A program focused on cervical cancer screening targeted to the local environment and
population like that outlined above will be a step towards addressing the problem of cervical cancer. As awareness of cervical cancer increases through the natural diffusion of information, there will be a greater demand for preventive services. As with many illnesses, the women hardest hit by cervical cancer will be those who are the least likely to know about it and more likely to lack the resources to foot the cost of treatment for invasive cancer. For these women, access to low-cost preventive services will be particularly salient.
Page | 43 As highlighted by the systematic review, access to cervical cancer screening is limited by lack of human and financial resources at the individual and at the institutional level. Therefore, a program such as that delineated above, that places a minimal burden on individuals as well as the existing
infrastructure is ideal. The systematic review was useful in identifying specific strategies that were integrated into the program plan. First and foremost, the systematic review highlighted the benefits of the screen-and-treat method over cytology in low-resource settings, reinforcing the need for VIA to be incorporated into any program facing similar challenges. One such challenge is that of cost. Although the systematic review did not explicitly compare the cost-effectiveness of VIA over the traditional
Papanicolau smear, one can infer that the more traditional route would be more expensive as it requires a functioning laboratory and cytotechnician. In fact, a systematic review of all the evidence concerning VIA up to 2003, supports this conclusion35. The program plan engages key stakeholders in addition to implementing appropriately timed outreach efforts to ensure uptake by the local communities. Uniform training of health providers and staff combined with quality assurance monitoring limits variability in services provided and places an emphasis on the delivery of high quality services. By taking a multi- pronged approach of education and outreach, advocacy, quality assurance monitoring, in addition to, mobilization of human resources from different levels of society, the efficacy and sustainability of the program is ensured. Continuous data collection throughout the life of the program provides real-time data for continuous program improvement and allows program physicians and staff to engage in academic research based on the work being done.
The overall emphasis of the evaluation plan is to ensure that the program is doing what it set out to do, that is, increase the number of women screened and decrease the incidence of invasive cervical cancer in the target communities and the state. To this end, the evaluation plan incorporates the use of both qualitative and quantitative data. A lot of emphasis is placed on documenting the experiences of staff and patients as opposed to more objective data. The subjective experiences of the
Page | 44 staff highlights nuances and allows for better tailoring of the program to suit the needs of the local community. Evaluation is focused on assessing changes in knowledge, attitudes and practice, assessing referral and follow-up, and uptake of screening by both health care providers and women in the
community. Determining the effect of screening on incidence of invasive cervical cancer is limited by the lack of baseline data. Also, proving that changes in the incidence of invasive cervical cancer is directly linked to the screening program would require a randomized controlled trial, hence, the true effect of the program will have to be deduced indirectly. The evaluation results will be used to improve the program. Favorable results will be presented to the Anambra State Commissioner of Health to lobby for adoption at the state government level.
The widespread implementation of the screen-and-treat method in Nigeria with the backing of the government will decrease the rates of cervical cancer in the country. By starting at the grassroots level, this program targets the women who would benefit the most.
Page | 45
Acknowledgements
I would like to thank Dr. Diane Calleson, my MPH adviser for all her assistance in developing this program plan. I would also like to thank Spencer Lindgren who assisted with the logistics. I would like to
thank my second reader Dr. Martha Carlough, whose insight proved invaluable. I would finally like to thank Dr. Yinka Olaniyan, my practicum adviser who provided country context and whose experience and expertise with the screen-and-treat method contributed greatly to the completion of this Master’s
Page | 46
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Appendix
Table 1. Summary of Cervical Cancer Screening Programs Analyzed
Program Goals Screening
Modality
Screening
Strategy/Implementation
Evaluation Outcome Program
Challenges Project Screen Soweto (1980- 1984)¥ To decrease cervical cancer in this community by organizing screening efforts from a laboratory base. Cytology- based screening A collaboration between SAIMR* cytology laboratory and some personnel of the PHCs¤
Increased screening capacity by training more cytotechnicians
Preliminary study identified the priority target population, gaps in knowledge, reasons and gaps in service delivery and patient tracing
Expansion of follow-up services
Delayed the public health education aspect Continuous record-keeping with annual analysis of the results There was a decline in the number of smears received and the incidence of CIN III and invasive cervical cancer after the introduction of PSS A massive public health education campaign may have strained the infrastructure set up by the project Cervical cancer screening received low priority by administration of primary health services The Cervical Health Implementation Project (CHIP) South Africa (2001 - 2003) To identify challenges in health services and in the community that inhibit effective screening and treatment of
Cytology Community participatory model
Health worker training workshops,
Health system tools and protocols were developed
A community awareness program Pre-test/Post-test study design Service organization improved Knowledge of screening policy increased from 43% to 82% among staff Only 50% of women with HSIL had a colposcopy
Staff resistance
Gaps in knowledge in both staff and clients about cervical cancer, SA’s screening policy Inconsistencies in laboratory results
Page | 52
cervical cancer.
and biopsy within 6 months
Screening coverage was less than 4% even though overall pap smears increased. SAFE /Cervicare Ghana (2001 – 2003) Objective: To “rigorously assess” the screen- and-treat approach – safety, acceptabilit y and feasibility with the possibility of scaling up screening efforts
VIA Jhpiego-led cervical cancer prevention program in partnership with the Ministry of Health/Ghana Health Service
Enroll and provide VIA for at least 3000 women between the ages of 25- 45 years
Phased approach: from urban to rural for a total of 3 sites
Integrate cervical cancer screening with existing reproductive health services Observational study based on one site Qualitative evaluation A total of 3665 women were screened by 4 nurses 13.2% were test- positive; 468 were eligible for cryotherapy and 91.2% of these women received cryotherapy 99.4% were satisfied or very satisfied with getting a VIA screen Complications from cryotherapy were minimal Qualitative evaluation showed acceptability and feasibility among women and their husbands as well as with providers. Persistent gaps and misconception s about cervical cancer among the women and their husbands CCPPZ Zambia VIA with adjunct Collaboration between CIDRZ and Zambian
Measurement of clinical
21,010 women were screened
Page | 53
(2006 – present) digital
cervicography
Ministry of Health
Link cervical cancer screening with HIV care and treatment services
Train mid-level providers to screen using VIA
Increase public awareness through the use of peer educators
outcomes: program uptake, screening test efficacy and treatment effectiveness Focus of evaluation was primarily HIV seropositive women 34.2% were seropositive for HIV
More than half of HIV+ women were VIA+ 22% of patients eligible for cryotherapy were lost to follow-up 25% of patients who needed histologic evaluation were no-shows Only 20% of women returned for their follow-up visits
1 cancer death prevented for every 46 HIV+ women screened
Page | 54 Logic Model http://prezi.com/wh0td2w1pya5/cc-screening-in-nigeria-logic-model/?kw=view- wh0td2w1pya5&rc=ref-36366819 Budget Proposal A. Personnel
Fixed Personnel Computation Cost
Program Manager $30,000/yr x 5 years $150,000
Administrative Assistant 1 $20,000/yr x 5 years $100,000 Administrative Assistant 2 $20,000/yr x 5 years $100, 000
Trainer $20,000/yr x 5 years $100,000
Variable Personnel
Community Health Workers $20 per day worked x 183 day maximum x 20 CHWs
$73,200 VIA Training Consultant $350/day x 5 day workshop $1750 VIA Quality Assurance Monitors $175/day x 5 days $875
Total Cost $525,825
B. Transportation
Purpose of Travel Items Computation Cost
Outreach Programs Bus/Car Hire for outreach
$64.50/day x 30 days $1935
Meals $10/day x 5 people x
30 days
$1500 CHW Training Public Transportation $5/day x 5 days of
training x 50 potential CHWs
$1250
Meals $10/day x 5 days x 50
potential CHWs $2500 Health Professional Training Reimbursement for transportation (including fuel costs or public transportation) $5/day x 5 days of training x 20 potential health professionals $500
Meals $10/day x 5 days x 20 potential health professionals
$1000
Total $8685
Page | 55
Item Computation Cost
Laptop computers $1000 x 4 $4000
Printer/Photocopier/Scanner/Fax $2800 x 1 $2800
Cellphones $120 x 4 fixed personnel $480
Total $7280
D. Supplies
There is an assumption that certain things will already be present in the clinic e.g. sterile space for placing sterile equipment, an enclosed space for privacy.
Cervical Screening Supplies Computation Cost Vaginal speculum, metal $8.00 x 5 speculums x 10
health facilities
$400 3%–5% acetic acid. $96/10L x 10 health facilities x
60 months
$57,600 Medical exam lamps $100 x 10 health facilities $1000 Large cotton swabs
(handmade using cotton batting and orange sticks or ring forceps).
$5 x 5 x 10 health facilities x 60 months
$15,000
Cryotherapy
Refrigerant gas supply $760 / year x 5 years x 10 health facilities
$38000 Cryotherapy system $2000 x 10 health facilities $20000 Probe tips (shallow conical, 20
and/or 25 mm diameter).
$290 x 10 health facilities $2900 Plastic sleeve. $125 x 10 health facilities $1250 Gas cylinders (keep one for
back-up).
$285 x 2 x 10 health facilities $5700
Gas $271/ tank/year x 2 tanks x 10
health facilities x 5 years
$27100
Other Supplies
High resolution cameras + Memory card
$750 x 10 health facilities $7500
Office supplies $50/month x 60 months $3000
CHW Training Materials Variable Health Professionals Training
Materials
Variable
Total $179,450
E. Other Costs
Description Computation Cost
Rent $700/month x 60 months $42,000
Cellphone Recharge Cards $10/week x 52 weeks x 5 years x 4 fixed personnel
$10,400
Page | 56 Total Budget:
Description Total Cost
Personnel $525,825 Transportation $8685 Equipment $7280 Supplies $179,450 Other costs $52,400 Total Costs $773,640