Improving screening coverage rates of cervical cancer prevention programs; a focus on communities.

COFFEY P,, ARROSSI S., BRADLEY, J., DZUBA., I., WHITE, S.

ACCP

Lugar: Seatle; Año: 2004 p. 44

Assuring high levels of participation in screening (i.e., coverage) and follow up is essential for effective cervical cancer prevention. However, obtaining high levels of coverage is challenging in both developed and developing countries. For example, in Europe, coverage ranges vary widely between and within countries: England, Iceland and rural areas of Sweden and Denmark have coverage rates greater than 80 percent, while they are at or below 60 percent in Austria, France, Italy and Spain. In Spain reported coverage for women aged 40 to 70 years ranged from 25 percent in Castilla-La Mancha to 61 percent in Madrid. In developing countries variation is also wide, with very high coverage rates in Chile (68 percent) and Costa Rica (77 percent), and very low or nonexistent coverage in most Asian and African countries. However, for the most part, screening coverage in developing countries is extremely low, resulting in high morbidity and mortality due to cervical cancer.   These low screening rates suggest that coverage strategies are not always optimized, particularly for women who are hard to reach. Various strategies for increasing screening coverage, primarily in developed countries, have been evaluated in the literature. They include strategies targeting individual women with invitation letters, face-to-face communication, or an educational intervention; strategies targeting health care providers such as physician reminders or incentive programs; and strategies involving the community such as mass media campaigns and outreach to family and community members. These strategies have had different degrees of success, depending on the populations addressed, settings where they were implemented, initial screening coverage levels, and the way in which the health system was organized. However, transferring some of these strategies from developed to developing countries has also been problematic. For example, the lack of population registry and postal systems will remain obstacles to increasing screening coverage with invitation letters. Furthermore, low-literacy levels and prevalence of inaccurate information relating to cervical cancer prevention in developing countries may mean that the effectiveness of other communication strategies may be compromised.   In developing countries, barriers to cervical cancer screening uptake include absence of knowledge about the disease, lack of familiarity with the concept of preventive health care, geographic and economic inaccessibility of services, poor quality of services, and lack of support from families and communities. This paper will discuss how strategies to increase coverage should focus on the community to address such issues. Focusing on the community in cervical cancer prevention activities matters because a woman’s ability to make an informed decision—and act on that decision—to receive cervical cancer screening and treatment services is influenced not only by her own beliefs and behavioral patterns, but also by existing social networks and institutions, or community. Social networks include a woman’s partner, family, friends, neighbors, members of women’s groups, religious groups, or associations with which she may be affiliated. Institutions include local administrative structures, health delivery structures, schools, or other civic associations that could support a woman’s decision and ability to seek services.   ACCP strategies to increase coverage that utilize a community focus include: (1) listening to, and learning from, the community; (2) involving community stakeholders in program development and implementation; and (3) responding in a way that addresses the needs of the community. These strategies were designed to increase and sustain demand and improve the quality of services, resulting in increased participation in screening and compliance with treatment recommendations.   This paper describes the community focus taken by ACCP projects from 1999 to 2004 in eight countries:  El Salvador, India, South Africa, Thailand, Ghana, Kenya, Peru, and Bolivia. We include an overview of the strategies mentioned above that were used to increase screening coverage, and we present lessons learned about how to meet women's needs effectively by having a community focus.