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TECHNICAL BRIEF

Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs A Review of the Evidence Base and Insights from Existing Field Programs

Š PSI/Gareth Bentley


Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Executive Summary Population Services International (PSI) partnered with the International Center for Research on Women (ICRW) to review the global evidence base on integration of cervical cancer prevention and voluntary family planning (FP) service delivery and to document field-based experiences on integrated programs across PSI’s global network. The objective was to highlight the programmatic benefits and challenges of designing, implementing, and evaluating integrated programs in contexts with high unmet need for FP and low cervical cancer screening coverage.

KEY FINDINGS The global literature review revealed significant gaps in documentation of ‘what works’ to design, deliver, and monitor high-quality integrated services. Insights are needed to inform: standardized communications and messages for target audiences; clinical training and job aids, including supportive supervision checklists; and informational systems necessary to support high-quality integrated care, including impact metrics to monitor health impact and quality of integrated services.

CONCLUSIONS Rigorous evaluation of the public health impact, feasibility and cost effectiveness of integrated services is needed to drive political and operational support for these programs. Existing communities of practice should be engaged to evaluate and document which integrated service delivery models are most feasible, acceptable, and sustainable in various country contexts. Services should be designed to respond to women and girls’ needs, preferences, and challenges in order to improve equitable access to these services.

NEXT STEPS The global health community can leverage existing support for global initiatives like FP2020 and the WHO Call to Action to Eliminate Cervical Cancer to grow the evidence base for integrated service delivery.

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Background Cervical cancer is a major cause of premature death and disability among women. Worldwide, approximately 311,000 women die of the disease, and 570,000 new cases are identified annually.1 Women in low- and middle-income countries (LMICs) account for >90% of all cases globally, in part due to limited access to cervical cancer prevention services.1 Cervical cancer is largely preventable with existing and available tools. Vaccination against high-risk strains of human papilloma virus (HPV), the virus that causes nearly all cervical cancer cases, in addition to regular screening among adult women who have already been exposed to HPV, has been shown to reduce both cervical cancer incidence and mortality.2 Women living with HIV, or those at high risk of HIV infection, are priority populations for cervical cancer prevention programs, given their higher risk for HPV infection and faster disease progression.3 Many of the same countries struggling with high cervical cancer rates often have high unmet need for family planning (FP), defined as the percentage of sexually-active women of reproductive age who wish to prevent or delay pregnancy but are not currently using contraception. As the global health community has prioritized both the reduction of unmet need for FP4 and, more recently, the global elimination of cervical cancer,5 there is an opportunity to review the evidence base and share practical considerations for integration of these services, with a view towards expanded access to products and services that improve women’s sexual and reproductive health. A limited number of implementing teams have generated program insights around the operational and practical components of

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PSI/Tanzania

integrated programs. A recent project supported by the Bill & Melinda Gates Foundation (BMGF) integrated cervical screening and preventive therapy (CCS&PT) into voluntary FP programs in four high-HIV burden African countries – Kenya, Nigeria, Tanzania, and Uganda – using multiple service delivery models, including static clinic and mobile outreach models. Program partners included Marie Stopes International, The International Planned Parenthood Federation, and Population Services International (PSI). The program resulted in increased use of both voluntary FP and CCS&PT services, with 2.1 million cervical screenings and 33,700 cryotherapy treatments performed between 2012-2017. The addition of cervical cancer prevention services within existing voluntary FP programming led to increased uptake of all contraceptive methods offered, with the most notable increases in voluntary long-acting reversible contraceptive (LARC) methods. While these program results are encouraging, more robust evidence is needed to quantify the synergistic effects of program integration, along with the practical trade-offs and opportunity costs of integrated services.

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Published documentation of best practices for integrating cervical cancer and voluntary FP programs is scarce, in part due to the limited implementation research published to date. To fill this gap, PSI partnered with the International Center for Research on Women (ICRW) to review existing evidence, highlight evidence gaps, and document field-based experiences of the integration of cervical cancer and voluntary FP programming. The objective was to highlight, for program implementers and policy makers, the benefits and challenges of designing, implementing, and evaluating integrated programs in LMICs with high

unmet need for voluntary FP and low cervical cancer screening coverage. Areas of focus for this review included: client and provider communications, clinical training and support, clinic logistics and client management, and routine monitoring and evaluation of integrated services focused at the primary level of care. The review purposively excluded literature on the programmatic integration of cervical cancer prevention into HIV care and services, which has been documented in other publications, in order to focus on the factors specific to integration of voluntary FP and cervical cancer programs.3, 6

Š Jake Lyell May 18, 2010 – PSI/PACE

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Vanessa Vick/Uganda

Literature Review To review the global evidence base on voluntary FP and cervical cancer integration, ICRW searched academic databases using the terms: “cervical cancer,” “family planning” OR “contraception” OR “reproductive health,” “screening,” and “integration.” It should be noted that specific screening and treatment modalities were not included as search terms, instead capturing all relevant methods with the use of the term ‘screening.’ Results were limited to English-language publications from LMICs, published since January 2000. Gray literature was searched using relevant projects/ publications, and by a Google search using the same search terms. Results were aggregated into a Mendeley database and reviewed by two researchers—one focused on identifying best practices on integration of voluntary FP and cervical cancer, the other focused on identifying programs that had integrated cervical cancer screening into FP services or other SRH services, such as STI screenings. PSI conducted an internal review of program reports to identify promising practices for voluntary family planning and cervical cancer integration. In addition, telephone interviews

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were conducted between PSI’s global and field-based technical teams to verify program practices and elicit additional insights. PSI program reports and management information systems (MIS) data were reviewed between November 2012 and October 2017 from 15 countries (11 in Africa, two in Latin America/ Caribbean and one in Asia) offering integrated voluntary FP and cervical cancer services through a variety of service delivery models (mobile outreach-based, static clinic-based, and offered within both private and public sectors). PSI’s ‘screen and treat’ programs included cytology, visual inspection with acetic acid (VIA), and one offering HPV testing. Preventive treatment included cryotherapy. Further evaluation for extensive lesions and/ or diagnosis and treatment of invasive cancer were not included, as they fall outside the scope of program offerings at the primary level. Collectively, PSI’s integrated programs have provided over 1.3 million cervical cancer screening and preventive (pre-cancer) treatment services, while simultaneously providing nearly 7.5 million couple years of protection (CYPs) through voluntary family planning provision to clients during the period under review.

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Key Findings The review from published and gray literature identified 10 programs across 12 countries in Africa, Asia, and Latin America with published documentation on voluntary FP and cervical cancer service integration. The majority of the programs highlighted the feasibility of roll out and expansion of VIA-based screening with same-day treatment with cryotherapy. A subset of these programs discussed other screening methods (e.g., HPV testing and/or Pap Smear testing). None of the programs described their referral procedures explicitly, in the event that women needed to access follow-up care. The information from these published resources was used to identify common challenges of integrating cervical cancer prevention services into existing voluntary FP programs. However, these resources provided limited practical guidance for implementers needing to overcome these challenges. Therefore, the literature review was complemented with insights from PSI programs, many of which are addressing common integration challenges through context-appropriate implementation strategies. The following sections summarize these challenges alongside available evidence and insights to improve integrated programming. The Basics of Integration: Which Services and Delivery Models to Consider There are several practical considerations for program teams as they plan to layer on cervical cancer prevention services into existing voluntary FP programs. Among the first questions to consider is which screening method will be employed, taking into account operational feasibility, costs, and personnel/ skills required.* The primary objective of cervical

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Vanessa Vick/Uganda

* Depending on target populations reached and program objectives, programs may also consider the benefits, cost and operational needs to offer HPV vaccination services as primary prevention for cervical cancer; however, the majority of HPV vaccine programs are operationalized through national Ministries of Health as part of their Expanded Program on Immunization (EPI).

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

PSI Clinic Mission Mbagala Dispensary: Sala Lewis

screening programs is the reduction of cervical cancer by detecting and treating pre-cancerous lesions before they progress further. In order to establish any screening program, treatment must be available to women who test positive and/or need additional care. Ideally, provision of treatment can be offered immediately upon detection of a screen-positive result (referred to as a ‘screen and treat’ program); however, at a minimum, women should be able to access treatment and/or additional follow up within a reasonable time frame following screening. It is the program’s responsibility to ensure that barriers to treatment are identified and adequately addressed prior to the initiation of a screening program. The World Health Organization’s 2014 publication, Comprehensive Cervical Cancer Control: A Guide to Essential Practice offers global guidance to implementers on how to set up a program, including technical evidence

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regarding the strengths and limitations of each screening tool available. As an initial step, program teams should consult this guidance to ensure evidence-based, quality programming, in addition to soliciting national guidance on cancer control and prevention. Other professional societies, including the American Society of Clinical Oncology (ASCO), have published resource-stratified guidelines for prevention and treatment of invasive cancer that can provide guidance on how to prioritize services with limited resources.7 The table below summarizes the most commonly employed screening methods currently available. Of course, implementers will need to balance program costs and feasibility with client demands to ensure a sustainable program. WHO guidance strongly recommends HPV testing in all settings; however, marketshaping interventions are currently needed to reduce the costs of HPV testing for the majority of LMIC settings.

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Table 1: Primary and Secondary Cervical Cancer Prevention Strategies for LMICs PRIMARY PREVENTION: Vaccination HPV Vaccine: 2-dose series of vaccine that protects against two or more high-risk HPV subtypes known to cause the majority of cervical cancers

ADVANTAGES

LIMITATIONS

• WHO recommends reaching girls 9-14 • Cost of the vaccine is prohibitive in many years of age LMIC settings • $4.50/dose for all GAVI-eligible countries • Effective dissemination strategies to • Clinical trials ongoing to determine maximize coverage for both in- and outwhether a single dose can provide lifeof-school youth8 long immunity • Because HPV vaccine does not fully protect against all cervical cancers, screening still recommended from 30 years of age

SECONDARY PREVENTION: Screening Method

ADVANTAGES

LIMITATIONS

Cervical Cytology (Pap Smear): Visual examination of cervical cells by a trained pathologist under a microscope following the collection of a cervical specimen; abnormalities graded according to the Bethesda system

• Reduces cervical cancer incidence and • Requires pelvic exam mortality when performed regularly • Requires multiple visits • Requires complex infrastructure for chain of custody of samples • Requires trained pathologist to interpret slides • Low sensitivity can result in under treatment/missed cases

Visual Inspection with Acetic Acid or Lugol’s Iodine (VIA/VILI): Visual examination of the cervix by a trained nurse or other clinical provider following the application of acetic acid or iodine to improve visualization of cervical pre-cancerous lesions/abnormalities

• • • •

Low cost Can be performed by lower cadre providers Offers immediate results Immediate treatment if it is available onsite

• Requires pelvic exam • Low sensitivity and specificity • Subjectivity of test causes high variability of results among providers • Requires extensive clinical supervision/ quality assurance

High-risk HPV testing (RNA/DNA): Automated test to detect molecular RNA/DNA from highrisk HPV types in vaginal and/or cervical samples

• Standardized test • Increased screening intervals • Improved test performance compared with Pap Smear and VIA/VILI • Women can collect their own vaginal sample (i.e., ‘self-sampling’)

• Equipment/supplies are expensive • Need for maintenance contract • Difficult to perform as a point-of-care test due to time needed to run assays • Low specificity can result in overtreatment

TREATMENT FOR PRE-CANCEROUS LESIONS

ADVANTAGES

LIMITATIONS

Cryotherapy: Ablation of lesions using compressed gas (carbon dioxide or nitric oxide) to destroy abnormal tissue

• Immediate treatment available at same • Requires pelvic/speculum exam visit; can be performed in about 15 minutes • Gas of adequate quality can be difficult to • Procedure can be performed by lower procure on a consistent basis cadre of providers • Gas procured in medical grade tanks weighing 100 Kg or more and difficult to transport • Maintenance of machines difficult in LMICs

Thermocoagulation or Thermal Ablation: Historically known as ‘cold coagulation,’ this method uses a heated metal probe to destroy abnormal tissue. Interest in this method has resurged following the difficulty in being able to scale cryotherapy treatment in LMICs

• Lightweight, portable • Battery-operated devices do not require electricity • Probes can be sterilized with a high-level disinfectant (HLD); autoclaves are not required

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• Though evidence base is growing, pending formal guidance from the WHO on safety, acceptability, and feasibility for LMIC settings

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Client Communications: How can health providers best support informed demand within integrated FP/CC programs? In general, PSI’s experience, consistent with the experiences of many other agencies, has been that the addition of cervical cancer services has been met with high demand, especially among women being screened for the first time. In the literature review, however, some programs reported low attendance for cervical cancer screening. Low demand can be due to a reliance on opportunistic screening of women seeking FP services9,10 who may not be prepared to receive cervical cancer screening at the same visit11 or a lack of trust in the quality of cervical cancer service offering.12 Where cervical cancer services are new or awareness is low, generating informed demand is necessary. Implementers need to know: 1) who are the priority target populations to engage for cervical cancer prevention programs, and 2) what are the key messages that they need to hear and understand? It is also important to devise communication strategies for secondary target populations (e.g., husbands, mothers-inlaw) and others who may influence women’s decisions about health-related matters. Messages for primary prevention with the HPV vaccine are targeted to parents of adolescents, ideally 9-14 years of age, who are considered the primary age group for vaccination (although WHO has endorsed the vaccine for women up to 26 years old). Key messages for parents and adolescents should center on the safety and effectiveness of the vaccine, target age groups, availability and costs associated with the vaccine, and where to go with questions related to the vaccine. Coupling awareness messages for the vaccine among women who come for screening can be an effective way

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Global HPV & Cervical Cancer Awareness Campaigns ‘All of Me’ - Brazil, Columbia, Mexico American Cancer Society ‘Ni Nyampinga’ – Rwanda ‘Yenga’ – Ethiopia The Girl Effect and GAVI ‘Sankalp’ – India PSI/Maverick Collective

Vanessa Vick/Uganda

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Sala Lewis

to amplify prevention and awareness among parents of vaccine-age children.13 For secondary prevention through cervical cancer screening and pre-cancer treatment, the target age group to reach is women 30 years and above (and all ages for women living with HIV). While this age category overlaps with voluntary FP programs, strategies are needed to ensure that health providers identify and prioritize the appropriate age groups for integrated services. In particular, program data are needed to better guide communication strategies by age across the spectrum of services to understand what messages resonate across generations, as well among key populations such as women living with HIV. Regarding message content, misconceptions regarding cervical cancer are common. Understandably, women may be frightened to hear the word ‘cancer,’ and women need to be reassured that the purpose of regular screening is to detect early lesions, before they progress to cancer. Therefore, women must be encouraged to come for screening prior to the development of signs and symptoms.

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Programs will also need to counsel on options for tertiary prevention, as screening programs will inevitably identify women with suspected invasive cancer or other abnormalities, and these women must also receive appropriate counseling regarding their options for followon care. It is critical that women know and understand the process for referral and follow up. In order for new or expanding programs to reach priority clients with key messages, social and behavior change (SBC) technical experts must work alongside front-line healthcare staff (e.g., clinicians, community mobilizers, and others) to develop standardized communications with culturally appropriate messages and calls to action for integrated services that can be tailored to a women’s health status, demographics, and individual preferences. Of course, individual program messages can be best amplified by national campaigns, and should include a mix of media channels (print, TV, radio, social media) and approaches to ensure that messages reach intended audiences effectively.

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Service Delivery Models Integrated service delivery models will also vary by program. As an initial design step, it is useful for implementers to identify which service channels (e.g., community-level outreach using community health workers, clinical mobile outreach, or static clinics) yield the highest volumes of female clients 30+ years of age, and which channels effectively reach women at high risk for HIV or those living with HIV, to ensure efficient use of program resources. The choice of service models and channels will be driven by identified need, program costs, staff capacity, and available infrastructure. The trade-off, as always, is the ability to balance high uptake of services with sustainable, highquality clinical programming.

COMMUNITY-LEVEL OUTREACH A particularly effective channel for community mobilization and demand generation is through community-level outreach using dedicated community health workers. The use of trained CHWs is recognized as a high impact practice to improve access and use of voluntary FP services.14 This is especially important for women who may be geographically distant from clinics, who feel stigmatized or who are otherwise unlikely to present for clinic-based services.14 In this context, dedicated CHWs can play a critical role in educating women on their risk for HPV and the need for regular cervical screening. They can also provide women the option to self-sample for HPV. Self-sampling has been shown to be widely accepted among women, since it allows for convenience and privacy and eliminates the need for a traditional pelvic exam.15 If she agrees to provide a sample, she is given a brush, a special container and instructed on how to collect the sample. In a 2016 HPV testing pilot conducted by PSI/Uganda, CHWs went door-to door in their catchment areas to educate women about cervical screening and offered the option to self-sample for HPV testing or follow up with a health provider at their local clinic. Among 5,343 participants, 93% of women chose to provide a self-collected sample over a provider-collected sample at a local clinic, indicating a strong preference for this screening option.16

CLINICAL MOBILE OUTREACH Mobile outreach is a convenient way for women to access services in their communities. When well organized and advertised in advance, mobile outreach can drive service uptake, especially for new services, until a critical mass can be reached; however, this approach is not always financially sustainable. Actively partnering with Ministry teams and ongoing national campaigns can ensure that integrated services are built into existing health programs endorsed at the national level.

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Outreach-based services can offer high uptake of both voluntary FP and cervical cancer screen and treat services, but providers may be overwhelmed by high turnout and, in turn, feel disappointed at being unable to meet client demand. Organization of outreach activities can ensure that services are provided efficiently. Planning for additional staff members for outreach days can reduce high client burden. Actively coordinating with Ministry teams to complement existing outreach activities can ensure that integrated services are built into existing health programs endorsed at the national and sub-national level.

STATIC CLINICS Static sites, either via public or private clinics, form the basis of most integrated service delivery models. A key question for program implementers is whether, and to what extent, the addition of cervical cancer services can influence uptake of voluntary FP services. As part of its operations research agenda, the CCS&PT program evaluated uptake of voluntary FP services, e.g., injectables, IUDs and implants, across 49 participating static clinics in Uganda over an 18-month period, beginning nine months prior and ending nine months following the launch of cervical cancer screen and treat services. Across 13 health clinics owned and operated by MSI or IPPF, client uptake of voluntary IUDs increased by 800%, from a mean of five women/facility/quarter before cervical cancer services were introduced to a mean of 41 women/facility/quarter following CCS&PT launch. For implants, voluntary uptake among clients increased threefold, from 17 women/facility/quarter to 59 women facility/quarter following the launch of cervical cancer services. Across 36 social franchise facilities, owned and operated by local health providers with support provided by PSI, the mean number of women obtaining a voluntary IUD increased by 75% from 24 clients/ facility/quarter to 42 clients/facility/quarter after cervical cancer services were introduced. Uptake of implants increased by 39% from 41 to 57 women/facility/ quarter following launch of CCS&PT services. Across all facilities, only a small number of women took up injectables during this period, and the resulting changes in service uptake were too minor to make meaningful comparisons. In client exit interviews, 72% of women stated that they came to the clinics for cervical cancer screening and accessed other services during their visit. While these numbers are small, and only represent a single program experience, they point to the potential of integrated services to support more women towards a broader range of voluntary, high impact services when offered in tandem. Future operational research is needed to tease out demand for individual services and identify the most feasible and cost-effective integrated service delivery strategies, including channels.

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Clinical Training & Support: How can providers ensure clients receive high quality services within their integrated voluntary FP and cervical cancer programs? One of the challenges with integrated programming is to ensure that providers are well equipped with the necessary tools, expertise and training to offer multiple highquality services efficiently, often in a single visit. Within the global literature review, many of the programs struggled with stock outs, dysfunctional equipment,12,17 and management of high client volumes for diagnostic exams, resulting in delays in providing patients with screening results.18 Maintaining a trained cadre of providers was challenging for several programs due to high volume of staff transfers or other turnover.9,12,17 One example found a surprisingly low rate of positive cases using

visual inspection methods in some centers, indicating some cases of pre-cancerous cervical lesions that were likely being missed. This is a key weakness of the VIA method, as noted above.9 To prepare for integrated service delivery, teams must start by evaluating the clinical skills, competencies, and staff needed to perform all procedures. In some countries, treatment with cryotherapy must be performed by a doctor, medical officer, or similarly qualified health professional. It is important to refer to national guidelines to know which cadres of staff are qualified to provide services. It is important to note that many countries have successfully changed policies to allow lower-tier providers (nurses and midwives) to conduct cervical cancer screening and preventive treatment with cryotherapy. In many contexts, most FP

Sala Lewis

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Common Integrated Service Delivery Challenges EQUIPMENT & SUPPLIES

PERSONNEL

LOGISTICS

• Initial procurement and maintenance • Ongoing training/supervision to conduct • Time and clinic space necessary to conduct of equipment (cryotherapy unit and multiple procedures (e.g., screening and multiple procedures in a single visit replacement parts, high-quality acetic acid) cryotherapy coupled with IUD insertion) • High client volume for one or both services, • Reliable supply of carbon dioxide or nitrous • VIA-based screening quality is highly especially in an outreach setting oxide gas used in cryotherapy dependent on the skill and training of • Need for functioning referral system to individual providers ensure that women receive follow-on care, • Staff turnover and loss of trained providers when needed

services are delivered primarily by nurses and midwives, with clinical officers and doctors performing voluntary permanent methods, where available. In most LMIC settings, clinical capacity building is needed to equip providers with the necessary skills to perform screening and/or pre-cancer treatment with cryotherapy, as these are not usually taught in pre-service medical curricula. Standardized training packages have been developed by global organizations, including WHO and the International Agency for Research on Cancer (IARC). Both initial and refresher trainings should include a mixture of didactic and practical experience with pre- and posttest evaluations to identify strengths or gaps in learning to be emphasized in subsequent training sessions. Whenever possible, teams

PSI/Tanzania Familia provider training for VIA-based screening and cryotherapy, July 2016

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should try to partner with highly qualified master trainers from the Ministry of Health and/or other local civil society partners to support local human resource capacity in each country. This is particularly needed for more advanced procedures, which are performed at the secondary and tertiary levels of care, including loop electrode surgical procedure (LEEP), cervical biopsy, and other forms of cancer care for women found with invasive cancer. For integrated services, ideally, clinical guidelines can be integrated to better streamline quality assurance when a provider is performing multiple procedures in a single visit, such as cervical cancer screening, cryotherapy and insertion of an IUD. Clinicians will need to be trained on the correct workflow for performing multiple procedures, including provision of necessary equipment, infection prevention protocols, and patient management of any immediate side effects or untoward events. Integrated service delivery guidelines can be developed in tandem with integrated supportive supervision checklists to promptly evaluate and provide constructive feedback for visits in which multiple procedures are performed and confirm that the necessary tasks are correctly followed. In addition, it is important that providers be trained on how to regularly calibrate equipment and conduct regular maintenance to ensure the

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

machines are functioning at optimal capacity for as long as possible. The WHO has published global guidance on the technical specifications for equipment and supplies needed for cervical cancer prevention programs.2 Clinic Logistics and Client Management: How do integrated service delivery programs ensure sufficient support for clinical staff? Service provider burden is a critical barrier to service integration. Specifically, staff fatigue due to increased workload and insufficient workforce pose challenges to implementing integrated programs and adequately meeting clients’ needs.18-22 Some clients seeking screening services endured long wait times and could only receive care at limited times in the day, which sometimes resulted in clients being turned away.12 Often providers are overwhelmed by the long lines of women presenting for cervical cancer screening and treatment services, especially in an outreach setting, where services may be offered to clients at low or no cost. This is especially true when services are being offered for the first time. When both FP and CC services are offered during mobile outreach visits, it can be even more difficult to satisfy high client demand. For this reason, advance planning and preparation is critical to meet demand and provide high-quality services in a way that also safeguards providers to relieve stress and fatigue and avoid burnout. This may include adequate service provider training, task shifting, and building capacity of lower level health center staff to reduce the workloads of doctors and nurses.23-24 By increasing the number of clinical staff attending to clients and making some minor

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“When we first began offering integrated outreach services, one service provider would see between 40–50 clients in 8 hours and would still not clear the queue. Providers would suffer a lot of burn out. Over time, as providers became proficient and we became better organized, screening one client would take around four minutes, with one-to-one FP counseling having been done with a provider before to this interaction. This enabled efficiency and enhanced quality of the screening services. Now outreach teams assess the likely turnout during mobilization and advise the quality team who then engage more providers based on the expected turnout and demand on the outreach day.” Christine Were, Reproductive Health Manager, Population Services Kenya

changes in client flow, it is possible to enhance the client experience and reduce service provider burden. These insights are consistent with literature on service level challenges.24 PSI’s local partner in Kenya, Population Services (PS) Kenya, conducted a clinic assessment to determine feasibility and readiness for delivery of integrated services to identify patterns of ‘client flow’ and adjusted clinic space (e.g., waiting areas, dedicated procedure rooms), to accommodate longer visits, saving time for both clients and providers. In addition, PS Kenya staff measured time taken per procedure/ visit to ensure staffing is adequate to meet client demand for services. Based on these assessments, the PS Kenya team calculated the time needed for integrated procedures to determine the number of clients who can be accommodated and assess when additional staff are needed for special events and campaigns. These types of organizational activities can streamline programs and help mitigate provider burnout.

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Benjamin Schilling

Monitoring & Evaluation: How can providers best monitor and evaluate integrated FP/CC programs? Among integrated programs documented in the global literature review, only four were evaluated by an external team.12,17 One indicated that government programs carried out process evaluations to assess feasibility of integrating cervical cancer screening and cryotherapy into routine services.9 A retrospective evaluation of another program identified loss to follow up as a major challenge.10 Few programs conducted internal evaluations of feasibility and acceptability of screening integration. No programs provided information on their routine monitoring systems for tracking clients. Documenting and tracking integrated service delivery at the client level has historically been a barrier to fully understanding the extent to which women are taking advantange of multiple, integrated services, including voluntary FP and cervical cancer services. One way to overcome this barrier is to create comprehensive client forms (e.g., service intake forms, medical records/histories) that use a unqiue identifier to anonymously link individual clients with their medical records. In

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Uganda, where comprehensive intake forms are used for all clients, program teams are able to review integrated service trends. For example, between 2015 and 2017, PSI/Uganda’s total of 214 ProFam social franchise clinics offered integrated services, and 306,318 women received a contraceptive method through the ProFam network.25 Of those, 145,291 (47.4%) also received cervical cancer screen and treat services.25 When stratified by contraceptive method, the highest proportion of cervical cancer service uptake was among women who opted for a voluntary LARC method, with IUDs comprising (59.8%), followed by implants at (25.7%)25. Identifying and monitoring such trends allows service delivery organizations to better serve clients’ individual needs and track integrated service offerings by population segment. At the national level, many Ministries of Health have now transitioned to the District Health Information System 2 (DHIS2) system to guide programmatic decisions by making relevant health information available in “real time.” Service delivery trends can be easily tracked using DHIS2 data dashboards to guide program resource allocation and inform decisions to evlauate and improve program performance.

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Referral Systems: How to ensure women receive any additional services they need? One key gap identified in the global literature review is the difficulty in establishing and maintaining strong referral networks for follow up after cervical screening. The literature review observed that integrated programs are not well equipped to provide treatment for women who are found to have cervical lesions that are too large for cryotherapy or that are suspicious for cervical cancer. When addressing this challenge, some programs have chosen to integrate cervical cancer screening services only into voluntary FP programs that are geographically close enough to treatment facilities where women can be referred for additional care, which may include treatment for large lesions, or cervical biopsy to diagnose Vanessa Vick/Uganda

Common Reasons for Loss-to-Follow Up Among Women No information on where to go for follow-up services Long distances and wait times for appointments at referral facilities No means of transportation Fear of traveling to a new city for care High cost of drugs and/or treatment costs of referral

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women suspected to have invasive cancer.9 Each of these visits requires that the system must have a reliable means to track women to share results and ensure timely and appropriate follow up. Unfortunately, most programs do not have standardized follow-up procedures to track uptake of these referrals.9,10,12,17,26,27 Programs that have been able to track referrals find that clients often face additional barriers to accessing the follow-on services they need, including lack of time,24 correct information about when/where to seek these additional services,26 and money for transport or to pay for the additional services.18,26,27 Even when women successfully complete a referral, most often, systems are not in place to track their health outcomes.28,9,10,17,27 Without this feedback loop, the true health impact of these programs cannot be fully measured. When referrals to higher levels of care are required, programs should identify and address, to the greatest extent possible, the most common barriers to referral uptake (see text box). Approaches to address these challenges include use of appointment systems with reminder calls and text messages.18 In some programs, the ability of programs to maintain a client roster with unique identifier codes for clients can ensure that they are tracked between screening and referral centers.9 Where transportation is the major barrier, it is possible to reimburse transportation costs or have directly provided transportation for women. Another solution that could improve treatment rates is coupling women with peer supporters to help them navigate follow-up visits and offer psychosocial support. While there is no single solution to providing accessible, affordable, and timely follow-on care, it is important to identify the constraints and work towards systemic solutions for all women in need.

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Vanessa Vick/Uganda

Next Steps and Future Priorities As countries continue to evaluate opportunities for launching and scaling up integrated services, sustained political will and stakeholder commitment is critical. To solidify support, it will be necessary to quantify key health outcomes (e.g., program coverage and associated public health impact; ability to reach priority populations for services and appropriate follow up), to identify drivers and demonstrate the cost effectiveness of integrated programs. These metrics will be best coupled with qualitative insights from target audiences to identify central themes that highlight women’s needs, preferences, and barriers to accessing integrated services and how these may differ by country and cultural context.

quality, integrated services to girls and women in need across LMICs; meanwhile, many programs are already offering integrated service delivery. Existing communities of practice should be engaged and supported to evaluate and document which integrated service delivery models are feasible, acceptable, and sustainable given the realities of human resource capacity and other health system constraints. There is an opportunity to leverage existing investments and political momentum of global initiatives such as FP2020, 90-90-90 targets in HIV, and the World Health Organization’s global Call to Action for Cervical Cancer Elimination to broaden support for integrated service delivery models.

There are several unresolved operational questions related to how to best deliver high

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

References 1. International Agency for Research on Cancer (IARC). 2018. GLOBOCAN: Global Cancer Factsheets. Accessed online at: https://gco.iarc.fr/today/fact-sheets-populations. 2. World Health Organization. Comprehensive Cervical Cancer Prevention and Control: A Healthier Future for Girls and Women; 2013. doi:ISBN 978 92 4 150514 3. UNAIDS. HPV, HIV and Cervical Cancer: Leveraging Synergies to Save Women’s Lives.; 2016. http://www. unaids.org/sites/default/files/media_asset/JC2851_HPV-HIV-cervicalcancer_en.pdf. Accessed February 17, 2018 4. Scoggins S, Bremner J. FP2020: The Way Ahead 2016-2017. https://www.edmonton.ca/city_government/ city_vision_and_strategic_plan/the-way-ahead.aspx. 5. Adhanom Ghebreyesus T. Cervical cancer: an NCD We Can Overcome. 2018. http://www.who.int/ reproductivehealth/DG_Call-to-Action.pdf. 6. Program for Appropriate Technology in Health (PATH). Planning Appropriate Cervical Cancer Prevention Programs, 2nd Edition.; 2000. http://screening.iarc.fr/doc/cxca-planning-appro-prog-guide.pdf. Accessed February 17, 2018. 7. Jeronimo J, Castle PE, Temin S, Denny L et al. Secondary Prevention of Cervical Cancer Resource-Stratified Guideline. J Glob Oncol. 2016;12;3(5):635-657. 8. Jennings, MC and Loharikar A. A vaccine to prevent against cervical cancer: context for the global public health practitioner. 2018; 6(4):629-636. 9. International Agency for Research on Cancer, World Health Organization. IARC Handbooks of Cancer Prevention: Cervix Cancer Screening; 2005. http://www.iarc.fr/en/publications/pdfs-online/prev/handbook10/ HANDBOOK10.pdf. Accessed February 17, 2018. 10. UNAIDS. HPV, HIV and Cervical Cancer: Leveraging Synergies to Save Women’s Lives; 2016. http://www. unaids.org/sites/default/files/media_asset/JC2851_HPV-HIV-cervicalcancer_en.pdf. Accessed February 17, 2018. 11. Ahmed T, Ashrafunnessa, Rahman J. Development of a visual inspection programme for cervical cancer prevention in Bangladesh. Reprod Health Matters. 2008;16(32):78-85. doi:10.1016/S0968-8080(08)32419-7 12. Basu P, Nessa A, Majid M, Rahman JN, Ahmed T. Evaluation of the National Cervical Cancer Screening Programme of Bangladesh and the formulation of quality assurance guidelines. J Fam Plan Reprod Heal Care. 2010;36(3):131-134. doi:10.1783/147118910791749218 13. Delany-Moretlwe S, Kelley KF, James S, Scorgie F et al. Human Papillomavirus Vaccine Introduction in South Africa: Implementation Lessons From an Evaluation of the National School-Based Vaccination Campaign. Global Health: Science and Practice. 2018. 14. USAID. High-Impact Practices in Family Planning (HIPs). Community health workers: bringing family planning services to where people live and work. Rural Heal Ser. 2015. 15. Gupta S, Palmer C, Bik EM, et al. Self-Sampling for Human Papillomavirus Testing: Increased Cervical Cancer Screening Participation and Incorporation in International Screening Programs. 2018; Front Pub Health 6:77. doi: 10.3389/fpubh.2018.00077 16. Cervical Cancer Screening & Preventative Therapy (CCS&PT) Operations Research in Uganda: Assessing Integration of Cervical Cancer Screening into Existing Sexual and Reproductive Health Networks and Describing Patient Referral Models; 2016. 17. Michelo B, Nalubamba M, Mbinji C, Chintu N. Integrating Cervical Cancer Screening within Family Planning Service Provision in Peri-Urban Zambia. doi:10.1186/s12885-015-1558-5 18. Paul P, Winkler JL, Bartolini RM, et al. Screen-and-Treat Approach to Cervical Cancer Prevention Using Visual Inspection with Acetic Acid and Cryotherapy: Experiences, Perceptions, and Beliefs from Demonstration Projects in Peru, Uganda, and Vietnam. Oncologist. 2013;18:1278-1284. doi:10.1634/theoncologist.2013-0253

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

19. Msyamboza KP, Phiri T, Sichali W, Kwenda W, Kachale F. Cervical cancer screening uptake and challenges in Malawi from 2011 to 2015: retrospective cohort study. BMC Public Health. 2016;16(1):806. doi:10.1186/ s12889-016-3530-y 20. Khozaim K, Orang’o E, Christoffersen-Deb A, et al. Successes and challenges of establishing a cervical cancer screening and treatment program in western Kenya. Int J Gynecol Obstet. 2014;124(1):12-18. doi:10.1016/j.ijgo.2013.06.035 21. Were E, Nyaberi Z, Buziba N. Integrating cervical cancer and genital tract infection screening into mother, child health and family planning clinics in Eldoret, Kenya. Afr Health Sci. 2010;10(1):58-65. 22. Mabeya H, Khozaim K, Liu T, et al. Comparison of conventional cervical cytology versus visual inspection with acetic acid among human immunodeficiency virus-infected women in Western Kenya. J Low Genit Tract Dis. 2012;16(2):92-97. doi:10.1097/LGT.0b013e3182320f0c 23. Subramanian S, Kibachio J, Hoover S, et al. Research for Actionable Policies: implementation science priorities to scale up non–communicable disease interventions in Kenya. J Glob Health. 2017;7(1). doi:10.7189/jogh.07.010204 24. Chary AN, Rohloff PJ. ajor challenges to scale up of visual inspection-based cervical cancer prevention programs: the experience of Guatemalan NGOs. Glob Heal Sci Pract. 2014;2(3):307-317. doi:10.9745/ GHSP-D-14-00073 25. Mwaka AD, Wabinga HR, Mayanja-Kizza H. Mind the gaps: a qualitative study of perceptions of healthcare professionals on challenges and proposed remedies for cervical cancer help-seeking in post conflict northern Uganda. BMC Fam Pract. 2013;14(1):193. doi:10.1186/1471-2296-14-193 26. Smit JA, Church K, Milford C, Harrison AD, Beksinska ME. Key informant perspectives on policy- and servicelevel challenges and opportunities for delivering integrated sexual and reproductive health and HIV care in South Africa. BMC Health Serv Res. 2012;12(1):48. doi:10.1186/1472-6963-12-48 27. Kwagga M, Lukwago B, Blumenthal PD, White HL. Integration of cervical cancer prevention services into an existing family planning program in Uganda. In: International Conference on Family Planning (ICFP), Kigali, Rwanda; 2018. 28. World Health Organization. Comprehensive Cervical Cancer Prevention and Control: A Healthier Future for Girls and Women; 2013. doi:ISBN 978 92 4 1505147

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Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs:

A Review of the Evidence Base and Insights from Existing Field Programs

Acknowledgements PSI wishes to acknowledge from each of the respective global and country teams who contributed in the development and refinement of this brief, including: Dr. Mbolatiana Razafimahefa, Association Béninoise pour la Marketing Social Benin Ms. Rachel Mutuku, PS Kenya Ms. Christine Were, PS Kenya Dr. Han Win Htat, PSI/Myanmar Dr. Peter Entonu, Society for Family Health, Nigeria Dr. Joseph Mashafi, PSI/Tanzania Dr. Milly Kaagwa, PSI/Uganda Ms. Cat Normile, PSI/Washington Dr. Mutinta Phiri, SFH/Zambia Dr. Nyaradzo Muhonde, PSI/Zimbabwe Ms. Sarah Thurston, PSI/Washington Mr. Stephano Guduyeka, PSI/Zimbabwe This brief was prepared by Population Services International (PSI), in partnership with the International Center for Research on Women (ICRW), made possible by the support of the American People through the United States Agency for International Development (USAID) under the Support for International Family Planning Organizations 2 (SIFPO2) Project (Cooperative Agreement No. AID-OAA-A-14-00037). The contents of this brief are the sole responsibility of PSI and ICRW and do not necessarily reflect the views of USAID or the United States Government. For more details on PSI’s cervical cancer programs, please contact Dr. Heather White, Senior Technical Advisor for NCDs, at: hwhite@psi.org. For more details on PSI’s voluntary family planning programs, please contact Pierre Moon, Project Director SIFPO2, at pmoon@psi.org.

SUGGESTED CITATION White, HL., Steinhaus, M., Sebany, M., Gregowski, A., Moon, P., and Blumenthal, PD. (2019). Integrating Cervical Cancer Prevention Services with Voluntary Family Planning Programs: Insights from the Field. Washington, DC: Population Services International and International Center for Research on Women.

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