff t-shirts. Services
include expenditures on consultant fees, IT support, utilities, and
vehicle maintenance. We estimated the cost of recurrent supplies and
services from expenditure records, and then conducted interviews with the
staff to establish allocation across different functions and time periods.
Capital goods and equipment are items with more than one year of useful
life and value of >$250; examples study vehicle, careHPV™ test
system, study motorbike and tablets. Costs of capital goods were amortized
on a 0% real discount rate basis over five years (useful life) assuming no
salvage value. We extracted cost information from expenditure records and
study logs, supplemented by interviews with administrative staff and the
team that delivered the services at each site. For both the CHCs and
home-based testing, we collected time and motion data daily on paper-based
forms to estimate personnel time spent on CHC activities. We omitted time
explicitly used for research, including regulatory activities and
administering research questionnaires. We enumerated the items (based on
numbers used for the community), multiplied the number by the cost of each
item whether purchased or donated, and estimated unit (per-screening)
costs from the sum of costs. Once total economic cost of each item was
calculated, each cost item was further allocated to program and
non-program purposes. To arrive at a unit cost (per completed screening),
total economic cost of each item that was designated for program purposes
was divided by the number of women screened at each community. Using the
unit-cost estimations, the micro-costing data was then aggregated to
estimate total costs per woman screened at a CHC and Home-based testing.
In the costing analyses, we compared costs across the six CHC communities,
and conducted a similar comparison across the six Home-based testing
communities. The costs per woman screened at each community was broken
down by type of costing input (personnel, services, recurrent goods,
capital), and phase (outreach, screening, and notification). Outcome
measures were overall cost per woman screened achieved through the CHCs
and home-based testing, and the cost per woman for each activity
comprising the screening intervention. The overall cost per woman screened
was calculated by dividing the total cost of all six sites, designated for
program purposes, by population uptake of HPV-based screening.
There are no missing values.