Jennifer L. Winkler

Factors affecting utilization of cervical cancer prevention services in low-resource settings

Strategies for introducing or strengthening cervical cancer prevention programs must focus on ensuring that appropriate, cost-effective services are available and that women who most need the services will, in fact, use them. This article summarizes the experiences of research projects in Bolivia, Peru, Kenya, South Africa, and Mexico. Factors that affect participation rates in cervical cancer prevention programs are categorized in three sections. The first section describes factors that arise from prevailing sociocultural norms that influence womens views on reproductive health, well being, and notions of illness. The second section discusses factors related to the clinical requirements and the type of service delivery system in which a woman is being asked to participate. The third section discusses factors related to quality of care. Examples of strategies that programs are using to encourage womens participation in cervical cancer prevention services are provided. This paper is available too at: http://www.insp.mx/salud/index.html.

Cervical screening by visual inspection, HPV testing, liquid‐based and conventional cytology in Amazonian Peru

Cervical cancer is an important public health problem in many developing countries, where cytology screening has been ineffective. We compared four tests to identify the most appropriate for screening in countries with limited resources. Nineteen midwives screened 5,435 women with visual inspection (VIA) and collected cervical samples for HPV testing, liquid‐based cytology (LBC) and conventional cytology (CC). If VIA was positive, a doctor performed magnified VIA. CC was read locally, LBC was read in Lima and HPV testing was done in London. Women with a positive screening test were offered colposcopy or cryotherapy (with biopsy). Inadequacy rates were 5% and 11% for LBC and CC respectively, and less than 0.1% for VIA and HPV. One thousand eight hundred eighty‐one women (84% of 2,236) accepted colposcopy/cryotherapy: 79 had carcinoma in situ or cancer (CIS+), 27 had severe‐ and 42 moderate‐dysplasia on histology. We estimated a further 6.5 cases of CIS+ in women without a biopsy. Sensitivity for CIS+ (specificity for less than moderate dysplasia) was 41.2% (76.7%) for VIA, 95.8% (89.3%) for HPV, 80.3% (83.7%) for LBC, and 42.5% (98.7%) for CC. Sensitivities for moderate dysplasia or worse were better for VIA (54.9%) and less favourable for HPV and cytology. In this setting, VIA and CC missed the majority of high‐grade disease. Overall, HPV testing performed best. VIA gives immediate results, but will require investment in regular training and supervision. Further work is needed to determine whether screened‐positive women should all be treated or triaged with a more specific test.

Use of formative research in developing a knowledge translation approach to rotavirus vaccine introduction in developing countries.

BackgroundRotavirus gastroenteritis is the leading cause of diarrheal disease mortality among children under five, resulting in 450,000 to 700,000 deaths each year, and another 2 million hospitalizations, mostly in the developing world. Nearly every child in the world is infected with rotavirus at least once before they are five years old.Vaccines to prevent rotavirus or minimize its severity are now becoming available, and have already been introduced into the public vaccine programs of several Latin American countries. The World Health Organization (WHO) has made rotavirus vaccine introduction in developing countries a high priority.The WHOs Guidelines for Vaccine Introduction indicates that a key determinant to achieving vaccine introduction is the public health priority of the disease, suggesting that where the disease is not a priority uptake of the vaccine is unlikely. WHO recommends conducting a qualitative analysis of opinions held by the public health community to determine the perceptions of the disease and the priority given to the vaccine.MethodsThis paper presents the formative research results of a qualitative survey of public health providers in five low- and middle-income countries to determine if and to what degree rotavirus is perceived to be a problem and the priority of a vaccine. Open-ended surveys were carried out through focus group discussions and one-on-one interviews.ResultsResearchers discovered that in all five countries knowledge of rotavirus was extremely low, and as a result was not considered a high priority. However, diarrhea among young children was considered a high priority among public health providers in the three poorest countries with relatively high levels of child mortality: India, Indonesia, and Nicaragua.ConclusionIn the poorest countries, advocacy and communication efforts to raise awareness about rotavirus sufficient for prioritization and accelerated vaccine introduction might benefit from a knowledge translation approach that delivers information and evidence about rotavirus through the broader context of diarrheal disease control, an existing priority, and including information about other new interventions, specifically low-osmolarity oral rehydration solution and zinc treatment.

Using pharmacies in Washington state to expand access to emergency contraception

The authors describe preliminary results from a 2-year demonstration project launched in July 1997 in Washington State to expand access to emergency contraceptive pills by promoting collaboration between pharmacists and independent prescribers in providing emergency contraception (EC). The project was undertaken to improve womens awareness and use of emergency contraception by using pharmacists to increase the availability of such contraceptive products. The authors also discuss the impact that the pills is having upon access to emergency contraception, and therefore the potential impact of the program upon rates of unintended pregnancy. Key components of the project include teaching pharmacists about emergency contraception, helping them link up with prescribers, informing women about the availability of emergency contraception, and evaluating the impact of the project. In the 4 months following the projects launch, the national emergency contraception hotline received 4934 calls from Washington State. Before the launch, the hotline averaged 100 calls per month from the state. Over the same period, area pharmacists at 111 participating pharmacies wrote and filled 2765 prescriptions for emergency contraception. The preliminary response to the project has been extremely positive.

Strategies to vaccinate against cancer of the cervix: feasibility of a school-based HPV vaccination program in Peru.

Operational research using a mixed method, cross-sectional, case-study approach assessed the feasibility and health system impact of large-scale implementation of human papillomavirus (HPV) vaccination into routine vaccine delivery by the Ministry of Health in Peru. The strategy was school-based vaccination of fifth grade girls in 527 primary schools in Piura region. Our evaluation showed that school-based HPV vaccination is feasible without major changes in existing health systems. This was reflected in the opinions of health personnel, the lack of impact on other vaccine coverage, and the high HPV vaccine coverage documented in routine records and by an independent community-based survey.

Determinants of Human Papillomavirus Vaccine Acceptability in Latin America and the Caribbean

Prophylactic human papillomavirus (HPV) vaccines provide promise as a key component of future cervical cancer prevention programs in the Latin America and the Caribbean region. The successful introduction and acceptance of these vaccines will depend on a range of factors including awareness of cervical cancer as a problem, affordability of the vaccine, political will, competition with other vaccines, feasibility of vaccine delivery and acceptability of the vaccine among the range of groups who will influence uptake. While existing data about acceptability from Latin America and the Caribbean is scarce, it is clear that health policymakers, providers and the general public lack knowledge about HPV and cervical cancer. Furthermore, they would value more local epidemiologic data related to cervical cancer. Price is currently a major barrier to vaccine acceptability and a priority for advocacy. More research is required in Latin America and the Caribbean to determine what messages and strategies will work in these communities.

Acceptability of self-collection sampling for HPV-DNA testing in low-resource settings: a mixed methods approach

BackgroundVaginal self-sampling with HPV-DNA tests is a promising primary screening method for cervical cancer. However, women’s experiences, concerns and the acceptability of such tests in low-resource settings remain unknown.MethodsIn India, Nicaragua, and Uganda, a mixed-method design was used to collect data from surveys (N = 3,863), qualitative interviews (N = 72; 20 providers and 52 women) and focus groups (N = 30 women) on women’s and providers’ experiences with self-sampling, women’s opinions of sampling at home, and their future needs.ResultsAmong surveyed women, 90% provided a self- collected sample. Of these, 75% reported it was easy, although 52% were initially concerned about hurting themselves and 24% were worried about not getting a good sample. Most surveyed women preferred self-sampling (78%). However it was not clear if they responded to the privacy of self-sampling or the convenience of avoiding a pelvic examination, or both. In follow-up interviews, most women reported that they didn’t mind self-sampling, but many preferred to have a provider collect the vaginal sample. Most women also preferred clinic-based screening (as opposed to home-based self-sampling), because the sample could be collected by a provider, women could receive treatment if needed, and the clinic was sanitary and provided privacy. Self-sampling acceptability was higher when providers prepared women through education, allowed women to examine the collection brush, and were present during the self-collection process. Among survey respondents, aids that would facilitate self-sampling in the future were: staff help (53%), additional images in the illustrated instructions (31%), and a chance to practice beforehand with a doll/model (26%).ConclusionSelf-and vaginal-sampling are widely acceptable among women in low-resource settings. Providers have a unique opportunity to educate and prepare women for self-sampling and be flexible in accommodating women’s preference for self-sampling.

Human Papillomavirus Vaccine Policy and Delivery in Latin America and the Caribbean

Cervical cancer caused by human papillomavirus (HPV) is a major preventable public health problem. Two vaccines are now available for primary prevention of HPV infection and their introduction offers new opportunities to enhance comprehensive cervical cancer prevention and control. Currently, HPV vaccine price is a significant barrier to rapid vaccine introduction and access. Therefore, making evidence-based decisions about whether and how to introduce HPV vaccine into the immunization schedule in the countries of Latin America and the Caribbean (LAC) requires a rigorous analysis of several factors. These include: estimates of disease burden, cost-effectiveness, operational feasibility of reaching a population of adolescent females and other key analyses that have been used in recent years to support the introduction of other vaccines, such as rotavirus and pneumococcal conjugate vaccines. Given the large number of public health priorities that are competing for limited public resources, developing and using a sound evidence base is of particular importance for vaccines, like HPV, which are currently available only at prices higher than other vaccines now in use. HPV vaccination provides the opportunity to dramatically improve womens health and partnerships must also be broad-based and effectively coordinated. This can be achieved by developing programs based on the lessons learned from vaccination strategies used to eliminate rubella and neonatal tetanus and for scaling up influenza vaccination in countries of LAC.

Parental acceptance of HPV vaccine in Peru: a decision framework.

Objective and Method Cervical cancer is the third most common cancer affecting women worldwide and it is an important cause of death, especially in developing countries. Cervical cancer is caused by human papillomavirus (HPV) and can be prevented by HPV vaccine. The challenge is to expand vaccine availability to countries where it is most needed. In 2008 Peru’s Ministry of Health implemented a demonstration project involving 5th grade girls in primary schools in the Piura region. We designed and conducted a qualitative study of the decision-making process among parents of girls, and developed a conceptual model describing the process of HPV vaccine acceptance. Results We found a nonlinear HPV decision-making process that evolved over time. Initially, the vaccine’s newness, the requirement of written consent, and provision of information were important. If information was sufficient and provided by credible sources, many parents accepted the vaccine. Later, after obtaining additional information from teachers, health personnel, and other trusted sources, more parents accepted vaccination. An understanding of the issues surrounding the vaccine developed, parents overcome fears and rumors, and engaged in family negotiations–including hearing the girl’s voice in the decision-making process. The concept of prevention (cancer as danger, future health, and trust in vaccines) combined with pragmatic factors (no cost, available at school) and the credibility of the offer (information in the media, recommendation of respected authority figure) were central to motivations that led parents to decide to vaccinate their daughters. A lack of confidence in the health system was the primary inhibitor of vaccine acceptance. Conclusions Health personnel and teachers are credible sources of information and can provide important support to HPV vaccination campaigns.

Screen-and-Treat Approach to Cervical Cancer Prevention Using Visual Inspection With Acetic Acid and Cryotherapy: Experiences, Perceptions, and Beliefs From Demonstration Projects in Peru, Uganda, and Vietnam

Cervical cancer is preventable but continues to cause the deaths of more than 270,000 women worldwide each year, most of them in developing countries where programs to detect and treat precancerous lesions are not affordable or available. Studies have demonstrated that screening by visual inspection of the cervix using acetic acid (VIA) is a simple, affordable, and sensitive test that can identify precancerous changes of the cervix so that treatment such as cryotherapy can be provided. Government partners implemented screening and treatment using VIA and cryotherapy at demonstration sites in Peru, Uganda, and Vietnam. Evaluations were conducted in the three countries to explore the barriers and facilitating factors for the use of services and for incorporation of screen-and-treat programs using VIA and cryotherapy into routine services. Results showed that use of VIA and cryotherapy in these settings is a feasible approach to providing cervical cancer prevention services. Activities that can help ensure successful programs include mobilizing and educating communities, organizing services to meet womens schedules and needs, and strengthening systems to track clients for follow-up. Sustainability also depends on having an adequate number of trained providers and reducing staff turnover. Although some challenges were found across all sites, others varied from country to country, suggesting that careful assessments before beginning new secondary prevention programs will optimize the probability of success.