Models for Integrating Cervical and/or Breast Cancer Prevention Interventions in Low- and Lower-Middle-Income Countries: A Scoping Review.

Abstract

Background and Rationale Cervical cancer and breast cancer are among the leading causes of cancer morbidity and mortality among women in low- and lower-middle-income countries (LLMICs). In these countries, a high proportion of cases are diagnosed at an advanced stage, which limits the options for curative treatment. Both cancers are the focus of global initiatives. The World Health Organization (WHO) Global Strategy to Accelerate the Elimination of Cervical Cancer (2020) sets three targets for 2030: • 90% of girls fully vaccinated against human papillomavirus (HPV) by the age of 15; • 70% of women screened with a high-performance test by age 35 and again by age 45; • 90% of women identified with precancerous lesions or cancer receiving treatment. The Global Breast Cancer Initiative (2021) aims to reduce breast cancer mortality by 2.5% per year through early detection, timely diagnosis and comprehensive management. Achieving these targets faces persistent barriers: limited service availability, shortages of human and material resources, geographical and financial barriers, and fragmented care pathways between screening, diagnosis and treatment. Sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) services are women’s most regular points of contact with the health system: family planning, antenatal and postnatal care, adolescent health, and child nutrition and immunization follow-up. Integrating the prevention of these cancers into these services could therefore increase contact opportunities, reduce missed opportunities and promote more efficient use of resources. In Burkina Faso, in several districts, prevention of mother-to-child transmission of HIV (PMTCT/EMTCT) services are also delivered within SRMNCAH services, making them an additional entry point. However, the integration models described in the literature are heterogeneous. They differ in the services integrated, the host services, the levels of care and the organizational arrangements. Terminology and indicators also vary from one study to another. A scoping review is therefore the appropriate approach to map this field, clarify concepts and identify knowledge gaps, rather than to measure the effectiveness of the models. Operational Definitions • Prevention interventions: HPV vaccination; health education; cervical cancer screening (visual inspection with acetic acid or Lugol’s iodine [VIA/VILI], HPV testing, cytology); treatment of cervical precancerous lesions; and breast cancer screening (clinical breast examination, mammography). • SRMNCAH services: family planning, antenatal and postnatal care, adolescent health, HIV services (including PMTCT/EMTCT), and child nutrition and immunization follow-up. • Integration model: the provision, at the same point of contact, of at least two services, namely one cervical or breast cancer prevention service and at least one other SRMNCAH service. • Cancer control approaches and strategies: arrangements that organize the screening, treatment and referral pathway (e.g., “screen-and-treat”) without, on their own, defining a joint service offer. They will be distinguished from models and recorded when they accompany a model. • LLMICs: countries classified as low-income or lower-middle-income according to the World Bank’s 2023 classification. General Objective This scoping review aims to identify, map and describe models for integrating cervical and/or breast cancer prevention into SRMNCAH services in LLMICs. Specific Objectives 1. Identify models for integrating the prevention of these cancers into SRMNCAH services implemented in LLMICs and described in documents published between 2005 and 2025. 2. Describe their characteristics: the SRMNCAH service serving as the point of contact, the integrated prevention services, target populations, levels of care and organizational arrangements. 3. Analyze the dimensions of integration mobilized by these models, with reference to the model of Valentijn et al. (2013) and the WHO framework on integrated people-centred health services (2016). 4. Identify the barriers and facilitators reported for their implementation. 5. Identify gaps in the literature and research priorities for designing models adapted to the health systems of LLMICs, particularly Burkina Faso. Methodology Study design. The review will follow the framework of Arksey and O’Malley (2005), as refined by Levac et al. (2010), and the Joanna Briggs Institute guidance (Peters et al., 2015; 2020). This design is justified by the heterogeneity of the literature (study designs, terminology, indicators) and by the aim of mapping rather than measuring effectiveness. Reporting will follow the PRISMA-ScR checklist (Tricco et al., 2018). Research question. Structured according to the Population-concept-context (PCC) framework, it has three components: • Which models for integrating cervical and breast cancer prevention into SRMNCAH services have been implemented in LLMICs? • Which dimensions of integration do these models mobilize? • Which barriers and facilitators are reported? The PCC elements are: • Population: adolescent girls and women targeted by the prevention of these two cancers, as well as service providers and programme managers. • Concept: integration into SRMNCAH services of HPV vaccination, health education, screening and treatment of cervical precancerous lesions, and breast cancer screening. • Context: LLMICs, all levels of care. Eligibility criteria. • Population: girls under 15 years of age (HPV vaccination); adolescent girls; women aged 25 to 69; service providers or programme managers. • Concept: description of the integration of at least one cervical or breast cancer prevention intervention into an SRMNCAH service. • Context: service located in an LLMIC (World Bank 2023 classification). • Document types included: quantitative, qualitative, mixed-methods and implementation primary research; institutional grey literature; documents written in English or French and published between 1 January 2005 and 31 December 2025. • Exclusions: abstracts without full text, books, letters, commentaries, literature reviews and meta-analyses. Relevant reviews will be used only for hand-searching reference lists. Information sources and search strategy. The search strategy will comprise five blocks: integration, screening, target cancers, SRMNCAH services and geographical area. Within each block, MeSH terms and truncated free-text keywords will be combined with the OR operator; the blocks will then be combined with the AND operator. The strategy will be adapted to PubMed/MEDLINE, CINAHL, Web of Science, the Cochrane Library, Cairn.info and Google Scholar. Institutional grey literature will be searched on : WHO, ministries of health, technical and financial partners. Search dates, websites consulted and terms used will be recorded. The reference lists of included studies and relevant reviews will be hand-searched. Study selection. After removal of duplicates in Zotero, two independent reviewers will screen each record by title and then by abstract, classifying it as “Include”, “Maybe” or “Exclude”. A pilot calibration will be conducted on [number] records, with an agreement threshold of [value]. A third researcher will resolve records classified as “Maybe” and any persistent disagreements. Full texts will be assessed by both reviewers using the same procedure, and each reason for exclusion will be recorded. The selection process will be presented in a PRISMA-ScR flow diagram. Data extraction. A data extraction form, piloted on a sample of publications, will capture: • study characteristics (authors, year, country and income group, design, population); • the SRMNCAH service serving as the host and the integrated prevention components; • organizational arrangements, the integration model and its dimensions; • reported outcomes, barriers and facilitators. One reviewer will extract the data and a second will verify it; disagreements will be resolved through discussion. Data will be recorded in a spreadsheet. Data analysis. The analysis will have two components: • Description of the corpus: distribution of studies by country, year, design and host service. The geographical distribution will be mapped using QGIS. • Qualitative synthesis: models will be identified with reference to the model of Valentijn et al. (2013) and the WHO framework (2016), then grouped according to the SRMNCAH service serving as the point of contact. A single study may relate to several models and several approaches. The hub-and-spoke model, a general framework for organizing referral between levels of care, will be recorded separately, as it is not specific to the control of these cancers. The dimensions of integration will be analyzed deductively, using an eight-dimension grid adapted from the Rainbow Model of Integrated Care (Valentijn et al., 2013), the WHO framework on integrated people-centred health services (2016) and the framework of Kodner and Spreeuwenberg (2002). The eight dimensions are: systemic, organizational, professional, clinical, functional, normative, community and intersectoral. This grid will be used to characterize the models, not to select or rank them; it will not be applied to cancer control approaches. Barriers and facilitators will be coded thematically in a separate step. Given the heterogeneity of study designs and indicators, the synthesis will be narrative and tabular. Expected Results The review will produce a structured map of models for integrating cervical and breast cancer prevention into SRMNCAH services in LLMICs. It will document the services serving as points of contact, the integrated prevention services, the levels of care involved and the organizational arrangements. It will distinguish integration models from the cancer control approaches that accompany them, as well as from the referral framework between levels of care. It will identify which dimensions of integration are well docume