COBIN-C Reports - Nepal Development Society

BRIEF REPORT

Study Title:

Community-Based Intervention for Cervical Cancer Screening Uptake in a Semi-Urban Area of Pokhara Metropolitan, Nepal: A Cluster Randomized Controlled Trial (COBIN-C)

Background

Cervical cancer remains a leading cause of cancer-related morbidity and mortality among women in low- and middle-income countries, including Nepal. Although largely preventable through HPV vaccination, screening, and timely treatment, and despite the existence of a national screening guideline, screening uptake in Nepal remains low. Barriers, including limited awareness, stigma, fear, poor accessibility, and a lack of family support, hinder participation.

In Nepal, an extensive network of over 50,000 Female Community Health Volunteers (FCHVs), who have long supported maternal and child health programs, remains underutilized in cervical cancer prevention. Given their established community trust and prior engagement in non-communicable diseases (NCD) prevention, FCHVs are well-positioned to promote screening through culturally appropriate education. To address this gap, we developed the COBIN-C (Community-Based Intervention for Cervical Cancer Screening Uptake) trial – a cluster randomized controlled trial assessing the effectiveness of an FCHV-led intervention to increase screening uptake among women aged 30-60 years in Pokhara Metropolitan City (formerly Lekhnath Municipality), Kaski district, Nepal. The study area, comprising 15 administrative wards with limited health infrastructure, was among the pilot sites for Nepal’s CCSP program. To our knowledge, no similar community-based interventions had previously been implemented in this setting during the study period.

This study responds to an urgent need for community-based strategies to improve cervical cancer screening uptake by leveraging Nepal’s trusted FCHVs network.

Objectives

General Objective:

To explore cervical cancer screening uptake, and to develop and evaluate FCHVs-led community-based intervention to increase cervical cancer screening uptake among women aged 30-60 years in a semi-urban area of Pokhara Metropolitan City, Nepal.

Specific objectives:

To systematically appraise the published literature on cervical cancer screening utilization, and associated barriers and facilitators, in Nepal.
To assess the cervical cancer screening uptake, knowledge, attitude, and preventive practices among women aged 30-60 years in a semi-urban area of Pokhara Metropolitan City in Nepal
To evaluate the effect of an FCHV-led intervention for increasing cervical cancer screening uptake in a semi-urban area of Pokhara Metropolitan City in Nepal

Methodology

Study Design: Community-based, open-label, two-arm cluster randomized controlled trial (CRCT). Trial Registration: Clinical Trials.gov NCT03808064

Study Setting: Semi-urban area of Pokhara Metropolitan City (formerly Lekhnath Municipality area), Nepal

Participants: 690 women aged 30-60 years recruited between April to June 2019

Randomization: 14 clusters randomly assigned (1:1 ratio) to intervention or control groups

Intervention: A 12-month cervical cancer screening awareness and referral program delivered by trained FCHVs

Control: Usual care (The current health education and promotion practices for cervical cancer screening at the community level provided by the government health system)

Outcomes:

Primary: Change in cervical cancer screening uptake from baseline to 12-month follow-up

Secondary: Change in the level of knowledge among women about cervical cancer screening and prevention

Key Findings

Completion Rate: 646 out of 690 women completed the trial (93.6%)

Primary Outcome: Significant increase (48%) in screening uptake in the intervention group (Relative Risk = 1.48, 95% CI: 1.32-1.66, P < 0.01) compared to the control group

Secondary Outcome: Median knowledge score increased from 2 [IQR 1-4] to 6 [IQR 3-9] in the intervention group. In the control group, knowledge scores remained nearly unchanged (2[IQR 1-5] to 3 [IQR 2-5])

Contributions to Global Health

Demonstrated that the FCHVs can successfully take on the role of promoting cervical cancer screening and prevention, providing both the practicality and impact of this task-shifting approach
Provided a scalable community health model applicable to low-resource settings
Reinforced the role of FCHV-led community engagement in strengthening preventive health interventions
Generated evidence to strengthen the cervical cancer screening component of Nepal’s national cancer control strategies

Publications and Knowledge Dissemination

Shrestha AD, Andersen JG, Gyawali B, Shrestha A, Shrestha S, Neupane D, et al. Cervical cancer screening utilization, and associated factors, in Nepal: a systematic review and meta-analysis. Public Health. 2022;210:16–25.

Shrestha AD, Neupane D, Ghimire S, Campbell C, Kallestrup P. Community-based intervention for cervical cancer screening uptake in a semi-urban area of Pokhara Metropolitan, Nepal (COBIN-C): study protocol for a cluster-randomized controlled trial. Trials. 2021;22(1):94.

Shrestha AD, Gyawali B, Shrestha A, Shrestha S, Neupane D, Ghimire S, et al. Knowledge, attitude, preventive practices and utilization of cervical cancer screening among women in Nepal: a community-based cross-sectional study. Eur J Cancer Prev. 2022;31(1):73-81.

Dhoj Shrestha A, Gyawali B, Shrestha A, Shrestha S, Neupane D, Ghimire S, et al. Effect of a female community health volunteer-delivered intervention to increase cervical cancer screening uptake in Nepal: a cluster randomized controlled trial. Preventive Medicine Reports. 2022;29:101948.

Future Directions

Scaling up FCHV-led cervical cancer screening promotion programs across rural and urban areas
Integrating cervical cancer awareness into existing reproductive health services
Exploring mobile health (mHealth) and reminder systems to increase screening uptake
Long-term assessment of cervical cancer incidence and early detection outcomes

Acknowledgements

We extend our sincere gratitude to the participating women, Female Community Health Volunteers (FCHVs), health facility staff, local stakeholders and the research team at Nepal Development Society. We are especially thankful to Abhishek Spakota, Amrita Thapa, Garima Neupane, Sabina Timilsina, Sneha Sharma, Sonam Magar, Tara Ballav Adhikari, Pabitra Babu Soti, and Hari Prasad Pokhrel for their dedicated support throughout the study. This study forms a part of the doctoral research at Aarhus University, Denmark (https://phd.health.au.dk/), and was funded by a university scholarship awarded to Aamod Dhoj Shrestha. The funding body had no role in the design of the study, data collection, analysis, interpretation, or reporting of the results.

Study Team

Aamod Dhoj Shrestha (PhD Fellow), Department of Public Health, Aarhus University, Denmark

Supervisors:

Professor Per Kallestrup (Main supervisor), Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark.

Associate Professor Christine Campbell, Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK.

Dr. Sarita Ghimire, Executive Director, Gyne-oncologist, Nepal Cancer Care Foundation, Lalitpur, Nepal.

Dr. Dinesh Neupane, Associate Scientist, Johns Hopkins University, Baltimore, Maryland, USA