PATH Integrating Cervical Cancer Prevention into RH Services

Publication date: 2001

Reproductive Health Reports Number 4 July 2001 Program Capacity Assessment Tool: Integrating Cervical Cancer Prevention into Reproductive Health Services Preparation of this publication was supported by the Bill and Melinda Gates Foundation through the Alliance for Cervical Cancer Prevention. Reproductive Health Reports is an occasional paper series summarizing selected PATH activities in the area of reproductive health research, program development, and field assessment. The work reported in this paper was funded by the Bill and Melinda Gates Foundation through the Alliance for Cervical Cancer Prevention. © PATH, 2001 Table of Contents Introduction . 5 The Tool . 7 How to Use this Tool . 9 A Tool to Assess Program Capacity to Integrate Cervical Cancer Prevention into Reproductive Health Services . 11 Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening . 13 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment . 25 Level 2a: Cervical Cancer Screening with Pap Smears . 25 Level 2b: Cervical Cancer Screening Using Visual Inspection with Acetic Acid . 42 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care . 57 Level 3a: Colposcopic Examination . 58 Level 3b: Cryotherapy Treatment . 67 Level 3c: Loop Electrosurgical Excision Procedure (LEEP) . 79 Resources . 91 Integrating Cervical Cancer Prevention into Reproductive Health Services 5 Introduction Cervical cancer is an important women’s health problem in developing countries, where it kills over 230,000 women each year. It is the third most common cancer worldwide and the leading cause of death from cancer among women in developing countries. At least 466,000 new cases are identified each year, 80 percent of which are in developing countries. Unlike many cancers, cervical cancer can be prevented. A first line of defense is to educate women about how to protect themselves against the human papillomavirus (HPV), a common infection that causes most cervical cancers. For women at risk of cervical cancer, secondary prevention is the key to saving lives. Cervical cancer can be prevented by using relatively inexpensive screening and treatment technologies to detect abnormal cervical tissue before it progresses to invasive cancer. Most developing counties, however, have been unable to implement comprehensive Pap smear screening-based programs. In countries where Pap smear screening is available, it often is accessible only to a small proportion of women through private-sector health care providers, or it is offered primarily to young women through maternal/child health or family planning clinics where the population being screened generally is not at high risk. These approaches have had little effect on morbidity and mortality. Cervical cancer screening programs are being redesigned to be more successful and effective. Strategies have been developed to limit screening to women at highest risk of high- grade dysplasia, to reduce the frequency of screening among women who have had at least one normal smear, and to recommend regular follow-up rather than treatment for young women with mildly abnormal smears. Even screening women in their 30s or 40s once in a lifetime can have a significant impact on mortality. Several alternative approaches to cervical cancer screening also have been proposed and are being evaluated in research studies. These include visual inspection with acetic acid (VIA) and HPV tests to identify cervical lesions without reliance on cytology. These approaches, however, still are being evaluated for clinical effectiveness, acceptability to clients and health care providers, and cost-effectiveness. These tests, combined with outpatient treatments for precancerous lesions, have the potential to extend a life-saving intervention to women who may not have other access to cervical cancer prevention services. As awareness of cervical cancer as a public health concern has been increasing, interest in developing effective interventions also has grown. The Program Capacity Assessment Tool is designed to help program planners assess a reproductive health program’s capacity for adding cervical cancer screening and dysplasia treatment services to existing reproductive health services. By completing worksheets at the end of each level, program planners can establish the type(s) of cervical cancer prevention services that can feasibly be added to existing services. The Tool also can provide valuable information about programs already offering cervical cancer prevention services. Reviewing questions pertaining to the types of cervical cancer prevention services being offered can provide insight that can contribute to improving program effectiveness and efficiency. The Program Capacity Assessment Tool uses a series of questions to encourage readers to think through the key elements of cervical cancer prevention program implementation. A more complete explanation of the issues can be found in PATH’s 2000 publication, Planning Appropriate Cervical Cancer Prevention Programs, 2nd Edition. PATH welcomes comments and feedback from users of the Program Capacity Assessment Tool. A Tool to Assess Program Capacity 6 Using This Document Any part of Program Capacity Assessment Tool: Integrating Cervical Cancer Prevention into Reproductive Health Services may be reproduced or adapted to meet local needs without prior permission from PATH, provided that PATH is acknowledged and the material is made available free of charge or at cost. PATH also welcomes feedback from individuals who have used this document. Please send a copy of adaptations or comments and suggestions to: Cervical Cancer Prevention Team PATH (Program for Appropriate Technology in Health) 4 Nickerson Street Seattle, WA 98109 USA Tel: (206) 285-3500 Fax: (206) 285-6619 Email: accp@path.org Integrating Cervical Cancer Prevention into Reproductive Health Services 7 The Tool The focus of this tool is to assess program capacity for adding cervical cancer screening and dysplasia treatment services to existing reproductive health services. Assessing program capacity allows organizations to explore their potential to expand services and to determine where additional resources and partners will be needed. Before proceeding with this tool, programs should consider whether cervical cancer is a serious enough health problem to warrant investment of resources, whether potential clients and providers believe that cervical cancer is a serious problem when compared to other health problems, and whether potential clients believe that the benefits associated with the cervical cancer interventions outweigh the disadvantages. PATH has developed a Health Need/Community Demand Assessment Tool that provides specific strategies to generate answers to the questions listed above. It is important to determine that the need and community demand for cervical cancer prevention services are high enough to merit moving forward to assess program capacity for implementing such services. Cervical cancer prevention programs require the following: • Awareness of cervical cancer among providers and targeted clients • Access to high quality Pap smear screening or an alternative screening method • Availability of providers trained in counseling women about screening and follow-up • Availability of treatment for women identified with precancerous lesions • Availability of equipment and supplies for screening and treatment • For cytology programs, availability of sufficient, reliable cytology laboratory services • Functioning system for recalling women for follow-up • Functioning referral networks While the level of service will vary from program to program (from offering education/ referral only to providing screening and treatment), programs must answer the following questions to meet the basic requirements for implementing effective cervical cancer prevention services: • What knowledge and skills exist among available staff and what skills need to be added to provide services? Depending on the level of service, staff must understand the natural history of cervical cancer and the benefits of screening and follow-up in preventing disease, take a reproductive health history, counsel women about screening, take a Pap smear or use an alternative method such as visual inspection, counsel clients about treatment options, and reach clients for necessary follow-up when screening results are returned. • What treatment options are available locally for women identified with dysplasia, cervical cancer, or other cervical abnormalities? Appropriate treatment for women identified with dysplasia (including outpatient treatments for high-grade dysplasia) must be available before a screening program can be put in place. Treatment, or at least palliative care, also must be available for women identified with cervical cancer. A Tool to Assess Program Capacity 8 • What clients will be targeted for services? Programs may want to first target women at the highest risk of cervical dysplasia before expanding services to a wider group of women. The age-specific incidence of cervical cancer peaks around the age of 55, and the age-specific incidence of severe dysplasia peaks around the age of 35. Therefore, in many regions, women age 30 to 50 often are at highest risk of dysplasia that is likely to progress to cancer. • What client population currently is being served and what is the capacity for outreach to draw in the targeted population? Women at highest risk for cervical cancer screening may be older than the current client population. Outreach may be required to raise awareness about the importance of cervical cancer screening among targeted clients so that they will use the expanded services • What facilities will be required? Additional private interviewing, counseling, and examination areas may be needed. • What commodities are available? Supplies and equipment for examinations and infection control are needed. Depending on the type of screening provided, additional equipment and supplies such as specula, slides, spatula, fixatives, acetic acid, and magnifying scopes may be needed. • What information systems exist and what adjustments may be required to ensure program success? Cervical cancer prevention services require that some women return for follow-up visits or are referred to another clinic for diagnosis and treatment. Systems will need to be in place to be able to ensure appropriate follow-up for women who are identified as having cervical abnormalities. The Program Capacity Tool provides specific strategies to answer the questions listed above. The answers can then be used to decide what, if any, specific program changes are needed, and what level of service to provide. Service Levels Level 1: Provide education and information about the importance of cervical cancer as well as referral for screening. Level 2: Provide cervical cancer counseling, screening, and referral for treatment. 2a: Pap smear screening 2b: Screening using visual inspection with acetic acid (VIA) Level 3: Provide cervical dysplasia diagnosis and treatment, in addition to referral for cancer care. 3a: Diagnosis through colposcopic examination 3b: Cryotherapy treatment 3c: Loop electrosurgical excision procedure (LEEP) treatment, also known as large loop excision of the transformation zone (LLETZ). Integrating Cervical Cancer Prevention into Reproductive Health Services 9 How to Use this Tool The questions included in the tool are intended to help managers critically think about a program’s potential to expand services to include cervical cancer prevention. The questions are not meant to be a test indicating a program’s quality, and there are no right or wrong answers. It is essential, however, that the answers realistically reflect the program’s capacities. A lower score on the ranking of barriers indicates only that a program may not be well positioned to expand its services at this time. With that in mind, several steps are essential to making the best use of this assessment tool. 1: Form an assessment team Program planners who want to determine the feasibility of integrating cervical cancer prevention into current activities would benefit from first establishing an assessment team. This team should include individuals who are involved in, and can represent, the managerial, fiscal, administrative, clinical, and educational aspects of the program. Ideally, this group will be no larger than three or four individuals. Together, the assessment team can identify realistic answers to the questions in each chapter and analyze the responses, helping them to make practical decisions about what level of service to offer. It is important for potential team members to understand the amount of time and level of commitment this assessment involves. Completing the entire questionnaire may take the team anywhere from several hours to as long as two or three days. Collection of information on community needs and health facilities will add additional time to the process. 2: Gather preliminary information Programs will need some idea of the community demand and health need for cervical cancer prevention services before using this tool. PATH’s Health Needs/Community Development Assessment Tool guides programs through this process.* Community demand for cervical cancer intervention is assessed through interviewing providers and actual/potential clients about (1) the need for cervical cancer interventions, and (2) whether they believe the benefits of the interventions outweigh the disadvantages. Health need is assessed by local experts, clinic records, referral providers, regional hospital and/or gynecological records, published epidemiological studies, and national or regional surveillance data. Specific indicators of health status that can be helpful in determining overall health need for the expansion of services include: • Cervical cancer incidence or mortality rate > 30-40/100,000 women • Proportion of Pap smears in women aged 30-50 showing high-grade dysplasia > 2-3% • The number of women in service area with symptoms of cervical cancer (which could be suggestive of a high cancer incidence rate) • High prevalence in service area of women seeking STD services, clients at high risk of STD, or women who have STD (> 8% of clients with syphilis, gonorrhea, or chlamydia) * Assessing Health Need/Community Demand for Cervical Cancer Control: Results from a Study in Kenya. Reproductive Health Reports No. 1: PATH (1996). A Tool to Assess Program Capacity 10 3: Start with the minimal desired level of service you would like to provide This tool is designed to help the assessment team identify the level of cervical cancer prevention services it can effectively provide. Therefore, the tool is designed so that the team begins by identifying the minimal desired level of service it would like to offer. By progressing through all the questions and completing the worksheet at the end of each level, the assessment team can determine whether it is feasible to integrate the new level of services. The team can then continue to the next level to determine whether additional services could be provided. For example, a program that answers all the questions in Level 1 and completes the worksheet may find that there are no obstacles to that level of service provision. As a result, the assessment team may decide to move on to Level 2 to determine whether it has the capacity to add Pap smear or VIA to its array of services. Some programs may find that this tool can be helpful in assessing the quality of services it already provides. Programs that already offer Pap smear screening services and that wish to add treatment services may find that reviewing questions from Level 2a will help them identify obstacles to their provision of effective Pap screening and think through how the obstacles can be overcome. Addressing these obstacles early on can help programs lay the groundwork for successful expansion of services. 4: Analyze the answers and develop an action plan The questions included in this tool are designed to help the assessment team identify training, outreach, facilities, information system, quality assurance, and material needs of their program. Each question in the assessment questionnaire asks you to reflect on the barriers that might exist. Barriers are scored on a scale from 0 to 5, with 0 indicating that no barrier exists and 5 indicating a barrier that would be very difficult to overcome. For example, you are asked about the availability of a light source for a visual examination and the magnitude of any barriers that exist in making a light source available. If a light source is readily available, there would be no barriers to implementation, and a score of 0 would be assigned to that question. Likewise, if no light source existed and it was impossible to identify a feasible light source in your setting, a score of 5 would be assigned to that question. �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Once each question in the assessment questionnaire is completed and the magnitude of barriers in relation to that question are is assessed, you are ready to move on to the summary worksheet at the end of the section. The worksheet is provided to assist you in determining if now is an appropriate time to expand services to include cervical cancer prevention and/or treatment. The worksheets use the number and magnitude of any barriers that are identified in the implementation of each section to calculate the capacity for program expansion. The scores of the magnitude of each barrier are added together to produce a total score. The total score is used to estimate the capacity of your program to expand services. The results of the program capacity assessment tool can then be used to develop an action plan that will guide the expansion process. Integrating Cervical Cancer Prevention into Reproductive Health Services 11 A Tool to Assess Program Capacity to Integrate Cervical Cancer Prevention into Reproductive Health Services 13 At this level, clinics would provide education and information about cervical cancer and its prevention, with an emphasis on how screening can detect precancerous lesions and prevent cancer. At the same time, clinics should refer clients who meet the local criteria for screening to other locations for screening and treatment. As part of broader efforts to prevent transmission of sexually transmitted infections (STIs), clinics also should describe the role of condoms and other barrier methods in preventing the spread of infections, including, to some extent, human papillomavirus (HPV), the primary causal agent of cervical cancer. The following questions are intended to help you evaluate whether education and information about cervical cancer and screening referral could be added without compromising the quality of current services offered in the clinic. A worksheet at the end of Level 1 will help you assess your program’s readiness to add these services. If you determine that integration of the new services is feasible, a plan of action will be needed that incorporates all the steps your clinic will need to take to implement education, information, and referral services. Include in your plan strategies for ensuring privacy, meeting training needs, providing appropriate referrals, and obtaining or developing necessary materials. Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening A Tool to Assess Program Capacity 14 Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening Considerations regarding referrals 1. Are referral options currently available for provision of effective cervical cancer screening services? Yes: Proceed to question 2. No: Identify barriers to identifying or establishing adequate referral sources and determine the feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Referral information should list location, hours, fees, and specific individuals to contact. This information needs to be available to all staff so that it can be easily distributed to clients as needed. Other mechanisms to ensure adequate referral systems include: • Standard protocol for referrals • Monitoring system for use of standard protocol • List of referral sites and their contact person(s) at site • Functioning communication systems in place between sites (letter, phone, fax, regular meetings, etc.) • Systems for follow-up/ tracking clients (with regular review to ensure that these systems are functioning) • Clear instructions for clients regarding the location of the site to which they are referred and how to make an appointment or when to go for services • System to ensure information sharing between primary and referral sites Integrating Cervical Cancer Prevention into Reproductive Health Services 15Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening 2. Does your program currently have an effective referral mechanism for health services other than cervical cancer? 2a. Yes: Can this system be adapted to include referrals for cervical cancer screening? If yes: Proceed to question 3. If no: Identify barriers to adapting your current referral system to accommodate the number of referrals for cervical cancer and assess the feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome 2b. No: Assess barriers to developing effective referral mechanism for health services, if needed, or systems for developing a stand-alone referral mechanism for cervical cancer screening. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome A Tool to Assess Program Capacity 16 Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening Considerations regarding health data 3. Do you have age-specific information on cervical cancer prevalence or incidence in your area to help you identify who should be targeted for education and information efforts? Yes: Proceed to question 4. No: Contact your health ministry or local cancer registry to determine the level of need or magnitude and identify those most in need of information. If this is not possible, describe barriers below. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Programs may want to first target women at the highest risk of cervical dysplasia. A reasonable target for a new cervical cancer program is to screen women aged 30 to 50 at least once. If additional financial resources are available to expand the program’s scope, program managers can consider expanding the targeted age group first to older women (up to age 60) and then to younger women (from age 30), as well as decreasing the interval between screenings of women. Integrating Cervical Cancer Prevention into Reproductive Health Services 17Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening Health providers’ knowledge, attitudes, and skills 4. Do service providers understand the importance of positive relationships with their women clients and work to foster these relationships? Yes: Proceed to question 5. No: Determine providers’ barriers or resistance to understanding and striving to develop positive relationships with their women clients. Assess the feasibility of overcoming these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome 5. Do service providers currently have adequate knowledge about cervical cancer and how to prevent it? Yes: Proceed to question 6. No: Identify barriers to increasing providers’ knowledge about cervical cancer. Identify staff who will need training, potential trainers, and feasibility of addressing barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome A staff survey can explore their knowledge and comfort level discussing: • What and where the cervix is • What cancer is and how it is detected • What causes cancer of the cervix and what groups are at highest risk • What can be done to prevent cancer of the cervix • A brief description of the test that will be used to detect those lesions that may turn into cancer • Appropriate follow-up and treatment if a cervical abnormality is detected Women frequently report that they are reluctant or unwilling to seek health care in general, and cervical cancer prevention services in particular, out of concerns about how they will be treated by their health care provider. The importance of a health care provider working to build a relationship with his or her client that is based upon trust and respect cannot be overstated. A Tool to Assess Program Capacity 18 Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening 6. Do service providers currently provide adequate education and information to clients on reproductive tract infections or other reproductive health issues? 6a. Yes: Can education and information on cervical cancer be included in these discussions? If yes: Proceed to question 7. If no: Examine barriers to including discussion of cervical cancer and assess the feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome 6b. No: Examine barriers to providing clients with adequate information and education on reproductive tract infections or other reproductive health issues and assess the feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Note: If it seems realistic that your program can address these barriers, continue with the first “yes” response to question 7. Integrating Cervical Cancer Prevention into Reproductive Health Services 19Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening 7. Do service providers at your program accept and support the provision of information and education for cervical cancer prevention? Yes: Proceed to question 8. No: Explore barriers to providers’ acceptance and support of providing information and education for cervical cancer prevention and assess feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome 8. Does your program currently have and use technical guidelines outlining how to provide effective information and education to clients? Yes: Proceed to question 9. No: Assess barriers to identifying and implementing technical guidelines and determine feasibility of overcoming these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Health programs lacking technical guidelines do not necessarily need to develop them on their own. Often, programs providing similar types of health services may have developed guidelines that they are willing to share. Even guidelines developed for use in other settings can potentially be adapted for use within your own program. A Tool to Assess Program Capacity 20 Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening 9. Will your program be able to add Level 1 services without compromising the quality of current services offered in the clinic, overburdening service providers, or increasing client waiting time? Yes: Proceed to question 10. No: Identify obstacles and assess feasibility of eliminating them. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Some practical considerations 10. Does your program’s current level of staffing allow service providers to add provision of information and education about cervical cancer to their workload? Yes: Proceed to question 11. No: Identify barriers to staff’s ability to add provision of information and education on cervical cancer to their workload, and assess feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Integrating Cervical Cancer Prevention into Reproductive Health Services 21Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening Programs may want to first target women at the highest risk of cervical dysplasia. A reasonable target for a new cervical cancer program is to screen women aged 30 to 50 at least once. If additional financial resources are available to expand the program’s scope, program managers can consider expanding the targeted age group first to older women (up to age 60) and then to younger women (from age 30), as well as decreasing the interval between screenings of women. 11. Does your program currently have adequate information, education, and communication (IEC) materials about cervical cancer? Yes: Proceed to question 12. No: Identify barriers to your program’s ability to obtain adequate information and education materials and assess feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Questions regarding the target group 12. Does your program attract women who are in the age range targeted by the referral site for cervical cancer screening? (A reasonable target for a cervical cancer program is to screen women aged 30 to 50 at least once.) Yes: Proceed to question 13. No: Determine whether your program has the capacity to perform outreach to women targeted by the referral clinic. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome To determine whether IEC materials are adequate, programs may consider the following: • Do clients understand important messages? • Are materials available in sufficient quantities for your program? • Are clinic service providers, counselors, outreach workers, and health educators satisfied with existing materials? A Tool to Assess Program Capacity 22 Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening Project monitoring 13. Is there a written plan for monitoring the implementation of expanded service delivery: (The plan should include types of data that will be easily collected, a timeline for data collection, and measurable indicators.) Yes: Proceed to summary worksheet. No: Assess barriers to establishing and implementing an effective monitoring plan for expanded service delivery. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Complete Level 1 Worksheet at the end of this section. This sheet will help you determine whether it is realistic to integrate education, information, and counseling services about cervical cancer prevention into your existing program. Integrating Cervical Cancer Prevention into Reproductive Health Services 23Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening Level 1 Worksheet Assessing your program’s capacity to provide information and education about cervical cancer and referral for screening. This worksheet helps you to perform some simple calculations for identifying whether your program is well positioned to add information and education about cervical cancer and referral for screening into its services. For each question, put the number you selected to rank the magnitude of the barrier in the space to the right. The question topics are numbered to correspond to the number of the question in the assessment questionnaire that you just completed. Remember that each barrier should be ranked from 0 to 5, with 0 = no barriers and 5 = very difficult barriers to overcome. Level 1 Worksheet scipoTnoitseuQ noitatnemelpmIotsreirraB morfrebmungnidnopserrocretnE( )noitseuqhcaeotrewsnaruoy snoitpolarrefeR.1 msinahcemlarrefergnitpadA.a2 ro metsyslarrefergnipoleveD.b2 atadhtlaeH.3 pihsnoitalertneilc/redivorpevitisoP.4 egdelwonkrecnaclacivreC.5 yticapacCEIrecnaclacivreC.a6 ro yticapacCEIITR.b6 CEIroftroppusredivorP.7 senilediugCEI.8 secivresfoytilauQ.9 gniffatsCEI.01 slairetamrecnaclacivrecCEI.11 puorgtegraT.21 gnirotinoMtcejorP.31 EROCSLATOT ).erocslatotetaluclacotnmulocnisrebmunlladdA( A Tool to Assess Program Capacity 24 Level 1: Providing Education and Information About Cervical Cancer and Referral for Screening It is likely that you identified some barriers to providing information and education in your program. The total score that you have derived from this worksheet is the result of the Level One Program Capacity Assessment. Use this number to help guide you regarding plans for program expansion. The result can be interpreted as follows: Results of Program Capacity Assessment If your total score was between 0 and 26, your program is very likely able to support the addition of new services. Most of the key components are probably in place, and with effective planning, your program could successfully integrate education and information services. If your total score was in the range of 27-52, your program probably has many of the important components in place that make it possible to adequately provide important information and education about cervical cancer prevention. If your total score was 53 or higher, your program probably is not prepared to add new activities to its current array of services. In this case, you may consider focusing your efforts on general strategies for STI prevention or toward referring women elsewhere for education and information about cervical cancer prevention. EROCSLATOT TLUSER SPETSTXEN 62-0 margorpotsreirrablaminiM noisnapxe DEECORP dnapxeotsnalphtiw secivres 25-72 otsreirrabelbaredisnoC noisnapxemargorp REDISNOC dnapxeotseigetarts neebevahsreirrabecnosecivres decuder 56-35 margorpotsreirrabereveS noisnapxe YALED secivresdnapxeotsnalp neebevahsreirrablitnu desserdda 25 Level 2a: Cervical Cancer Screening with Pap Smears Level 2a assumes that your program has the capacity to provide education and information discussed in Level 1. At Level 2a, services are expanded to provide cervical cancer counseling, screening, and referral for treatment or further evaluation. Pap smear is the current standard test for cervical cancer screening in many countries and requires trained personnel; appropriate equipment, supplies, and clinical facilities; effective and efficient cytology laboratories; and patient follow-up capabilities. The following questions are intended to help you evaluate whether Pap smear screening services could be added without compromising the quality of current services offered in the clinic, overburdening service providers, or increasing client waiting time. A worksheet at the end of this level will help you assess your program’s readiness to add these services. If you determine that integration of the new services is feasible, a plan of action will be needed that incorporates all the steps your clinic will need to take to implement Pap smear screening services. Include in your plan the changes necessary for providing privacy, meeting training needs, and procuring necessary supplies. If Pap smear screening is not feasible in your setting, proceed to Level 2b, “Cervical Cancer Screening Using Visual Inspection with Acetic Acid (VIA).” Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment A Tool to Assess Program Capacity 26 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Access and acceptability 1. Will the community in general, and women in particular, know about and accept the provision of cervical cancer counseling, Pap smear screening, and referrals for diagnosis and treatment? Yes: Proceed to question 2. No: Assess barriers to community and women’s awareness and acceptance of these services. Determine the feasibility of your program addressing these barriers through community outreach and education. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 27 Counseling considerations 2. Does your program currently provide effective counseling to women on reproductive health issues? 2a. Yes: Is it feasible to integrate cervical cancer counseling into these existing services? If yes: Proceed to question 3. If no: Explore barriers to integrating cervical cancer into existing counseling services and determine feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome 2b. No: Determine barriers to providing effective counseling to women on reproductive health issues and assess feasibility of eliminating these barriers. If these barriers seem surmountable, return to the first “Yes” response for this question. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome A Tool to Assess Program Capacity 28 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment 3. Do service providers have adequate counseling skills such as empathic listening or reflective feedback that enable them to communicate effectively with women about important reproductive health issues? Yes: Proceed to question 4. No: Identify barriers, staff training needs, potential trainers, and the feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome 4. Is a private area available at your program where counseling can be provided? Yes: Proceed to question 5. No: Identify barriers to establishing a private area and assess the feasibility of eliminating these barriers: Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 29 Availability of adequate laboratory services 5. Is there an accessible and reliable cytology laboratory service that is capable of handling the estimated increase in Pap smears? Yes: Proceed to question 6. No: Assess barriers to strengthening laboratory capacities and the feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Note: If it is clear that it will not be possible to eliminate these barriers, proceed to section 2b on visual inspection with acetic acid on page 42 of this manual. Considerations when assessing a laboratory’s capacity to do Pap smears: • Where is the lab located? • What transportation mechanisms exist? • How frequently can smears be transported to the lab? • How quickly are the results sent back to the institutions (maximum recommended interval between testing and results is one month) • For smears stored for transportation, what storage systems exist? Are these systems appropriate? • Can you easily communicate with the lab to ask questions about specific results? • Can the lab accommodate the additional slides that your clinic’s screening service would require? • Does the lab have quality control mechanisms in place? What are they? The World Health Organization suggests that cytology laboratory services be centralized to allow for a specialized division of labor and a sufficient number of abnormal smears, which help maintain the interest and diagnostic skills of the cytotechnologists and cytopathologists. The annual number of specimens processed by a cytology laboratory service should preferably be 25,000, and the laboratory should be headed by a full-time cytopathologist. All abnormal or questionable smears and a fraction (i.e., 10%) of the negatives should be reviewed by the responsible cytopathologist. A Tool to Assess Program Capacity 30 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Staff capacity to provide screening services 6. Does your program’s current level of staffing allow service providers to add provision of counseling, Pap screening, and treatment referral for cervical cancer prevention to their workload? Yes: Proceed to question 7. No: Identify barriers to staff’s ability to add provision of information and education on cervical cancer to their workload, and assess feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome 7. Are service providers at your program currently well trained and able to perform speculum examinations? Yes: Proceed to question 8. No: Assess barriers to training service providers in performing speculum exams. Determine how you would obtain supplies and identify and train appropriate service providers to perform speculum exams, and assess feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome There are four steps to providing a pelvic exam: • Examine the abdomen and groin. • Inspect the external genitalia. • Perform the speculum and bimanual examinations. • Perform the rectovaginal examination, if necessary. —Cervical Cancer Prevention Guidelines for Low-Resource Settings, JHPIEGO. Draft, April 2000. Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 31 8. Are service providers skilled at obtaining and preparing high-quality cervical samples? 8a. Yes: Does your program have the capacity to provide ongoing training to ensure a high quality of care in obtaining and preparing high-quality cervical samples for cytology? If yes: Proceed to question 9. If no: Identify barriers that prevent your program from being able to provide refresher training to service providers. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome 8b. No: Assess barriers that would prevent your program from being able to provide initial and refresher training to service providers. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome If these barriers seem surmountable, return to the first “Yes” response for this question. Taking a Pap smear involves: • Speculum exam (For information on how to perform a speculum exam, see McIntosh, et al. in the list of helpful resources at the end of this manual.) • Ectocervical sampling with a wooden spatula to scrape cells from the external cervix • Endocervical sampling using a cotton swab or Cytobrush to obtain cells from the endocervical canal • Spreading specimens on a glass slide • Immediately treating specimens with fixative (or air dry). Some considerations when assessing staff ability to take a Pap smear include: • Do service providers have adequate knowledge of Pap screening technique? • When and where did they receive their training? • Have they been using their skills in recent years? • Would they benefit from refresher training? • Which staff will need training on Pap smear technique? • Who would provide this training? • What would it cost? A Tool to Assess Program Capacity 32 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment 9. Do service providers at your program have adequate knowledge and skills with regard to practicing effective infection prevention procedures to ensure safe speculum examinations? Yes: Proceed to question 10. No: Identify barriers to practicing effective infection prevention procedures and assess feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Material requirements for Pap smear screening 10. Does your program have a private area in which to perform the pelvic exam? Yes: Proceed to question 11. No: Identify barriers to establishing a private area and assess the feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Infection prevention skills include hand washing, waste disposal, and instrument processing. The three basic steps for processing instruments, gloves, and other items are: • Decontamination • Cleaning, and either • Sterilization or high-level disinfection Drawing curtains around the screening area can help to create a private space. It is also helpful to turn the examination table so that the woman’s feet are not facing a doorway or public space. Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 33 11. Is a sufficient light source available? Yes: Proceed to Question 12. No: Determine the feasibility of obtaining an adequate light source. At a minimum, a flashlight is sufficient. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome A window may provide enough light for taking the Pap smear (though it is important to ensure privacy if window light is being used). If not, a light source such as a goosenecked lamp or a flashlight (torch) can be used. The light must be enough to see the upper end of the vagina where the cervix is usually found, but should not create so much heat that it is uncomfortable for either the client or the provider. A high quality flashlight provides adequate light without too much heat. A Tool to Assess Program Capacity 34 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment 12. The following supplies must be available in the clinic in sufficient quantities to perform the number of Pap smears you plan to provide. Do or will you have these supplies? Yes � No � Speculum Yes � No � Exam table Yes � No � Exam gloves Yes � No � Large cotton swabs to remove excess mucus or discharge Yes � No � Wooden or plastic spatula Yes � No � Cytobrush or cotton swabs for obtaining cells from endocervical canal Yes � No � Clean glass slides with frosted end (or some other mechanism that enables labeling of the slide) Yes � No � Suitable fixative Yes � No � Containers and packing material for transport of slides Yes � No � Record and request forms Yes � No � Lead pencils Yes � No � Filing cabinet for records or other record- keeping system (such as a computer) Based on your answers above, consider any existing barriers to obtaining these supplies and having continuous access to them. Note: If having continuous access to the supplies listed in question 12 is not feasible for your program, consider focusing your efforts on general strategies for making STI prevention and treatment available locally or consider Level 2b, “Cervical Cancer Screening Using Visual Inspection with Acetic Acid (VIA).” Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 35 13. The following supplies are necessary for infection prevention. Do or will you have the following available in your clinic? Yes � No � Soap, towels Yes � No � Water supply or potable water Yes � No � Pails for decontamination Yes � No � Chlorine Yes � No � Detergent Yes � No � Brushes Yes � No � Functioning sink Yes � No � Utility gloves Yes � No � Functioning boiler/steamer or autoclave Yes � No � Covered storage containers Based on your responses above, consider any existing barriers to obtaining them and having continuous access to them. Note: If having continuous access to the supplies listed in question 13 is not feasible for your program, consider focusing your efforts on general strategies for making STI prevention and treatment available locally before you consider providing cervical cancer screening services. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome A Tool to Assess Program Capacity 36 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Diagnosis and treatment referral sites 14. Is there a health center or hospital within a reasonable distance to your program sit that provides effective diagnosis and treatment (cryotherapy or LEEP) for precancerous lesions? Yes: Proceed to question 15. No: Identify barriers to health centers or hospitals providing effective diagnosis and treatment and assess the feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Note: If referral options for effective diagnosis and treatment are not available or feasible for women in your community, consider focusing your efforts on general strategies for making STI prevention and treatment available locally before you consider providing Pap smear screening. Considerations when assessing the referral site’s ability to meet women’s needs: • Where are the services located? • What are their hours? • How long does it take for women to travel to these services from their homes? • Do clients present for referred services? • Do clients receive services within a reasonable time frame after they present for services? • Have women been satisfied with these services in the past? • Is the care of good quality? • Is there a cost to services? • What options do women have if they cannot afford the cost of these services? Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 37 15. Does your program currently have an effective referral mechanism for other types of health services? 15a. Yes: Can this system be adapted to include referrals for cervical cancer diagnosis and treatment? If yes: Proceed to question 16. If no: Assess barriers to establishing effective referral mechanisms for cervical cancer diagnosis and treatment within already existing referral mechanisms. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome 15b. No: Assess barriers to the development of effective referral mechanisms and the feasibility of eliminating them. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Referral information should list location, hours, fees, and specific individuals to contact. This information needs to be available to all staff so that it can be easily distributed to clients as needed. Other mechanisms to ensure adequate referral systems include: • Standard protocol for referrals • Monitoring system for use of standard protocol • List of referral sites and contact person(s) at site • Functioning communication systems in place between sites (letter, phone, fax, regular meetings, etc.) • Systems for follow-up/ tracking clients (with regular review to ensure that these systems are functioning) • Clear instructions for clients regarding the location of the site to which they are referred and how to make an appointment or when to go for services • System to ensure information sharing between primary and referral sites A Tool to Assess Program Capacity 38 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Follow-up mechanisms 16. Does your program currently have an effective mechanism for following clients who have been screened? Yes: Proceed to question 17. No: Assess barriers to establishing effective follow-up mechanisms for women who have been screened. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Well-functioning information systems are essential to successful client follow-up. Program monitoring and evaluation, quality assurance, and identification of women at risk also can be strengthened by developing effective information systems. Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 39 Project monitoring 17. Is there a written plan for monitoring the implementation of expanded service delivery? (The plan should include types of data that will be easily collected, a timeline for data collection, and measurable indicators.) Yes: Proceed to summary worksheet. No: Assess barriers to establishing and implementing an effective monitoring plan for expanded service delivery. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Complete Level 2a Worksheet at the end of this section. This sheet will help you determine whether it is realistic to integrate cervical cancer prevention, education, information, counseling, and pap smear screening and treatment referral services into your existing program. A Tool to Assess Program Capacity 40 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Level 2a Worksheet Assessing your program’s capacity to provide cervical cancer counseling, Pap smear screening, and treatment referral This worksheet helps you to perform some simple calculations to help identify whether your program is well positioned to add cervical cancer counseling, Pap smear screening, and treatment referral into its services. For each question, put the number you selected to rank the magnitude of the barrier in the space to the right. The question topics are numbered to correspond to the number of the question in the assessment questionnaire that you just completed. Remember that each barrier should be ranked from 0 to 5, with 0 = no barriers and 5 = very difficult barriers to overcome. Level 2a Worksheet scipoTnoitseuQ noitatnemelpmIotsreirraB ruoymorfrebmungnidnopserrocretnE( ).noitseuqhcaeotrewsna ytilibatpeccadnasseccA.1 gnilesnuocrecnaclacivrecetargetnI.a2 ro gnilesnuochtlaehevitcudorperevitceffE.b2 slliksgnilesnuoC.3 ycavirpgnilesnuoC.4 ecivresyrotarobaL.5 gniffatsetauqedA.6 snoitanimaxemulucepS.7 selpmaslacivrecgniniatbonisredivorprofgniniartrehserfeR.a8 ro gniniatbonisredivorprofgniniartrehserferdnalaitinI.b8 selpmaslacivrec slliks/egdelwonknoitneverpnoitcefnI.9 ycavirpnoitanimaxE.01 secruosthgiL.11 sraemspaProfseilppuS.21 noitneverpnoitcefnirofseilppuS.31 tnemtaertdnasisongaidotsseccA.41 larreferevitceffegnitargetnI.a51 ro larreferevitceffegnihsilbatsE.b51 msinahcempu-wolloF.61 gnirotinomtcejorP.71 EROCSLATOT )erocslatotetaluclacotnmulocnisrebmunlladdA( Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 41 It is likely that you identified some barriers to providing information and education in your program. The total score that you have derived from this worksheet is the result of the Level Two Program Capacity Assessment. Use this number to help guide you regarding plans for program expansion. The result can be interpreted as follows: Results of Program Capacity Assessment If your total score was between 0 and 34, your program is very likely able to support the addition of new services. Most of the key components are probably in place, and with effective planning, your program could successfully integrate cervical cancer counseling, screening, and treatment referral services. If your total score was in the range of 35-68, your program probably has many of the important components in place that make it possible to adequately provide cervical cancer counseling, screening, and treatment referral. If your total score was 69 or higher, your program probably is not prepared to add new activities to its current array of services. In this case, you may consider focusing your efforts on providing information and education about STI prevention or cervical cancer specifically and toward referring women elsewhere for cervical cancer counseling, screening, and treatment. Discussion of Worksheet Findings It is important to note that this numeric scale is intended only to offer guidance when considering your program’s readiness to integrate new services. Important issues such as political factors, staff morale, or social concerns—all issues that could influence a program’s ability to take on new activities—may not be identified by using this tool. The assessment team may make their best decision about whether to integrate new services by carefully weighing the barriers described above and combining that information with their own understanding of the program’s assets and challenges. Furthermore, even programs scoring highly on this scale should pay particularly close attention to any barriers that are rated 3-5. A program’s inability to address a key barrier can make it impossible to provide effective services. Since all of the components outlined in the assessment questionnaire are important to successful integration of additional services, any program that has more than two scores of 5 may consider stopping to address that particular barrier before proceeding with the addition of new services. EROCSLATOT TLUSER SPETSTXEN 43-0 margorpotsreirrablaminiM noisnapxe DEECORP dnapxeotsnalphtiw secivres 86-53 otsreirrabelbaredisnoC noisnapxemargorp REDISNOC dnapxeotseigetarts neebevahsreirrabecnosecivres decuder 58-96 margorpotsreirrabereveS noisnapxe YALED secivresdnapxeotsnalp neebevahsreirrablitnu desserdda A Tool to Assess Program Capacity 42 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Level 2b: Cervical Cancer Screening Using Visual Inspection with Acetic Acid (VIA) Level 2b assumes that your program has the capacity to provide education and information discussed in Level 1. While Pap smear is the standard test for cervical cancer screening in most countries, the programmatic and logistic requirements of a Pap smear based program are not feasible in all environments. Alternatives to the Pap smear for cervical cancer are currently under investigation and may provide a reasonable screening solution for some areas. The following questions are intended to help you evaluate whether VIA screening services could be added without compromising the quality of current services offered in the clinic, overburdening service providers, or increasing client waiting time. A worksheet at the end of this Level will help you assess your program’s readiness to add these services. If you determine that integration of the new services is feasible, a plan of action is needed that incorporates all the steps your clinic will need to take to implement VIA screening services. Include in your plan strategies for ensuring privacy, meeting training needs, and procuring necessary supplies. If you cannot achieve all necessary steps, your clinic may not be an appropriate location for cervical cancer screening. VIA and Pap screening share many of the same requirements with regard to counseling, addressing women’s concerns, referral mechanisms, infection control, and follow-up. Feel free to either complete the questions again in this section or refer back to the answers you supplied from Level 2a. Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 43 Access and acceptability 1. Will the community in general, and women in particular, know about and accept the provision of cervical cancer counseling, VIA, and referrals for diagnosis and treatment? Yes: Proceed to question 2. No: Assess barriers to community and women’s awareness and acceptance of these services. Determine the feasibility of your program addressing these barriers through community outreach and education. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome A Tool to Assess Program Capacity 44 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Counseling considerations 2. Does your program currently provide effective counseling to women about reproductive health issues? 2a. Yes: Is it feasible to integrate cervical cancer counseling into these existing services? If yes: Proceed to question 3. If no: Explore barriers to integrating cervical cancer into existing counseling services and determine feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome 2b. No: Determine barriers to providing effective counseling to women on reproductive health issues and assess feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 45 3. Do service providers have adequate counseling skills such as empathic listening or reflective feedback that enable them to communicate effectively with women about important reproductive health issues? Yes: Proceed to question 4. No: Identify barriers, staff training needs, potential trainers, and the feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Staff capacity to provide VIA services 4. Does your program’s current level of staffing allow service providers to add provision of counseling, VIA, and treatment referral for cervical cancer prevention to their workload? Yes: Proceed to question 5. No: Identify barriers to staff’s ability to add provision of information and education on cervical cancer to their workload, and assess feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome A Tool to Assess Program Capacity 46 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment 5. Are service providers at your program currently well trained and able to perform speculum examinations? Yes: Proceed to question 6. No: Assess barriers to training service providers in performing speculum exams. Determine how you would obtain supplies and identify and train appropriate service providers to perform speculum exams, and assess feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome 6. Do service providers have adequate knowledge and skills to perform VIA? Yes: Proceed to question 7. No: Identify barriers to service providers’ ability to attain adequate knowledge and skills to perform VIA. Determine whether these barriers can be addressed. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Training is an essential component of an effective VIA program. Staff must have standardized training and ample opportunities to view various kinds of cervical abnormalities, including moderate and severe dysplasia. The time and effort required should not be underestimated. Procedures for training will depend on the background and level of experience of the service provider. Ongoing training and supervision is important for all levels of providers performing VIA. There are four steps to providing a pelvic exam: • Examine the abdomen and groin. • Inspect the external genitalia. • Perform the speculum and bimanual examinations. • Perform the rectovaginal examination, if necessary. —Cervical Cancer Prevention Guidelines for Low-Resource Settings, JHPIEGO. Draft, April 2000. Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 47 7. Does your program have the capacity to provide ongoing training to ensure that those performing VIA are providing high-quality care? Yes: Proceed to question 8. No: Identify barriers that prevent your program from being able to provide ongoing refresher training in VIA. Determine whether these barriers can be addressed. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome 8. Do service providers at your program have adequate knowledge and skills with regard to practicing effective infection prevention procedures to ensure safe speculum examinations? Yes: Proceed to question 9. No: Identify barriers to practicing effective infection prevention procedures and assess feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Some considerations when assessing whether you would be able to provide VIA screening training to your staff: • Which staff will need training related to VIA technique? • Who would provide the training? • What would it cost? • Would this be feasible? • How will provider performance be evaluated and monitored? Infection prevention skills include hand washing, waste disposal, and instrument processing. The three basic steps for processing instruments, gloves, and other items are: • Decontamination • Cleaning, and either • Sterilization or high-level disinfection A Tool to Assess Program Capacity 48 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Material requirements for VIA 9. Is a private area available at your program where counseling and screening can be provided? Yes: Proceed to question 10. No: Identify barriers to establishing a private area and assess the feasibility of eliminating these barriers: Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome 10. Is a sufficient light source available? Yes: Proceed to question 11. No: Determine the feasibility of obtaining an adequate light source. At a minimum, a flashlight is sufficient. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Drawing curtains around the screening area can help to create a private space. It is also helpful to turn the examination table so that the woman’s feet are not facing a doorway or public space. Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 49 11. The following supplies are needed for VIA. Do you have or will you have the following supplies available in your program? Yes � No � Speculum Yes � No � Exam table Yes � No � Exam gloves Yes � No � Record form for recording findings Yes � No � Acetic acid/vinegar Yes � No � Large cotton swabs (for applying acetic acid to cervix) Yes � No � Filing cabinet for records or other record- keeping device (such as a computer) Based on your responses above, consider any existing barriers to obtaining these supplies and having continuous access to them. Note: If having continuous access to the supplies listed in question 11 is not feasible for your program, consider focusing your efforts on general strategies for making STI prevention and treatment available locally before you consider providing VIA. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome A Tool to Assess Program Capacity 50 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment 12. The following supplies are needed for infection prevention. Do or will you have these supplies? Yes � No � Soap, towels Yes � No � Water supply or potable water Yes � No � Pails for decontamination Yes � No � Chlorine Yes � No � Detergent Yes � No � Brushes Yes � No � Functioning sink Yes � No � Utility gloves Yes � No � Functioning boiler/steamer or autoclave Yes � No � Covered storage containers Based on your responses above, consider any existing barriers to obtaining these supplies and having continuous access to them. Note: If having continuous access to the supplies listed in question 12 is not feasible for your program, consider focusing your efforts on general strategies for making STI prevention and treatment available locally before you consider providing VIA. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 51 Diagnosis and treatment referral sites 13. Is there a health center or hospital within a reasonable distance to your program site that provides effective diagnosis and treatment (cryotherapy or LEEP) for precancerous lesions? Yes: Proceed to question 14. No: Identify barriers to health centers or hospitals providing effective diagnosis and treatment and assess the feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Note: If referral options for effective diagnosis and treatment are not available or feasible for women in your community, consider focusing your efforts on general strategies for making STI prevention and treatment available locally before you consider providing VIA. Considerations when assessing the referral site’s ability to meet women’s needs: • Where are the services located? • What are their hours? • How long does it take for women to travel to these services from their homes? • Do clients present for referred services? • Do clients receive services within a reasonable time frame after they present for services? • Have women been satisfied with these services in the past? • Is the care of good quality? • Is there a cost to services? • What options do women have if they cannot afford the cost of these services? A Tool to Assess Program Capacity 52 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment 14. Does your program currently have an effective referral mechanism for other types of health services? 14a. Yes: Can this system be adapted to include referrals for cervical cancer diagnosis and treatment? If yes: Proceed to question 15. If no: Assess barriers to establishing effective referral mechanisms for cervical cancer diagnosis and treatment within already existing referral mechanisms. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome 14b. No: Assess barriers to the development of effective referral mechanisms and the feasibility of eliminating them. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Referral information should list location, hours, fees, and specific individuals to contact. This information needs to be available to all staff so that it can be easily distributed to clients as needed. Other mechanisms to ensure adequate referral systems include: • Standard protocol for referrals • Monitoring system for use of standard protocol • List of referral sites and contact person(s) at site • Functioning communication systems in place between sites (letter, phone, fax, regular meetings, etc.) • Systems for follow-up/ tracking clients (with regular review to ensure that these systems are functioning) • Clear instructions for clients regarding the location of the site to which they are referred and how to make an appointment or when to go for services • System to ensure information sharing between primary and referral sites Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 53 Follow-up mechanisms 15. Does your program currently have an effective mechanism for following clients who have been screened? Yes: Proceed to question 16. No: Assess barriers to establishing effective follow-up mechanisms for women who have been screened. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Alternative cervical cancer screening information systems may be maintained at the community level through women’s health organizations or mobile health workers, augmenting hospital- or clinic-based information systems. Review of individual screening and follow-up needs can be incorporated into an organization’s regular meetings, which can be particularly helpful to low- literate women. A Tool to Assess Program Capacity 54 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Project monitoring 16. Is there a written plan for monitoring the implementation of expanded service delivery? (The plan should include types of data that will be easily collected, a timeline for data collection, and measurable indicators.) Yes: Proceed to summary worksheet. No: Assess barriers to establishing and implementing an effective monitoring plan for expanded service delivery. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Complete Level 2b Worksheet at the end of this section. This sheet will help you determine whether it is realistic to integrate education, information, counseling, and screening services about cervical cancer prevention into your existing program. Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment Integrating Cervical Cancer Prevention into Reproductive Health Services 55 Level 2b Worksheet Assessing your program’s capacity to provide cervical cancer counseling, VIA screening, and treatment referral This worksheet helps you to perform some simple calculations to help identify whether your program is well positioned to add cervical cancer counseling, VIA screening, and treatment referral into its services. For each question, put the number you selected to rank the magnitude of the barrier in the space to the right. The question topics are numbered to correspond to the number of the question in the assessment questionnaire that you just completed. Remember that each barrier should be ranked from 0 to 5, with 0 = no barriers and 5 = very difficult barriers to overcome. Level 2b Worksheet scipoTnoitseuQ noitatnemelpmIotsreirraB morfrebmungnidnopserrocretnE( ).noitseuqhcaeotrewsnaruoy ecnatpeccaytinummoC.1 gnilesnuocrecnaclacivrecetargetnI.a2 ro gnilesnuochtlaehevitcudorperhsilbatsE.b2 slliksgnilesnuoC.3 gniffatsetauqedA.4 snoitanimaxemulucepS.5 egdelwonk/slliksAIV.6 noisivrepus/gniniartAIV.7 slliks/egdelwonknoitneverpnoitcefnI.8 aeraetavirP.9 ecruosthgiL.01 AIVrofseilppuS.11 noitneverpnoitcefnirofseilppuS.21 tnemtaertdnasisongaidotsseccA.31 larreferrecnaclacivrecetargetnI.a41 ro larreferevitceffehsilbatsE.b41 smsinahcempu-wolloF.51 gnirotinomtcejorP.61 EROCSLATOT )erocslatotetaluclacotnmulocnisrebmunlladdA( A Tool to Assess Program Capacity 56 Level 2: Cervical Cancer Counseling, Screening, and Referral for Treatment It is likely that you identified some barriers to providing information and education in your program. The total score that you have derived from this worksheet is the result of the Level Two Program Capacity Assessment. Use this number to help guide you regarding plans for program expansion. The result can be interpreted as follows: Results of Program Capacity Assessment If your total score was between 0 and 32, your program is very likely able to support the addition of new services. Most of the key components are probably in place, and with effective planning, your program could successfully integrate cervical cancer counseling, screening, and treatment referral services. If your total score was in the range of 33-64, your program probably has many of the important components in place that make it possible to adequately provide cervical cancer counseling, screening, and treatment referral. If your total score was 65 or greater, your program probably is not prepared to add new activities to its current array of services. In this case, you may consider focusing your efforts on providing information and education about STI prevention or cervical cancer specifically and toward referring women elsewhere for cervical cancer counseling, screening, and treatment referral. Discussion of Worksheet Findings This numeric scale is intended only to offer guidance when considering your program’s readiness to integrate new services. Important issues such as political factors, staff morale, or social concerns—all issues that could influence a program’s ability to take on new activities— may not be identified by using this tool. The assessment team may make their best decision about whether to integrate new services by carefully weighing the barriers described above and combining that information with their own understanding of the program’s assets and challenges. Furthermore, even programs scoring highly on this scale should pay particularly close attention to any barriers that are rated 3-5. A program’s inability to address a key barrier can make it impossible to provide effective services. Since all of the components outlined in the assessment questionnaire are important to successful integration of additional services, any program that has more than two scores of 5 may consider stopping to address that particular barrier before proceeding with the addition of new services. EROCSLATOT TLUSER SPETSTXEN 23-0 margorpotsreirrablaminiM noisnapxe DEECORP dnapxeotsnalphtiw secivres 46-33 otsreirrabelbaredisnoC noisnapxemargorp REDISNOC dnapxeotseigetarts neebevahsreirrabecnosecivres decuder 08-56 margorpotsreirrabereveS noisnapxe YALED secivresdnapxeotsnalp neebevahsreirrablitnu desserdda 57 Level 3 assumes that your program has the capacity to provide information and education as described in Level 1 and has met the screening requirements described in Level 2a or 2b. At Level 3, services are expanded to provide counseling, diagnosis, and treatment of cervical dysplasia and referral for cases of suspected cervical cancer. Colposcopy is widely accepted as a diagnostic test for cervical dysplasia, especially when accompanied by biopsy. Treatment options include the use of cryotherapy and/or the Loop Electrosurgical Excision Procedure (LEEP). The following questions are intended to help you evaluate whether counseling, colposcopy, treatment of precancer, and referral for invasive cancer treatment could be added without compromising the quality of current services offered in the clinic, overburdening service providers, or increasing client waiting time. Level 3a focuses on colposcopic examination as a way to diagnose dysplasia. Level 3b adds treatment of dysplasia with cryotherapy. Level 3c adds LEEP services to treat cervical dysplasia. A worksheet at the end of this level will help you assess your program’s readiness to add these services. If you determine that integration of the new services is feasible, a plan of action will be needed that incorporates all the steps your clinic will need to take to implement each type of diagnosis and treatment service. Include in your plan the changes necessary for providing privacy, meeting training needs, and procuring necessary supplies. Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care A Tool to Assess Program Capacity 58 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Level 3a: Colposcopic Examination A colposcopic examination, followed by biopsy if indicated, is the standard diagnostic procedure for cervical lesions in areas where resources are not limited. In resource-poor settings, colposcopic diagnosis may not be possible. This assessment tool is designed to assist you in determining whether or not colposcopic assessment will be possible in your clinical setting. Other options include performing a second screening test, using a hand-held magnifying device instead of a colposcope for diagnosis, performing biopsies without magnified guidance, and providing treatment on the basis of a VIA assessment. Note: If your program is considering providing colposcopy, you must then offer viable treatment and follow-up options, both for precancer and cancer, either at the clinic or through referral. Availability of adequate laboratory services 1. Is there an accessible and reliable laboratory service that is capable of handling the estimated increase in histological specimens in a reasonable timeframe? Yes: Proceed to question 2. No: Assess barriers to strengthening laboratory capacities and the feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Some programs use colposcopy to screen for precancer, but do not obtain a histological specimen. Instead treatment is performed based on colposcopy alone. If you want to examine your program’s readiness to obtain biopsies, then be sure to answer questions 4 and 5. Considerations when assessing a laboratory’s capacity to examine biopsy specimens • Where is the lab located? • What transportation mechanisms exist? • How frequently can specimens be transported to the lab? • How quickly are the results sent back to the institutions? (Maximum recommended interval between testing and results is one month.) • For specimens stored for transportation, what storage systems exist? Are these systems appropriate? • Can you easily communicate with the lab to ask questions about specific results? • Can the lab accommodate the additional specimens that your clinic’s screening service would require? • Does the lab have quality control mechanisms in place? What are they? Integrating Cervical Cancer Prevention into Reproductive Health Services 59Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Staff capacity to provide screening services 2. Does your program’s current level of staffing allow service providers to add provision of cervical cancer counseling, diagnosis, and referral for suspected cervical cancer to their workload? Yes: Proceed to question 3. No: Identify barriers to staff’s ability to add provision of cervical cancer counseling, diagnosis, and referral for suspected cervical cancer to their workload, and assess feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome 3. Are service providers at your program currently well trained and able to perform colposcopic examinations? Yes: Proceed to question 4. No: Assess barriers to training service providers in performing diagnostic exams. Determine how you would identify and train appropriate service providers to perform colposcopic exams and assess feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome “Classical” colposcopy uses acetic acid with or without the use of Schiller’s iodine, and “saline” colposcopy uses saline solution to bathe the cervix. The steps used in a colposcopy exam are as follows: 1. Explain the procedure to the woman. 2. Obtain her informed consent. 3. Obtain a relevant history about past obstetrical and gynecological events and history of any potentially harmful and relevant exposures and susceptibilities. 4. Insert the vaginal speculum and inspect the cervix. 5. Apply normal saline solution to note abnormalities in cervical capillaries and surface blood vessels and to identify the inner and outer borders of the transformation zone. 6. Apply acetic acid to inspect the squamocolumnar junction and any areas of abnormal transformation zone. 7. Apply Schiller’s iodine to assist in clearly delineating the borders of a lesion. 8. Obtain a cervical biopsy. 9. Perform an endocervical curettage, if indicated. 10.Inspect vaginal walls, vulva, perineum and perianal areas. 11. Explain the examination findings to the woman. 12.Document examination findings. A Tool to Assess Program Capacity 60 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care 4. Are service providers skilled at obtaining and preparing high-quality biopsy/endocervical curettage specimens? 4a. Yes: Does your program have the capacity to provide ongoing training to ensure high-quality care in obtaining and preparing high-quality biopsy/ endocervical curettage specimens for histological analysis? If yes: Proceed to question 5. If no: Identify barriers that prevent your program from being able to provide refresher training to service providers. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome 4b. No: Assess barriers that would prevent your program from being able to provide initial and refresher training to service providers. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Cervical Biopsy Procedure Once an abnormal transformation zone is detected, the area is evaluated and compared with other similar areas to determine the biopsy site. The biopsy instrument is applied firmly to the cervical surface. Once the specimen is obtained, it is placed in formalin. Gentle pressure with a silver nitrate stick or a cotton-tipped applicator dipped in ferric subsulphate paste is then applied to the biopsy site to cauterize the wound. Endocervical Curettage Endocervical curettage obtains a histological sample by using a curette to scrape the endocervical canal. Lesions that are located in the endocervical canal are not usually visible through colposcopy. In those cases, endocervical curettage may be indicated. Integrating Cervical Cancer Prevention into Reproductive Health Services 61Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Material requirements for colposcopy 5. The following supplies must be available in the clinic in sufficient quantities to perform the number of diagnostic examinations you plan to provide. Do or will you have these supplies? Yes � No � Colposcope Yes � No � Examination table that allows the examiner to insert the speculum and see the cervix Yes � No � Bivalve speculum Yes � No � Punch biopsy instruments Yes � No � Endocervical curettes Yes � No � Light source that allows the examiner to see the cervix General supplies Yes � No � Vaginal swabs Yes � No � Examination gloves Yes � No � Containers and packing material for transport of specimens Yes � No � Record and request forms Yes � No � Lead pencils Yes � No � Filing cabinet for records or other record- keeping system (such as a computer) Based on your responses above, consider any barriers to obtaining these supplies and having continuous access to them. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome While colposcopes can cost $5,000, colposcopes can be found for as little as $1500. A new portable colposcope that costs about one-third the price of a standard colposcope is also available. A Tool to Assess Program Capacity 62 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Cancer care referral sites 6. Is there a health center or hospital within a reasonable distance to your program site that provides effective treatment or palliative care for suspected cervical cancer? Yes: Proceed to question 7. No: Identify barriers to providing referrals to health centers or hospitals providing effective treatment for suspected cervical cancer and assess the feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Note: If referral options for effective treatment of suspected cervical cancer are not available or feasible for women in your community, consider focusing your efforts on community- based strategies that provide financial, transportation and other types of resources to women in need of treatment. Considerations when assessing the referral site’s ability to meet women’s needs: • Where are the services located? • What are their hours? • How long does it take for women to travel to these services from their homes? • Do clients seek services at the referral site? • Do clients receive services within a reasonable time frame after they present for services? • Have women been satisfied with these services in the past? • Is the care of good quality? • Is there a cost to services? • What options do women have if they cannot afford the cost of these services? Integrating Cervical Cancer Prevention into Reproductive Health Services 63Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care 7. Does your program currently have an effective referral mechanism for other types of health services? 7a. Yes: Can this system be adapted to include referrals for treatment of suspected cervical cancer? If yes: Proceed to Question 8. If no: Assess barriers to establishing effective referral mechanisms for treatment of suspected cervical cancer within already existing referral mechanisms. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome 7b. No: Assess barriers to the development of effective referral mechanisms and the feasibility of eliminating them. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Note: If these barriers seem surmountable, return to the first “Yes” response for question 7. Referral information should list location, hours, fees, and specific individuals to contact. This information needs to be available to all staff so that it can be easily distributed to clients as needed. Other steps to ensure adequate referral systems include: • Standard protocol for referrals • Monitoring system for use of standard protocol • List of referral sites and contact person(s) at site • Functioning communication systems in place between sites (letter, phone, fax, regular meetings, etc.) • Systems for follow-up/ tracking clients (with regular review to ensure that these systems are functioning) • Clear instructions for clients regarding the location of the site to which they are referred and how to make an appointment or when to go for services • System to ensure information sharing between primary and referral sites A Tool to Assess Program Capacity 64 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Project monitoring 8. Is there a written plan for monitoring the implementation of expanded service delivery? (The plan should include types of data that will be easily collected, a timeline for data collection, and measurable indicators.) Yes: Proceed to summary worksheet. No: Assess barriers to establishing and implementing an effective monitoring plan for expanded service delivery. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Complete Level 3a Worksheet at the end of this section. This sheet will help you determine whether it is realistic to integrate education, information, counseling, screening, and diagnostic services about cervical cancer prevention into your existing program. Integrating Cervical Cancer Prevention into Reproductive Health Services 65Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Level 3a Worksheet Assessing your program’s capacity to provide dysplasia diagnosis and treatment, and referral for cancer care This worksheet helps you to perform some simple calculations for identifying whether your program is well positioned to add dysplasia diagnosis and treatment, and referral for cancer care into its services. For each question, put the number you selected to rank the magnitude of the barrier in the space to the right. The question topics are numbered to correspond to the number of the question in the assessment questionnaire that you just completed. Remember that each barrier should be ranked from 0 to 5, with 0 = no barriers and 5 = very difficult barriers to overcome. Level 3a Worksheet scipoTnoitseuQ noitatnemelpmIotsreirraB morfrebmungnidnopserrocretnE( ).noitseuqhcaeotrewsnaruoy ecivresyrotarobaL.1 gniffatsetauqedA.2 slliksdnagniniartetauqedA.3 lacigolotsihgniniatbonisredivorprofgniniartgniognO.a4 selpmas ro gniniatbonisredivorprofgniniartrehserferdnalaitinI.b4 selpmaslacigolotsih sisongaidcipocsoplocrofseilppuS.5 eracevitaillap/tnemtaertsseccA.6 larrefertnemtaertevitceffeetargetnI.a7 ro larrefertnemtaerthsilbatsE.b7 gnirotinomtcejorP.8 EROCSLATOT )erocslatotetaluclacotnmulocnisrebmunlladdA( A Tool to Assess Program Capacity 66 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care It is likely that you identified some barriers to providing information and education in your program. The total score that you have derived from this worksheet is the result of the Level Three Program Capacity Assessment. Use this number to help guide you regarding plans for program expansion. The result can be interpreted as follows: Results of Program Capacity Assessment If your total score was between 0 and 16, your program is very likely able to support the addition of new services. Most of the key components are probably in place, and with effective planning, your program could successfully integrate cervical cancer counseling, screening, and treatment referral services. If your total score was in the range of 17 to 32, your program probably has many of the important components in place that make it possible to adequately provide cervical cancer counseling, screening, and treatment referral. If your total score was 33 or greater, your program probably is not prepared to add new activities to its current array of services. In this case, you may consider focusing your efforts on providing Level 1 or 2 services (if indicated by your worksheet results from those levels). Discussion of Worksheet Findings It is important to note that this numeric scale is intended only to offer guidance when considering your program’s readiness to integrate new services. Important issues such as political factors, staff morale, or social concerns—all issues that could influence a program’s ability to take on new activities—may not be identified by using this tool. The assessment team may make their best decision about whether to integrate new services by carefully weighing the barriers described above and combining that information with their own understanding of the program’s assets and challenges. It also should be emphasized that even programs scoring highly on this scale should pay particularly close attention to any barriers that are rated 3-5. A program’s inability to address a key barrier can make it impossible to provide effective services. Since all of the components outlined in the assessment questionnaire are important to successful integration of additional services, any program that has more than two scores of 5 may consider stopping to address that particular barrier before proceeding with the addition of new services. EROCSLATOT TLUSER SPETSTXEN 61-0 margorpotsreirrablaminiM noisnapxe DEECORP dnapxeotsnalphtiw secivres 23-71 otsreirrabelbaredisnoC noisnapxemargorp REDISNOC dnapxeotseigetarts neebevahsreirrabecnosecivres decuder 04-33 margorpotsreirrabereveS noisnapxe YALED secivresdnapxeotsnalp neebevahsreirrablitnu desserdda Integrating Cervical Cancer Prevention into Reproductive Health Services 67Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Level 3b: Cryotherapy Treatment At this level, services are expanded to provide treatment for precancerous lesions using cryotherapy. (Generally, treatment is recommended for moderate to severe dysplasia only. Most mild dysplasia regresses spontaneously.) Cryotherapy destroys abnormal cells by using a low-temperature probe (-60°C to -90°C) to freeze the transformation zone. Cryoprobes varying in size and shape may be used depending on the size and grade of the lesion as well as the shape of the cervix. Carbon dioxide (CO2), liquid nitrogen, or nitrous oxide are generally used as refrigerants. Cryotherapy can be done without anesthesia, although its use may reduce discomfort for the patient. Treatment generally consists of applying the coolant continuously for a 3-minute freeze, followed by a 5-minute thaw and then another 3-5 minute freeze. This procedure, called the “double freeze” technique, usually is performed without anesthesia. Cryotherapy is highly effective with small and moderate-sized lesions (85-90% cure rate), and is associated with few complications and/or side effects. Once trained, a nonphysician can perform the procedure. No electricity is required, and the procedure is relatively inexpensive. A Tool to Assess Program Capacity 68 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Access and acceptability 1. Will the community in general, and women in particular, know about and accept the provision of cervical cancer counseling and treatment by cryotherapy? Yes: Proceed to question 2. No: Assess barriers to community and women’s awareness and acceptance of these services. Determine the feasibility of your program addressing these barriers through community outreach and education. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Integrating Cervical Cancer Prevention into Reproductive Health Services 69Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Staff capacity to provide cryotherapy 2. Does your program’s current level of staffing allow service providers to add provision of counseling, diagnosis, treatment, and referral for suspected cervical cancer to their workload? Yes: Proceed to question 3. No: Identify barriers to staff’s ability to add provision of counseling, diagnosis, treatment, and referral for suspected cervical cancer to their workload, and assess feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome 3. Are service providers at your program currently well trained and able to perform cryotherapy? Yes: Proceed to question 4. No: Assess barriers to training service providers in performing cryotherapy. Determine how you identify and train appropriate service providers to perform cryotherapy and assess feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Key informational points should include: • Description of the procedure. • Side effects—cramping for about a week and watery vaginal discharge for 3-4 weeks. • Warning signs—counsel patients to return if discharge changes to foul- smelling and puss-like or if there is heavy bleeding. • Abstinence—explain the necessity of abstinence for 4 weeks. (If abstinence is unlikely, advise condom use for prevention of STIs.) • Follow up—reminder to return for follow-up visit. A Tool to Assess Program Capacity 70 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care 4. Do service providers at your program have adequate knowledge and skills with regard to practicing effective infection prevention procedures to ensure safe cryotherapy treatment? Yes: Proceed to question 5. No: Identify barriers to practicing effective infection prevention procedures and assess feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Integrating Cervical Cancer Prevention into Reproductive Health Services 71Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Material requirements for cryotherapy 5. The following supplies must be available in the clinic in sufficient quantities to perform the number of cryotherapy treatments you plan to provide. Do or will you have these supplies? Yes � No � Examination table that allows the examiner to insert the speculum and see the cervix Yes � No � Bivalve speculum A cryotherapy set including: Yes � No � Wide cervical probe Yes � No � Regular supply of carbon dioxide or nitrous oxide Yes � No � Timer Yes � No � Light source that allows the examiner to see the cervix General supplies: Yes � No � Vaginal swabs Yes � No � Examination gloves Yes � No � Wooden spatula Yes � No � Chlorine solution for decontaminating instruments Yes � No � Record form for recording findings Based on your responses above, consider any barriers to obtaining these supplies and having continuous access to them. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Approximate costs of cryotherapy units: Cryotherapy units generally vary in initial purchase price from about US$1,000 to $3,000 in developing countries. The cylindrical canisters containing refrigerant can be filled and reused and are available in a wide variety of sizes. For example, CO2 canisters range from 2-kg canisters, which enable treatment of approximately four to five people, to 130-kg canisters or larger. Although each type of refrigerant has different freezing points, all are effective in treating CIN. Liquid nitrogen and nitrous oxide are cleaner than CO2, leading to fewer mechanical problems related to blockage of the tube from the tank to the probe. They are, however, more expensive than CO2. To avoid blockage problems, only medical grade or “bone dry” CO2 should be used. It is important that adequate tank pressure be maintained. If pressure is low, optimal temperatures may not be reached and tissue destruction can be inadequate. Various sizes of cryotherapy probes are available. Probes of adequate size to completely cover a lesion must be used for successful treatment. A Tool to Assess Program Capacity 72 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Follow-up of treated clients 6. Does your program currently have an effective mechanism for following clients who have been treated? Yes: Can this system be adapted to include follow-up of clients who have been treated with cryotherapy? If yes: Proceed to question 7. If no: Assess barriers to establishing effective follow- up mechanisms for cryotherapy treatment within already existing referral mechanisms. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome The purpose of follow-up visits is: • To ensure there is no infection; • To ensure that no visible lesions remain; • To monitor the client following effective treatment by encouraging her to return for screening at an appointed time in the future. Ideally, a woman should return for a post-cryotherapy check at 3-4 weeks after the procedure to rule out any infection or other complication. To ensure that the procedure has been successful, JHPIEGO recommends repeat VIA at 6 months. If the cervix still appears abnormal, the woman should be referred to an appropriate surgical facility for cone biopsy. If no lesion is noted, JHPIEGO suggests that the patient be reassured and asked to return in five years for a repeat VIA. Integrating Cervical Cancer Prevention into Reproductive Health Services 73Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care 7. Is there a health center or hospital within a reasonable distance to your program site that provides effective care for women who experience serious infection or bleeding as a result of cryotherapy? Yes: Proceed to question 8. No: Identify barriers to providing referrals to health centers or hospitals providing effective care for women who experience serious infection or bleeding as a result of cryotherapy, and assess the feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome A Tool to Assess Program Capacity 74 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Cancer treatment referral 8. Is there a health center or hospital within a reasonable distance to your program site that provides effective treatment (including palliative care) for suspected cervical cancer? Yes: Proceed to question 9. No: Identify barriers to providing referrals to health centers or hospitals providing effective treatment for suspected cervical cancer, and assess the feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Integrating Cervical Cancer Prevention into Reproductive Health Services 75Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care 9. Does your program currently have an effective referral mechanism for other types of health services? 9a. Yes: Can this system be adapted to include referrals for treatment of suspected cervical cancer? If yes: Proceed to Question 10. If no: Assess barriers to establishing effective referral mechanisms for treatment of suspected cervical cancer within already existing referral mechanisms. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome 9b. No: Assess barriers to the development of effective referral mechanisms and the feasibility of eliminating them. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Note: If referral options for effective treatment of suspected cervical cancer are not available or feasible for women in your community, consider focusing your efforts on community- based strategies that provide financial, transportation and other types of resources to women in need of treatment. A Tool to Assess Program Capacity 76 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Project monitoring 10. Is there a written plan for monitoring the implementation of expanded service delivery? (The plan should include types of data that will be easily collected, a timeline for data collection, and measurable indicators.) Yes: Proceed to summary worksheet. No: Assess barriers to establishing and implementing an effective monitoring plan for expanded service delivery. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Complete Level 3b Worksheet at the end of this section. This sheet will help you determine whether it is realistic to integrate education, information, counseling, screening, diagnostic, and treatment services about cervical cancer prevention into your existing program. Integrating Cervical Cancer Prevention into Reproductive Health Services 77Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Level 3b Worksheet Assessing your program’s capacity to perform cryotherapy This worksheet helps you to perform some simple calculations to help identify whether your program is well positioned to add cryotherapy into its services. For each question, put the number you selected to rank the magnitude of the barrier in the space to the right. The question topics are numbered to correspond to the number of the question in the assessment questionnaire that you just completed. Remember that each barrier should be ranked from 0 to 5, with 0 = no barriers and 5 = very difficult barriers to overcome. Level 3b Worksheet scipoTnoitseuQ noitatnemelpmIotsreirraB rewsnaruoymorfrebmungnidnopserrocretnE( ).noitseuqhcaeot —ytilibatpeccadnasseccaytinummoC.1 yparehtoyrc gniffatsetauqedA.2 slliksdnagniniartetauqedA.3 slliks/egdelwonknoitneverpnoitcefnI.4 yparehtoyrcrofseilppuS.5 smsinahcempu-wolloF.6 snoitacilpmocrofetislarrefeR.7 recnacdetcepsusrofetislarrefeR.8 larrefertnemtaertrecnacevitceffeetargetnI.a9 ro arrefertnemtaertrecnacevitceffehsilbatsE.b9 gnirotinomtcejorP.01 EROCSLATOT etaluclacotnmulocnisrebmunlladdA( )erocslatot A Tool to Assess Program Capacity 78 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care It is likely that you identified some barriers to providing information and education in your program. The total score that you have derived from this worksheet is the result of the Level Three Program Capacity Assessment. Use this number to help guide you regarding plans for program expansion. The result can be interpreted as follows: Results of Program Capacity Assessment If your total score is between 0 and 20, your program is very likely able to support the addition of new services. Most of the key components are probably in place, and with effective planning, your program could successfully integrate cervical cancer counseling, screening, and treatment referral services. If your total score was in the range of 21 to 40, your program probably has many of the important components in place that make it possible to adequately provide cervical cancer counseling, screening, and treatment referral. If your total score was 41 or greater, your program probably is not prepared to add new activities to its current array of services. In this case, you may consider focusing your efforts on providing information and education about STI prevention or cervical cancer specifically and toward referring women elsewhere for cervical cancer counseling, screening, and treatment referral. Discussion of Worksheet Findings This numeric scale is intended only to offer guidance when considering your program’s readiness to integrate new services. Important issues such as political factors, staff morale, or social concerns—all issues that could influence a program’s ability to take on new activities— may not be identified by using this tool. The assessment team may make their best decision about whether to integrate new services by carefully weighing the barriers described above and combining that information with their own understanding of the program’s assets and challenges. Even programs scoring highly on this scale should pay particularly close attention to any barriers that are rated 3-5. A program’s inability to address a key barrier can make it impossible to provide effective services. Since all of the components outlined in the assessment questionnaire are important to successful integration of additional services, any program that has more than two scores of 5 may consider stopping to address that particular barrier before proceeding with the addition of new services. EROCSLATOT TLUSER SPETSTXEN 02-0 margorpotsreirrablaminiM noisnapxe DEECORP dnapxeotsnalphtiw secivres 04-12 otsreirrabelbaredisnoC noisnapxemargorp REDISNOC dnapxeotseigetarts neebevahsreirrabecnosecivres decuder 05-14 margorpotsreirrabereveS noisnapxe YALED secivresdnapxeotsnalp neebevahsreirrablitnu desserdda Integrating Cervical Cancer Prevention into Reproductive Health Services 79Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Level 3c: Loop Electrosurgical Excision Procedure (LEEP) At this level, services are expanded to provide cervical cancer treatment using LEEP. This method, also known as large loop excision of the transformation zone (LLETZ), is a method of outpatient excisional biopsy and treatment that is used to remove the entire transformation zone. The primary advantage of LEEP over destructive techniques (such as cryotherapy) is that it removes rather than destroys suspicious tissue, thus producing a histologic sample for pathologic review. It may also be more suitable than cryotherapy for many larger lesions. LEEP treatment is effective (80%-96% cure rate for all lesions) and is associated with few complications and/or side effects. The primary side effect, perioperative bleeding, occurs in about 3%-8% of all women who undergo the procedure. A physician, electricity, anesthesia, and a resupply of loops are required to perform LEEP. Because of this, the equipment is more expensive than that required for cryotherapy. Access and acceptability 1. Will the community in general, and women in particular, know about and accept the provision of cervical cancer counseling and treatment by LEEP? Yes: Proceed to question 2. No: Assess barriers to community and women’s awareness and acceptance of these services. Determine the feasibility of your program addressing these barriers through community outreach and education. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome A Tool to Assess Program Capacity 80 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Staff capacity to provide treatment services 2. Does your program’s current level of staffing allow service providers to add provision of counseling, diagnosis, treatment, and referral for suspected cervical cancer to their workload? Yes: Proceed to question 3. No: Identify barriers to staff’s ability to add provision of counseling, diagnosis, treatment, and referral for suspected cervical cancer to their workload, and assess feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome 3. Are service providers at your program currently well trained and able to perform LEEP? Yes: Proceed to question 4. No: Assess barriers to training service providers in performing LEEP. Determine how you would obtain supplies, identify and train appropriate service providers to perform cryotherapy, and assess feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Key informational points should include: • Description of the procedure. • Side effects—bleeding or infection a few days up to a week following the procedure. • Warning signs—counsel patients to return if discharge changes to foul- smelling and puss-like or if there is heavy bleeding. • Abstinence—advise abstinence for 4 weeks. (If abstinence is unlikely, advise condom use of prevention of STIs.) • Long-term effects—may cause cervical stenosis (obstruction of the pathway between the vagina and uterus). • Long-term effects on fertility are unknown. Integrating Cervical Cancer Prevention into Reproductive Health Services 81Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care 4. Do service providers at your program have adequate knowledge and skills with regard to practicing effective infection prevention procedures to ensure safe LEEP procedures? Yes: Proceed to question 5. No: Identify barriers to practicing effective infection prevention procedures and assess feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome A Tool to Assess Program Capacity 82 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Material requirements for LEEP 5. The following supplies must be available in the clinic in sufficient quantities to perform the number of LEEP treatments you plan to provide. Do or will you have these supplies? Yes � No � Examination table that allows the examiner to insert the speculum and see the cervix Yes � No � Insulated non-conductive or special plastic speculum (with a strong locking mechanism) that will not allow transmission of the current from the loopelectrode to the vagina and that has an outlet for smoke evacuation. Yes � No � Electrosurgical unit (that runs off mains electricity and/or another power source) Yes � No � Supply of loops Yes � No � Compact smoke evacuator with an adequate filter to remove steam or smoke generated during the procedure. Smoke evacuators are usually separate devices, but some LEEP units now have them built in. Yes � No � Light source that allows the examiner to see the cervix Yes � No � Vaginal swabs Yes � No � Examination gloves Yes � No � Colposcope Yes � No � Return electrodes Yes � No � Suture set Yes � No � Lugol’s solution (to delineate the transformation zone prior to treatment) Yes � No � Monsel’s paste (to control bleeding) Yes � No � Local anesthetic Yes � No � Vasoconstrictive agent such as epinephrine Yes � No � Adjunct equipment associated with administering local anesthesia, including needles and syringes Yes � No � Chlorine solution for decontaminating instruments Yes � No � Record form for recording findings Approximate costs of LEEP equipment: • Electrosurgical units (produced by a number of companies) cost between US$3,000 and US$6,000). • Loops are available in disposable or reusable forms (US$15 to US$60 per loop, depending on the country). Programs in countries such as India, Kenya, and South Africa have had loops made locally (using steel wire) at a fraction of the cost of imported loops. If reusable loops (good for 10 to 25 procedures) are preferred, they must be decontaminated, disinfected, and cleaned thoroughly with a scrubbing pad to remove carbonized material, and they must be sterilized before reuse. Continue question on next page. Integrating Cervical Cancer Prevention into Reproductive Health Services 83Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care (5. continued ) Based on your responses above, consider any barriers to obtaining these supplies and having continuous access to them. Note: Identify barriers to obtaining the required supplies and assess the feasibility of eliminating these barriers. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Referral sites for complications 6. Is there a health center or hospital within a reasonable distance to your program that provides effective care for women who experience serious infection or bleeding as a result of cryotherapy? Yes: Proceed to question 7. No: Identify barriers to providing referrals to health centers or hospitals providing effective care for women who experience serious infection or bleeding as a result of cryotherapy, and assess the feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome A Tool to Assess Program Capacity 84 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Follow-up of treated clients 7. Does your program currently have an effective mechanism for following clients who have been treated? Yes: Can this system be adapted to include follow-up of clients who have been treated with LEEP? If yes: Proceed to question 8. If no: Assess barriers to establishing effective follow- up mechanisms for cryotherapy treatment within already existing referral mechanisms. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome The purpose of the follow- up visit is: • To ensure there was no infection; • To ensure the procedure was effective; • To monitor the client following effective treatment by encouraging her to return for screening at an appointed time in the future. Wright et al. recommend that patients return for follow-up 3 months after LEEP. At this visit, a Pap smear sample should be obtained, a colposcopy performed, and an endocervical curettage collected, if indicated. Colposcopy-directed biopsies should be taken from abnormal areas. Clients should be seen again at 6 and 12 months after treatment to obtain Pap smear samples only. Integrating Cervical Cancer Prevention into Reproductive Health Services 85Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Cancer treatment referral 8. Is there a health center or hospital within a reasonable distance to your program site that provides effective treatment (including palliative care) for suspected cervical cancer? Yes: Proceed to question 9. No: Identify barriers to providing referrals to health centers or hospitals providing effective treatment for suspected cervical cancer and assess the feasibility of addressing these barriers. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Note: If referral options for effective treatment of suspected cervical cancer are not available or feasible for women in your community, consider focusing your efforts on community- based strategies that provide financial, transportation and other types of resources to women in need of treatment. Considerations when assessing the referral site’s ability to meet women’s needs: • Where are the services located? • What are their hours? • How long does it take for women to travel to these services from their homes? • Do clients present for referred services? • Do clients receive services within a reasonable time frame after they present for services? • Have women been satisfied with these services in the past? • Is the care of good quality? • Is there a cost to services? • What options do women have if they cannot afford the cost of these services? A Tool to Assess Program Capacity 86 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care 9. Does your program currently have an effective referral mechanism for other types of health services? 9a. Yes: Can this system be adapted to include referrals for cervical cancer diagnosis and treatment? If yes: Proceed to question 10. If no: Assess barriers to establishing effective referral mechanisms for cervical cancer diagnosis and treatment within already existing referral mechanisms. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome 9b. No: Assess barriers to the development of effective referral mechanisms and the feasibility of eliminating them. Describe barriers here: Rank the magnitude of these barriers: � 1 = No barriers � 2 = Barriers easy to overcome � 3 = Moderate barriers � 4 = Significant barriers � 5 = Barriers difficult to overcome Integrating Cervical Cancer Prevention into Reproductive Health Services 87Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Project monitoring 10. Is there a written plan for monitoring the implementation of expanded service delivery? (The plan should include types of data that will be easily collected, a timeline for data collection, and measurable indicators.) Yes: Proceed to summary worksheet. No: Assess barriers to establishing and implementing an effective monitoring plan for expanded service delivery. Determine whether these barriers can be effectively addressed. Describe barriers here: Rank the magnitude of these barriers: �1 = No barriers �2 = Barriers easy to overcome �3 = Moderate barriers �4 = Significant barriers �5 = Barriers difficult to overcome Complete Level 3c Worksheet at the end of this section. This sheet will help you determine whether it is realistic to integrate education, information, counseling, screening, diagnostic, and treatment services about cervical cancer prevention into your existing program. A Tool to Assess Program Capacity 88 Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care Level 3c Worksheet Assessing your program’s capacity to provide cervical cancer counseling, screening, treatment, or treatment referral This worksheet helps you to perform some simple calculations to help identify whether your program is well positioned to add cervical cancer counseling, screening, treatment, or treatment referral into its services. For each question, put the number you selected to rank the magnitude of the barrier in the space to the right. The question topics are numbered to correspond to the number of the question in the assessment questionnaire that you just completed. Remember that each barrier should be ranked from 0 to 5, with 0 = no barriers and 5 = very difficult barriers to overcome. Level 3c Worksheet scipoTnoitseuQ noitatnemelpmIotsreirraB morfrebmungnidnopserrocretnE( ).noitseuqhcaeotrewsnaruoy ecnatpeccaytinummoC.1 gniffatsetauqedA.2 slliks/gniniartPEEL.3 noitneverpnoitcefni—slliks/egdelwonK.4 PEELrofseilppuS.5 pu-wolloftneilC.6 snoitacilpmocPEELrofslarrefeR.7 eracevitaillap/tnemtaertsseccA.8 larrefertnemtaertrecnacetargetnI.a9 ro larrefertnemtaertrecnachsilbatsE.b9 gnirotinomtcejorP.01 EROCSLATOT )erocslatotetaluclacotnmulocnisrebmunlladdA( Integrating Cervical Cancer Prevention into Reproductive Health Services 89Level 3: Dysplasia Diagnosis and Treatment, and Referral for Cancer Care It is likely that you identified some barriers to providing information and education in your program. The total score that you have derived from this worksheet is the result of the Level Three Program Capacity Assessment. Use this number to help guide you regarding plans for program expansion. The result can be interpreted as follows: Results of Program Capacity Assessment If your total score is between 0 and 20, your program is very likely able to support the addition of new services. Most of the key components are probably in place, and with effective planning, your program could successfully integrate cervical cancer counseling, screening, and treatment referral services. If your total score was in the range of 21 to 40, your program probably has many of the important components in place that make it possible to adequately provide cervical cancer counseling, screening, and treatment referral. If your total score was 41 or greater, your program probably is not prepared to add new activities to its current array of services. In this case, you may consider focusing your efforts on providing information and education about STI prevention or cervical cancer specifically and toward referring women elsewhere for cervical cancer counseling, screening, and treatment referral. Discussion of Worksheet Findings This numeric scale is intended only to offer guidance when considering your program’s readiness to integrate new services. Important issues such as political factors, staff morale, or social concerns—all issues that could influence a program’s ability to take on new activities— may not be identified by using this tool. The assessment team may make their best decision about whether to integrate new services by carefully weighing the barriers described above and combining that information with their own understanding of the program’s assets and challenges. Even programs scoring highly on this scale should pay particularly close attention to any barriers that are rated 3-5. A program’s inability to address a key barrier can make it impossible to provide effective services. Since all of the components outlined in the assessment questionnaire are important to successful integration of additional services, any program that has more than two scores of 5 may consider stopping to address that particular barrier before proceeding with the addition of new services. EROCSLATOT TLUSER SPETSTXEN 02-0 margorpotsreirrablaminiM noisnapxe DEECORP dnapxeotsnalphtiw secivres 04-12 otsreirrabelbaredisnoC noisnapxemargorp REDISNOC dnapxeotseigetarts neebevahsreirrabecnosecivres decuder 05-14 margorpotsreirrabereveS noisnapxe YALED secivresdnapxeotsnalp neebevahsreirrablitnu desserdda Integrating Cervical Cancer Prevention into Reproductive Health Services 91 Resources The following materials informed the development of this publication and may help guide programs that are considering adding cervical cancer prevention services: Blumenthal P. Atlas for Unaided Visual Inspection of the Cervix. Baltimore, MD: JHPIEGO Corporation, 1997. McIntosh, N. et al. Cervical Cancer Prevention Guidelines for Low-Resource Settings. Baltimore, MD: JHPIEGO Corporation, (draft) April 2000. Miller, A.B. Cervical Cancer Screening Programmes: Managerial Guidelines. Geneva: World Health Organization, 1992. PAHO (Pan American Health Organization). Cancer of the uterine cervix. Bulletin of the Pan American Health Organization (special issue) 30(4), December 1996. (Available in English and Spanish.) PAHO (Organizacion Panamericana de la Salud). Manual de normas y procedimientos para el control del cancer de cuello uterino. Organizacion Panamericana de la Salud, Serie PALTEX Para Ejecutores de Programas de Salud, No. 6. Washington, D.C.: PAHO, 1990. PATH, Planning Cervical Cancer Prevention Programs. 2nd ed. Seattle, WA: PATH, 2000. World Health Organization (WHO). Cancer Pain Relief. 2nd ed. (with a guide to opioid availability). Geneva: WHO, 1996. World Health Organization (WHO). Cancer Pain Relief and Palliative Care: Report of a WHO Expert Committee. Technical Report Series 804. Geneva: WHO, 1990. World Health Organization (WHO). Cytological Screening in the Control of Cervical Cancer: Technical Guidelines. Geneva: WHO, 1988. The following web sites may be helpful to programs interested in adding cervical cancer prevention services: The University of Pennsylvania’s Onco Link web site provides one example of information for women about Pap smears. http://cancer.med.upenn.edu/specialty/gyn_onc/cervical/screening/pap_test.html The National Cervical Cancer Coalition has developed a list of questions and answers about the Pap test. While this information is geared toward patients in the United States, much of the information is more broadly applicable. http://www.nccc-online.org/ Reproductive Health Outlook (RHO), the reproductive health web site produced by PATH (Program for Appropriate Technology in Health), is especially designed for reproductive health program managers and decision makers working in developing countries and low- resource settings and includes comprehensive information on cervical cancer prevention. http://www.rho.org/index.html 4 Nickerson Street, Seattle, WA 98109 Tel: (206) 285-3500 / Fax: (206) 285-6619, E-mail: info@path.org / URL: www.path.org

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