Challenges associated with follow-up care after implementation of an HPV screen-and-treat program with ablative therapy for cervical cancer prevention in Iquitos, Peru: a mixed methods study

Abstract

Background: Cervical cancer is a preventable cancer; however, decreasing its prevalence requires early detection and treatment strategies that reduce rates of loss to follow-up. This study explores factors associated with loss to follow-up among HPV-positive women after implementation of a screen-and-treat approach with visual triage and ablative therapy for cervical cancer prevention in Iquitos, Peru.

Methods: We conducted semi-structured interviews with nurse-midwives (n = 15) working in cervical cancer prevention and women (n = 24) who were recorded as lost to follow-up after positive HPV results. We used the Health Care Access Barriers Model to guide analysis. We utilize manifest content analysis to describe barriers to follow-up according to the nurse-midwives and thematic analysis to report themes from the women's perspectives. We also report the steps and time taken to contact women and report discrepancies and concordances between nurse-midwives and women regarding reasons for loss to follow-up.

Results: Women in this study expressed a desire to receive treatment. Barriers, including fragmented and incomplete registry systems, made receiving follow-up care more challenging. Nurse-midwives faced structural barriers in attempting to deliver positive results to women who were challenging to contact, and women did not have clear knowledge of how to receive their HPV results. Women faced cognitive barriers including a lack of understanding about HPV results and treatment procedures, fear or anxiety about HPV or treatment, and confusion about the follow-up process. Women also reported having important work matters as a barrier. Reported financial barriers were minimal. There was agreement between women's and nurse-midwives' reported barriers to follow-up in slightly over half of the cases.

Conclusion: This study highlights the barriers to follow-up after implementation of a primary-level HPV-based screen-and-treat approach. While some barriers that have previously been associated with loss to follow-up were not observed in this study (e.g., financial), we emphasize the need for screen-and-treat programs to focus on strategies that can address incomplete registry systems, structural challenges in results delivery, cognitive barriers in understanding results and treatment, and work-related barriers.

Keywords: Cervical Cancer; HPV Screening; Lost to follow-up; Screen-and-treat.

Figure 1

A summary of the processes for data collection. The yellow boxes depict action taken during the data collection process, the gray boxes describe the data source, and the blue boxes show the data collection.

Figure 2

Continuum of care model depicting where women were LTFU or completed care according to the nurse-midwives

Figure 3

Summary of barriers to the completion of care according to the nurse-midwives

Figure 4

Summary of the process of finding women for interviews

Figure 5

Summary of the number of women successfully contacted by nurse-midwives, the researcher, both, or neither

Figure 6

Continuum of care model depicting where women were LTFU or completed care according to the women themselves

Figure 7

Depiction of the agreement and disagreement in reasons for loss to follow-up between nurse-midwives and women