Setting and study participants

The catchment area for this study included 15 CHPS demarcated zones in the Ga East Municipal of Greater Accra Region, Ghana, with a total of 30 CHNs. In 2015, 15 CHNs were recruited from two subdistricts (Dome and Taifa) in collaboration with officials from the CHPS programme. These CHNs, who had prior working knowledge of community and health resources, participated in a 2-week onsite introductory VIA/cervicography training modelled after the JHIPEGO course used globally,39 plus 3 months smartphone-based mentorship for improving VIA diagnostic and management skills using imaging of the cervix.36 We interviewed all CHNs (n=15) who participated in this study. They had 2 years of nurse training and were employed by the Ghana Health Service that participated in this study. Additionally, we used prospective purposive and criteria sampling techniques to recruit patient participants (n=21, of 169 screened) including those of different ages, those receiving cryotherapy or further treatment (n=6), and from both CHCs. To triangulate data, an expert reviewer and a head nurse were additionally interviewed.

Multiple smartphones were evaluated in a pilot assessment for their quality of imaging, cost and ease of use. The Samsung Duos was the best option available in Ghana at the time of this study with reasonable image resolution, ability to auto and manually focus, LED camera flash and battery life. A protocolised consistent approach to photography and image transfer was established and used throughout. Training in effective photography of the cervix using smartphones and proper lighting and position of patient as well as the camera was provided during the in-person training. During the immediate feedback phase, for each patient, the CHN sent the best image captured to the mentor for feedback; this resulted in an average of 11 images per CHN.

Data collection and procedures

Data collection included semi-structured individual interviews conducted at the CHCs in either English or a local Ghanaian language with a trained professional interpreter. Nine CHNs participated in an additional focus group. CHNs responded to 10 open-ended questions with probes regarding attitudes, perceptions of and experience with onsite training, cervical cancer screening, smartphone imaging of the cervix, a 3-month mentorship via text messaging, opinions on the feasibility of VIA/cervicography screening at CHCs and at the national level, and overall logistical barriers and further recommendations (for interview tool, please see online supplementary file 1). Topics for the expert reviewer and head nurse included logistical barriers, opportunities and experiences with VIA/cervicography training and mentorship. Patients were posed 10 open-ended questions with directing probes regarding knowledge, attitudes and experience with cervical cancer screening, VIA/cervicography or cryotherapy and imaging of the cervix using smartphones, privacy concerns, stigma and perceptions of community members, and suggestions to improve the screening programme (for interview tool, please see online supplementary file 2). Interviewers (RA and AN) had previously worked with CHNs in the CHPS programme, and had prior knowledge of the programme, working conditions and health system characteristics in the CHCs. At the beginning of each interview, it was made clear that the information from the participants would be deidentified with no direct link between interview data and participants’ identifying information so that they could discuss their experience openly. All interviews were audiorecorded. Notes were taken by trained interpreters, translated into English when needed and checked for interpreter accuracy. Informed consent was obtained from all participants. We clarified that participation would not affect participants in any negative way and that they could withdraw answers or from the study at any time and that non-participation would not adversely affect participants.

Data analysis

Data were analysed by two researchers (RA and HC) using a qualitative descriptive approach and content analysis to identify core perceptions, experience and attitudes. We developed preliminary coding, performed critical deliberation about initial codes and reviewed codes for similarities and variations to assure a high level of agreement. Codes fell into distinct but overarching categories. Reviewers independently reviewed and coded all transcripts, then met to review codes, discuss and identify concepts grouped into the specific categories and described and agreed on major important emergent themes. The study was approved by the Noguchi Institute Institutional Review Board in Ghana as well as the IRB of New York University School of Medicine.

Patient and public involvement

At early stage of this study, formal and informal discussions with patients and non-study staff of CHCs were held to better develop the research question and understand the potential impact of research, and factor in their current experience and priorities to the extent they were relevant and possible.

Perception and experiences of community health nurses

Quotes supporting findings on the perceptions and experiences of CHNs can be found in table 1. CHNs viewed the onsite training and its format as effective and comfortable. The majority reported that working with a combination of the speculum, mannequins, real patients and flashcards helped prepare them for actual screenings. Although all agreed that learning the pelvic anatomy was interesting, some mentioned that classroom lectures were not contextual, and that they learnt more working with real patients. Majority stated that it was beneficial that the trainer taught them how to use the speculum, take photos and do the gynaecology exam. Largely, nurses did not feel that financial incentives were needed to encourage learning.

Overwhelmingly, they agreed with adequacy of 3 months mentorship and emphasised the importance of having a back-up expert to further interpret the images and mentor them after the initial onsite training. Although some CHNs expressed anxiety about performing the screenings, almost all agreed that having expert support made them and the patients feel more confident during the process and that the expert reviewer’s responsiveness and individualised support improved their competency. Most CHNs elaborated that seeing positive VIA cases was very important and was integral in learning, but all agreed that negative cases were easier. CHNs also agreed that almost all patients understood when they were told to wait for the expert to confirm a potentially positive or negative case during mentorship period, as feedback was provided by the mentor either immediately or within 24 hours, depending on availability of the mentor. Another helpful aspect of the 3-month training period was peer-to-peer support from colleagues for diagnostic input.

Overall, the CHNs found smartphones easy to use for cervicography and sending photos to the mentor, and experienced few logistical issues (such as issues with SIM cards, texting or network). Electricity outage was an occasional barrier which was largely addressable. Although some nurses had some initial difficulty with taking quality photos, the expert support helped to improve quality of images over time. CHNs elaborated that describing the process to patients and showing them their cervical pictures made them more assured and comfortable with screening. Almost all CHNs felt that smartphone-based cervicography VIA is very easy to integrate into the screening process. Overall, nurses were proud of their work. They suggested a peer support network to discuss pictures and cases. Nurses overwhelmingly mentioned that they would appreciate having a certificate of training completion to mark their achievement and competency.

CHNs believed that more and more people will come to get screened because it has already received attention, and both information and acceptability seem to be increasing in the community. Nurses believed that they are the most appropriate personnel to administer this service, especially considering the sensitive nature of the procedure, and because of the familiarity and trust they have garnered within communities. CHNs acknowledged that potential screening cost would be a barrier, and that assuring the screening was free of charge was important. They reported a general lack of knowledge of cervical cancer and screening as challenges to attracting patients. CHNs reported that some patients believed that screenings were unnecessary because they were asymptomatic. Other barriers to convincing patients included anticipated pain during the procedure, potential cost and fear of knowing about a positive screening result. CHNs reported that educating patients on cervical cancer and screening, and its importance in preventing cancer helped overcome these barriers. CHNs also relied on their existing trusting relationships with patients to encourage screening. They felt that most patients accepted undressing for the exam, with some patients comparing the nudity to the experience of childbirth. CHNs reported that their patients had minimal privacy concerns with having their cervix photographed, since the picture was anonymous and viewed only by the patient, nurse and the expert reviewer.

Overwhelmingly, nurses did not face any major technical challenges in performing VIA. A minority mentioned that it was difficult at times, but manageable, to find the actual cervix. Logistical challenges included the cost of transportation, both for patients and CHNs; at times, securing a steady supply of equipment and resources; the quality of equipment including exam beds and the relatively small size of the screening area which posed minor challenges to maintaining patient privacy. Commonly used medical exam beds were available in all facilities or mobile units. Lighting was supported by stationery medical exam lamps. Bedsheets, gloves, and other supplies and materials for screening were all part of usual supplies in the clinics/health facilities and used based on Ghana’s Ministry of Health recommendations for infection control and OBGYN exam. Smartphones had flashlights and were used for photography in a protocolised fashion developed for this study. None of the CHNs perceived transport time as a barrier for patients; however, the transportation cost was among the most common reasons women missed screening appointments. Almost all CHNs agreed that paying for transportation would improve the screening process. CHNs suggested ways to improve awareness and education by making announcements through radio, TV, newspapers and social media. To improve patient screening participation, they suggested going door-to-door, and reaching out to local churches. They also indicated the need for both nationwide education and community mobilisation. Other improvements of the experience included access to equipment for screening such as better quality, sturdier exam beds; offering screenings at opportune times like when women are at health centres for other reasons, or screening in the community. They suggested expanding screening services to include breast cancer, diabetes and blood sugar levels, hepatitis B and hypertension. Several mentioned a recent reduction in previous services due to a lack of funding, emphasising the importance of keeping these services free to the public.

Perceptions and experiences of the nurse supervisor and expert reviewer

Both the supervisor and expert reviewer generally agreed with CHNs regarding the appropriateness of the training and its incorporation and adequacy of both theoretical and practical trainings. They added the need to reduce the size of the training groups in order to provide more personalised attention to each training during the initial onsite sessions (groups of 6–7 rather than 15–20). This would also allow the trainer to identify and provide targeted attention to different trainees. The expert reviewer did not cite any logistical challenges with receiving and sending images and mentoring and providing feedback. Actually, the reviewer spent some time helping a few CHNs improve the quality of their photos but she did not find this a significant challenge. She found the process very rewarding and elaborated on the importance of providing 3-month remote mentorship to help advance and further polish CHNs’ diagnostic skills as a more practical training that complemented classroom exposure. This in turn improved the reviewer confidence regarding the competence of CHNs and screening quality.

Perception and experiences of patients

Largely, both patients who were screened negative and those who were screened positive and received cryotherapy shared similar perceptions and experiences. Quotes from patients exemplifying each theme are presented in table 2. None of the patients, including the cryotherapy patients, had ever been screened before, and most had no prior knowledge of cancer or screening. For the few with some prior knowledge, past exposure included TV or radio, or informal information from nurses when visiting health facilities on unrelated occasions. Only a small number of patients understood the concept of screening, prevention and the importance of knowing ones’ disease status. Many expressed misconceptions, either their own or beliefs they had heard from others. One patient elaborated on misconceptions, sharing her belief that cervical cancer is caused by inserting things into the vagina. Other misconceptions about screening included worrying about being ‘clean’ or ‘neat’ enough to be screened or that nurses would put their hands inside patients. Most patients did not discuss the screening with anyone, and decided to participate in the screening on their own. Only a few asked partners for approval and the majority reported that their husbands or partners supported their decision. They elaborated that some men did not think the screening was relevant to them; however, most, but not all, men in the community support screening. A few said that some men had issues with it but generally if women decided to get screened, then they could find a way without their partner’s approval.

Most patients appreciated cervical photography and wanted to see the picture of their own cervix. For many, the photos helped answer their questions and, for some, it reassured them about the procedure. Some women wanted to take their cervical images to show to their partners or keep as a record. Therefore, if and when patients requested to have their cervical digital images and had a smartphone, providers allow them to take the picture or transferred images securely to the patient’s smartphone. These images were all deidentified and anonymised. Printing images was not possible or provided. Due to the anonymity, the majority were comfortable with having pictures taken. Only one patient had questions and requested reassurance about potential sharing of her images on the internet. Most others trusted the CHNs and understood and agreed with the process of smartphone-based VIA. Patients were generally appreciative of CHNs’ persistence in educating them and addressing misunderstandings and misconceptions through describing the screening process, cancer detection and treatment, and relaying the importance of prevention. Some patients mentioned that the CHNs showing pictures of cancerous lesions and describing risk factors for cervical cancer was often effective in encouraging screening. The majority of patients reported little or no stigma from relatives or community members for getting screened. Although most patients stated that a large number of women in the community support screenings, some alluded that barriers included embarrassment or shyness and low health literacy. While some women discussed misconceptions in their community regarding the procedure itself, most clients were optimistic that more men and women would support the screening if they were educated more about the procedure.

Majority of clients had no specific expectations of the screening prior to their procedure, and they largely trusted the CHNs as health professionals. Overall, clients found it easier, shorter, and less painful than expected. Some expected a much more complicated or painful procedure such as that the uterus to be taken out and washed and inspected. Although a few experienced initial discomfort, it was often relatively minor and short-lived. None of the clients had any significant logistical barriers during the screening. A few mentioned issues with transport cost, the majority thought that screening time was reasonable, and appreciated the screening being free. Some clients skipped work to be screened. Majority of clients were happy with the screening, and did not offer any specific recommendations for improvement. Some clients inquired about and suggested providing breast cancer screening. Most of them acknowledged it was important to have more announcements and awareness, in one case suggesting that nurses go house to house in order to educate people. Individual women who received cryotherapy after screening positive through VIA cited positive experiences with the process and did not report any specific privacy issues, or additional pain or discomfort or logistical barriers.

Limitations

Our study was not without limitations. Although the CHPS programme in Ghana was based on previous service delivery models from rural areas, the two pilot study areas were part of an expansion of the programme, in which the model was adapted to peri-urban and urban areas. Thus, findings may not be generalisable to rural areas, particularly given differences by region in access to social and healthcare resources. As this evaluation was a pilot study to evaluate the effectiveness of using mHealth strategies to extend and improve training in VIA to CHNs, additional challenges may be associated with scaling up such an intervention to larger areas. Additionally, there is a possibility of bias towards acceptability of the intervention. However, we included all CHNs in two facilities rather than relying on a self-selected sample, and patients were recruited using criteria sampling. We also included all clients who received cryotherapy to explore their views towards the screening and treatment strategies. Finally, this qualitative study by its nature only generates hypotheses which need to be further tested quantitatively for validity and generalisability. Nevertheless, we were able to observe existing community perceptions through the lens of participating patients and nurses as they were also asked and subsequently elaborated on views and perceptions from their own community different or consistent with that of their own.