title: Effect of self-collection of HPV DNA offered by community health workers at home visits on uptake of screening for cervical cancer (the EMA study): a population-based cluster-randomised trial.
abstract: BACKGROUND
  Control of cervical cancer in developing countries has been hampered by a failure to achieve high screening uptake. HPV DNA self-collection could increase screening coverage, but implementation of this technology is difficult in countries of middle and low income. We investigated whether offering HPV DNA self-collection during routine home visits by community health workers could increase cervical screening.
  
  
  METHODS
  We did a population-based cluster-randomised trial in the province of Jujuy, Argentina, between July 1, 2012, and Dec 31, 2012. Community health workers were eligible for the study if they scored highly on a performance score, and women aged 30 years or older were eligible for enrolment by the community health worker. 200 community health workers were randomly allocated in a 1:1 ratio to either the intervention group (offered women the chance to self-collect a sample for cervical screening during a home visit) or the control group (advised women to attend a health clinic for cervical screening). The primary outcome was screening uptake, measured as the proportion of women having any HPV screening test within 6 months of the community health worker visit. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02095561.
  
  
  RESULTS
  100 community health workers were randomly allocated to the intervention group and 100 were assigned to the control group; nine did not take part. 191 participating community health workers (94 in the intervention group and 97 in the control group) initially contacted 7650 women; of 3632 women contacted by community health workers in the intervention group, 3049 agreed to participate; of 4018 women contacted by community health workers in the control group, 2964 agreed to participate. 2618 (86%) of 3049 women in the intervention group had any HPV test within 6 months of the community health worker visit, compared with 599 (20%) of 2964 in the control group (risk ratio 4·02, 95% CI 3·44-4·71).
  
  
  CONCLUSIONS
  Offering self-collection of samples for HPV testing by community health workers during home visits resulted in a four-fold increase in screening uptake, showing that this strategy is effective to improve cervical screening coverage. This intervention reduces women's barriers to screening and results in a substantial and rapid increase in coverage. Our findings suggest that HPV testing could be extended throughout Argentina and in other countries to increase cervical screening coverage.
  
  
  BACKGROUND
  Instituto Nacional del Cáncer (Argentina).
authors.affiliation: Consejo Nacional de Investigaciones Científicas y Técnicas, and Centro de Estudios de Estado y Sociedad, Buenos Aires 1193, Argentina. Electronic address: silviarrossi2020@gmail.com.
authors.forename: Silvina
authors.initials: S
authors.lastname: Arrossi
authors.affiliation: Instituto Nacional del Cáncer (Argentina), Buenos Aires 1067, Argentina.
authors.forename: Laura
authors.initials: L
authors.lastname: Thouyaret
authors.affiliation: International Agency for Research on Cancer, Lyon 69372, France.
authors.forename: Rolando
authors.initials: R
authors.lastname: Herrero
authors.affiliation: Ministerio de Salud de la Provincia de Jujuy, San Salvador de Jujuy 4600, Argentina.
authors.forename: Alicia
authors.initials: A
authors.lastname: Campanera
authors.affiliation: Ministerio de Salud de la Provincia de Jujuy, San Salvador de Jujuy 4600, Argentina.
authors.forename: Adriana
authors.initials: A
authors.lastname: Magdaleno
authors.affiliation: Instituto Nacional del Cáncer (Argentina), Buenos Aires 1067, Argentina.
authors.forename: Milca
authors.initials: M
authors.lastname: Cuberli
authors.affiliation: Instituto Nacional del Cáncer (Argentina), Buenos Aires 1067, Argentina.
authors.forename: Paula
authors.initials: P
authors.lastname: Barletta
authors.affiliation: Programa Nacional de Prevención de Cáncer Cervicouterino, Buenos Aires 1002, Argentina.
authors.forename: Rosa
authors.initials: R
authors.lastname: Laudi
authors.affiliation: Instituto Nacional del Cáncer (Argentina), Buenos Aires 1067, Argentina.
authors.forename: Liliana
authors.initials: L
authors.lastname: Orellana
mesh_terms: D000328:Adult; D000368:Aged; D001118:Argentina; D003153:Community Health Services; D005260:Female; D006792:House Calls; D006801:Humans; D008403:Mass Screening / Q000379:methods / Q000706:statistics & numerical data*; D008875:Middle Aged; D030361:Papillomavirus Infections / Q000175:diagnosis*; D012648:Self Care; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis*; D014626:Vaginal Smears / Q000706:statistics & numerical data*