By Moreen Njoroge, T-19

Cervical cancer is the second most common cancer in women worldwide and the most common cancer among women in sub-Saharan Africa. The risk for cervical pre-cancer and cancer is increased by the biological effects of co-infection with HIV and HPV, both of which have a higher prevalence in sub-Saharan Africa and especially in Migori, Kenya where the seroprevalence of HIV/AIDS is not uncommon. The social and economic factors in Migori, Kenya make cervical cancer control more difficult to achieve with the established standard of care in developed countries. A major barrier to accessing screening and treatment services for cervical cancer in this region is poor health literacy associated with the lower educational-attainment rates in Kenya, especially for women. Structural barriers associated with increased cervical cancer mortality rates include lack of diagnostic tools for screening, understaffing in clinics and hospitals, a paucity of pathology laboratories and the long waiting times associated with screening-result transmission. The lack of treatment methods such as cryotherapy in government hospitals due to unavailability or costs of supplies leads to lower attainment of treatment and increased mortality. Due to the prohibitive costs of transportation to the treatment site/hospital as well as the costs of treatment such as chemotherapy or radiation therapy, many women opt out of treatment for cervical cancer. A major asset in the community is the presence of community leaders namely chiefs as their influence in their communities could be leveraged to address loss-to-follow-up. Additionally, Migori has the advantage of having a large concentration of community health workers who have been integrated into the priorities and budget of Kenya’s Ministry of Health. In such a resource-limited setting, their presence has been used as an asset in conducting health outreach to promote cervical cancer screening. Individual-level financial assistance for transportation costs does not always alleviate this structural barrier which requires a more government-integrated and sustainable approach. By working with the Reproductive Health Center Migori District Hospital, I hope to address 1) why women who are diagnosed with pre-cancerous lesions or cancerous lesions do not receive treatment in the referral hospitals/clinics in the region and 2) how spatial mapping tools can be utilized to ensure women are not lost to follow-up during the treatment cascade.

The use of geographic information systems (GIS) can create correlations between availability and accessibility of resources and loss-to-follow-up rates in order to promote local as well as national community engagement in addressing cervical cancer. The goal of my project is to use the visual data I gather from GIS spatial mapping to examine the association between cervical cancer screening and sociodemographic characteristics that function as risk factors for loss to follow-up. With this data, I am working with researchers at the Center for Global Reproductive Health under Dr. Megan Huchko’s Cervical Cancer Screening & Prevention study (CCSP), community leaders, and community health workers to create maps. Along with the results from previous studies and Phase I of the CCSP study, I will be able to create a tool that can be used to evidence-informed intervention strategies. By utilizing GIS mapping technology, we are able to use traditional health data such as the frequency of women who are HPV positive among those we screened as well as location of treatment sites to then display them in a more dynamic manner to the county health management team, stakeholders, or the general public.

When I first arrived, I spent the first week attending a community health campaign where I was able to see firsthand how screening is performed. However, more importantly, I was able to see the difficulty of attending a screening campaign due to the types of roads one has to travel through. With this, I confirmed the importance of ensuring that I map distance to the CHCs and treatment sites as this variable would definitely have an effect on screening and treatment rates.  As a preliminary step, I went back to the past three communities where CHCs were held to collect the GPS-coordinates of women who were screened but were not enumerated. Enumeration involves collecting not only the GPS-coordinates of women, but also their sociodemographic characteristics which we can use as proxies for predicting screening and treatment rates. This involved working directly with the community health workers to first, train them how to use the gps-coordinate collection tablets and secondly, how to appropriately interpret the survey questions. Having this data was essential to ensuring the completeness of the data as well as the accuracy of the maps.

I am using ArcGIS as well as other spatial mapping tools to display the locations of villages/communities within Migori, Kenya with population characteristics such as age, occupation and education level as well as spatial locations of hospitals/clinics providing cryotherapy treatment. The ultimate goal is to determine whether there is a significant association between 1) distance to the treatment sites, 2) access to counseling services, 3) occupation and 4) education level, 5) frequency of outreach services by the community health workers loss-to-follow-up. We will then be able to visualize loss-to-follow-up “hot spots” in each community in Migori based on the interpretation of the sociodemographic variables.

Although the research product will be delivered by the end of my time in Kenya, I will also conduct the data analysis in-country as this will allow me to confirm the feasibility of the map and the associated meanings of the map. Long term, the results from this project will empower health workers with knowledge of spatial mapping tools in order to better target their outreach to women most in need of an enhanced linkage to care strategy. Other projected benefits include more targeted community health campaigns if we are able to determine what villages have the least access to the CHCs based on their prior knowledge of the campaigns. Additionally, these maps will give us the ability to analyze and identify modifiable factors that could be improved upon for women to get treatment. Lastly, through the duration of this project, I have been able to see the importance of more integrated services at the community health campaigns. Therefore, I have created an opportunity for increased partnership with local women’s organization such as the Kenya Women Microfinance Trust who will provide financial literacy education to the women we screen.

With the support from DukeEngage and McKinsey & Company, this project fits into the goal of evaluating the efficacy of a community-driven approach to ensuring women are linked to treatment which comes from awareness of the barriers to accessing treatment. By using a quantitative measure such as a spatial map, I will be able to identify patterns that may not be evident in standard data presentations, allowing me, in collaboration with the health workers at Migori District Hospital, to hypothesize reasons why women may be lost to follow-up by assigning qualitative interpretations to the data on the maps. This final research product will allow us to visualize the resources available in Migori, Kenya, the trends in loss-to-follow-up in terms of the variables on the map such as distance to the clinic, access to supportive services such as community health workers, and frequency of outreach and educational programs in each community.


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