Patricia S. Coffey

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.

Count every newborn; A measurement improvement roadmap for coverage data

BackgroundThe Every Newborn Action Plan (ENAP), launched in 2014, aims to end preventable newborn deaths and stillbirths, with national targets of ≤12 neonatal deaths per 1000 live births and ≤12 stillbirths per 1000 total births by 2030. This requires ambitious improvement of the data on care at birth and of small and sick newborns, particularly to track coverage, quality and equity.MethodsIn a multistage process, a matrix of 70 indicators were assessed by the Every Newborn steering group. Indicators were graded based on their availability and importance to ENAP, resulting in 10 core and 10 additional indicators. A consultation process was undertaken to assess the status of each ENAP core indicator definition, data availability and measurement feasibility. Coverage indicators for the specific ENAP treatment interventions were assigned task teams and given priority as they were identified as requiring the most technical work. Consultations were held throughout.ResultsENAP published 10 core indicators plus 10 additional indicators. Three core impact indicators (neonatal mortality rate, maternal mortality ratio, stillbirth rate) are well defined, with future efforts needed to focus on improving data quantity and quality. Three core indicators on coverage of care for all mothers and newborns (intrapartum/skilled birth attendance, early postnatal care, essential newborn care) have defined contact points, but gaps exist in measuring content and quality of the interventions. Four core (antenatal corticosteroids, neonatal resuscitation, treatment of serious neonatal infections, kangaroo mother care) and one additional coverage indicator for newborns at risk or with complications (chlorhexidine cord cleansing) lack indicator definitions or data, especially for denominators (population in need). To address these gaps, feasible coverage indicator definitions are presented for validity testing. Measurable process indicators to help monitor health service readiness are also presented. A major measurement gap exists to monitor care of small and sick babies, yet signal functions could be tracked similarly to emergency obstetric care.ConclusionsThe ENAP Measurement Improvement Roadmap (2015-2020) outlines tools to be developed (e.g., improved birth and death registration, audit, and minimum perinatal dataset) and actions to test, validate and institutionalise proposed coverage indicators. The roadmap presents a unique opportunity to strengthen routine health information systems, crosslinking these data with civil registration and vital statistics and population-based surveys. Real measurement change requires intentional transfer of leadership to countries with the greatest disease burden and will be achieved by working with centres of excellence and existing networks.

A review of the effectiveness and acceptability of the female condom for dual protection

The female condom remains the sole female-initiated method of dual protection against unintended pregnancy and sexually transmissible infections (STIs), including HIV. We reviewed published data on the effectiveness and acceptability of the female condom for protection against pregnancy and infection. Overall, use of the female condom is low and several barriers hinder the wider adoption of the use of the method. Research on effectiveness has focussed on pregnancy, STIs and biological markers of semen exposure. Although the data available suggest that female condoms (or a mixture of female and male condoms) may provide similar degrees of protection against pregnancy and STIs as do latex male condoms alone, this conclusion has not been demonstrated and thus comparative research is urgently needed.

Involving the community in cervical cancer prevention programs.

Underutilization of cervical cancer prevention services by women in the high‐risk age group of 30–60 years can be attributed to health service factors (such as poor availability, poor accessibility, and poor quality of care provided), to womens lack of information, and to cultural and behavioral barriers. The Alliance for Cervical Cancer Prevention (ACCP) partners have been working to identify effective ways to increase womens voluntary participation in prevention programs by testing strategies of community involvement in developing countries. The ACCP experiences include developing community partnerships to listen to and learn from the community, thereby enhancing appropriateness of services; developing culturally appropriate messages and educational materials; making access to high‐quality screening services easier; and identifying effective ways to encourage women and their partners to complete diagnosis and treatment regimens. Cervical cancer prevention programs that use these strategies are more likely to increase demand, ensure follow‐through for treatment, and ultimately reduce disease burden.

Women's Perspectives on Cervical Screening and Treatment in Developing Countries: Experiences with New Technologies and Service Delivery Strategies

ABSTRACT This review of studies conducted by partners in the Alliance for Cervical Cancer Prevention (ACCP) examines womens perspectives on, and acceptability of, new cervical cancer screening and treatment approaches, management by mid-level staff, single-visit strategies, treatment side effects, and post-treatment abstinence requirements in low-resource settings. All screening, managed by female nurses and irrespective of method or constellation of methods, appeared to be highly acceptable. Similarly, cryotherapy treatment, including cryotherapy managed by nurses immediately after screening, was well-received by women in the studies. Minor side effects, although rather prevalent, and difficulties with post-treatment abstinence, did not appear to significantly deter women from recommending the procedure to friends. Rather, a sense of relief was evident, a feeling that it was better to be treated than not treated, and better to be treated sooner rather than later. While full replication may not be possible, this does not lessen the fact that screening and treatment in developing countries, even with new technologies, immediate treatment and even using mid-level providers, can be very acceptable to women if provided in a safe, caring and preferably all-female environment.

Determination of extended-interval gentamicin dosing for neonatal patients in developing countries.

Background: Infectious diseases account for an estimated 36% of neonatal deaths globally. The purpose of this study was to determine safe, effective, simplified dosing regimens of gentamicin for treatment of neonatal sepsis in developing countries. Methods: Neonates with suspected sepsis in the neonatal intensive care unit (NICU) at Christian Medical College and Hospital (CMC), Vellore, India (n = 49), and Dhaka Shishu Hospital (DSH), Bangladesh (n = 59), were administered gentamicin intravenously according to the following regimens: (1) 10 mg every 48 hours for neonates <2000 g; (2) 10 mg every 24 hours for neonates 2000–2249 g; and (3) 13.5 mg every 24 hours for neonates ≥2500 g. Serum gentamicin concentration (SGC) at steady state and pharmacokinetic indices were determined. Renal function was followed while under treatment and hearing was examined 6 weeks to 3 months after discharge. Results: All neonates, except 1 weighing 2000–2249 g at DSH, had a peak SGC >4 μg/mL. Overall, 5 (10%) and 17 (29%) infants had a peak SGC level ≥12 μg/mL from CMC and DSH, respectively, and 10 (20%) and 4 (7%) cases from CMC and DSH, respectively, had a trough SGC level ≥2 μg/mL. However, no infant <2000 g had a trough SGC level ≥2 μg/mL. We found no evidence of gentamicin nephrotoxicity or ototoxicity. Conclusion: Safe, therapeutic gentamicin dosing regimens were identified for treatment of neonatal sepsis in developing country settings. Administration of these doses could be simplified through use of Uniject, a prefilled, single injection device designed to make injections safe and easy to deliver in developing country settings.

Couples' acceptability of the SILCS diaphragm for microbicide delivery.

BACKGROUND Disposable plastic applicators used in microbicide gel studies are expensive and have a negative environmental impact. The SILCS diaphragm is a barrier contraceptive that could offer a reusable delivery system. STUDY DESIGN Thirty-six couples in this randomized, cross-over study evaluated single- and double-sided gel delivery from a SILCS diaphragm compared with gel from an applicator. Couples used each gel scenario during two acts of intercourse and completed acceptability questionnaires after each. RESULTS All three scenarios received favorable ratings for ease of application, acceptability and perceived effectiveness. Both female and male participants tended to rate the gel applicator significantly more favorably than either SILCS gel delivery scenarios for all attributes except messiness/leakage and effectiveness. Additionally, about 60% of female participants and about half of male participants preferred the gel applicator to either of the gel delivery systems using SILCS. The preference for the SILCS scenario for pregnancy protection was statistically significant for both sexes. Male participants were also significantly more likely to prefer the SILCS single-sided delivery system to the gel applicator for protection from sexually transmitted infection. CONCLUSIONS In this study population, participants found the gel applicator to be more acceptable than either single- or double-sided gel delivery from a SILCS diaphragm. Further research of the SILCS as a microbicide delivery system should be implemented to assess its acceptability among study populations that reflect diverse potential user groups such as women and men from both low and high HIV prevalence settings including HIV-positive populations and with and without experience using female barrier methods.

Comparative acceptability of the SILCS and Ortho ALL-FLEX diaphragms among couples in the Dominican Republic

BACKGROUND The SILCS diaphragm is a new, single-size contraceptive diaphragm. The objective of this crossover pilot study was to assess the fit and acceptability of the SILCS diaphragm compared to the Ortho ALL-FLEX diaphragm to validate the product design among parous women in a low-resource setting. STUDY DESIGN Sexually active couples not at risk of pregnancy and at low risk of sexually transmitted infection were recruited and randomly assigned to one of two groups to determine order of device use. Couples used each device four times and provided feedback on key performance indicators via product-use questionnaires, a simple coital log and a gender-specific debriefing interview. RESULTS Twenty couples provided data on a total of 160 product uses (80 for each device). Couples indicated that both diaphragms were acceptable with respect to ease of use, comfort and satisfaction with sex. At the end of the study, 19 of 20 women and 15 of 20 men reported preferring the SILCS diaphragm over the Ortho diaphragm (p<or=.01 for both). CONCLUSION Short-term acceptability of the SILCS and Ortho diaphragms during use was comparable, although overall both women and men preferred the SILCS diaphragm over the Ortho diaphragm. Acceptance of diaphragms in general, and the SILCS diaphragm in particular, is likely among couples willing to use a barrier method.

A low cost, colour coded, hand held spring scale accurately categorises birth weight in low resource settings

Aims: To determine the accuracy of a low cost, spring calibrated, hand held scale in classifying newborns into three weight categories (⩾2500 g, 2000–2499 g, <2000 g). Methods: The test device was compared to a gold standard digital baby scale with precision to 2 g. In Sarlahi district, Nepal, 1890 newborns were eligible for the study. Measurements were collected for both the test device and the digital scale from 1820 (96.3%) newborns. Results: The overall low birth weight (LBW) prevalence rate for the gold standard digital scale was 28.1% (511/1820). Sensitivity (93.7%) and specificity (97.6%) of the test device was high compared to LBW classifications based on digital weight measurements. Classification of infants into the <2000 g category was 5.0% and 4.7% for the gold standard and test device, respectively. Sensitivity and specificity of the test device in identifying infants <2000 g was 87.8% and 99.6%, respectively. Positive predictive values were high (>91%) for both weight categories Conclusions: This low cost, simple-to-use device classified infants into weight categories with a high degree of consistency and accuracy that exceeds that of surrogate measures. This new device is useful for identifying and targeting life saving interventions for LBW, high risk infants in settings where infants are born in the home and conventional weighing scales are unavailable.

Short-term acceptability of a single-size diaphragm among couples in South Africa and Thailand

Background The SILCS diaphragm is a new, reusable, single-size cervical barrier device that is designed to offer the same barrier protection as a standard diaphragm with improved user acceptability. Methods This non-randomised, non-blinded, non-significant risk, multi-site pilot study assessed the short-term acceptability of the SILCS diaphragm among women with no previous diaphragm experience. Sites in South Africa and Thailand recruited couples not at risk of pregnancy and at low risk of sexually transmitted infections. Couples used the SILCS diaphragm four times and provided feedback on the ease of handling, comfort, and sensation during sex. Data were collected via detailed product-use questionnaires, simple coital logs and gender-specific debriefing interviews. Results A total of 41 couples completed the study, providing data from 164 product uses. The SILCS device fits women representing a range of diaphragm sizes, parity and body mass index. Women from both sites reported that the SILCS diaphragm was easy to use and provided good comfort and sensation in over 80% of all product uses. Men from both sites reported good comfort and sensation in over 60% of all product uses. Conclusion The SILCS diaphragm appears to be acceptable to women and men in low-resource settings. These data suggest that the SILCS design should be tested in broader populations to assess effectiveness and acceptability.