DOI: 10.5061/dryad.tht76hdxf
title: Comparison of the costs of HPV testing through Community health campaigns versus Home-based testing in rural western Kenya: A micro-costing study

description: 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.
description: 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.
 <b>Costing
 methods</b> 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 &gt;$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.
description: There are no missing values.