ArticlesSafety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project
Introduction
Worldwide, over 470 000 new cervical cancer cases occur yearly—about the same as the number of maternal deaths every year.1, 2 Tragically, although this disease is preventable by screening linked with treatment, most women die because few developing countries (where most cases arise) have successful prevention programmes, attributable in large part to the complex infrastructure needed for traditional cytology-based programmes.3, 4, 5, 6
To address this health inequity, effective practical alternatives to cytology for detection of precancerous lesions are being investigated. Research has established the viability of visual inspection with acetic acid (VIA) to identify precancerous lesions.7, 8, 9, 10, 11, 12, 13, 14, 15 Besides its high sensitivity and low-cost, VIA is simple enough for nurses to provide at low levels of the health-care system, with locally available supplies. Because results are immediate, loss to follow-up is kept to a minimum.5, 16, 17, 18
Showing whether VIA can be efficiently and safely linked to treatment in low-resource settings is the logical next step in assessment of its potential role in developing country programmes. One way to achieve the best secondary prevention in low-resource settings is to couple testing with an immediate offer of diagnosis, treatment, or both for test-positive cases; essentially, a single-visit approach.19 A VIA-based, single-visit approach differs from the traditional approach in that diagnostic referral—eg, for colposcopy or biopsy—is restricted only to cases ineligible for treatment immediately post-testing.
Some people feel that this approach is inappropriate for developing countries, because the safety of non-physicians treating precancerous lesions in low-resource settings has never been established.20 Additionally, writers of a Lancet Commentary15 noted that identification of many women with low-grade lesions (with VIA) might not be cost effective. To address these information gaps, a team from the USA (JHPIEGO Corporation) and Thailand (Royal Thai College of Obstetricians and Gynaecologists [RTCOG]), in collaboration with the Thai Ministry of Public Health (hereafter Ministry), initiated a multisite demonstration project in rural Thailand, where screening coverage remains low. The project aimed to establish the safety, acceptability, and feasibility of efficiently implementing a VIA and cryotherapy-based, single-visit approach to cervical-cancer prevention in a rural, low-resource setting. Cryotherapy was selected because it: has a cure rate comparable to other common outpatient procedures;21, 22, 23 is easily learned; does not need electricity; requires few consumables; has a documented history of low complication rates;22, 24 and has an established performance record in the hand of non-physicians in developed countries.25 We describe key results of this demonstration project with an alternative, field-based, resource-appropriate approach to cervical-cancer prevention.
Section snippets
Methods
The project was done in four districts in Roi-et Province, Thailand, because it is mostly rural, services have been unsuccessful here in the past, and a tertiary referral facility is reasonably close (Ministry of Public Health). The project recruited women between February, 2000, and October, 2000, and was approved by two Institutional Review Boards (Johns Hopkins Bayview Medical Center, USA, and Ministry of Public Health, Thailand), and received official support of the Ministry.
Results
5999 women were VIA tested (figure 1); they were mean age 36·7 years (SD 4·35) and had 5·6 years of education (SD 2·74). 5837 (97·3%) were married or cohabiting with a partner. More than half (3516; 58·6%) received mobile services in a primary centre; the others received services at a district hospital. 798 (13·3%) were VIA positive. The test-positive rate did not differ significantly between static and mobile services (13·9% vs 12·9%, respectively; p=0·23). However, it did differ significantly
Discussion
These results clearly show that a single-visit approach with VIA followed by immediate treatment with cryotherapy for those testing positive (or referral as indicated) is safe, acceptable, feasible, and with sustained effort, can achieve moderate population coverage. The project provides important safety information for policymakers in developing countries who are considering how best to initiate or strengthen fledgling cervical-cancer prevention programmes. Follow-up data indicate no
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