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A Participatory Assessment to Identify Strategies for Improved Cervical

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A Participatory Assessment to Identify Strategies for Improved Cervical Temas de actualidad / Current topics Cervical cancer remains a leading cause of death for A participatory women in many countries of the world. In Latin America and the Caribbean, cervical cancer has be- assessment to identify come the primary cause of cancer-related deaths strategies for improved among women despite the introduction of screen- ing programs more than 30 years ago. Each year in cervical cancer Latin America and the Caribbean 52 000 new cases are diagnosed, and 25 000 women die of the disease prevention and (1). Bolivia has one of the highest cervical cancer in- cidence rates in the Americas (58.1/100 000 women) treatment in Bolivia (2). An estimated 661 deaths per year in Bolivia are attributed to cervical cancer, equivalent to an age- standardized mortality rate of 22.2/100 000. This compares with 7.6/100 000 in Argentina and 12/ 1 Ilana G. Dzuba, 100 000 for all of South America. These statistics are Ruth Calderón,2 Siri Bliesner,3 particularly noteworthy given that cervical cancer 4 can be prevented by the timely identification and Silvana Luciani, treatment of precancerous lesions (3, 4). Fernando Amado,5 Bolivia is one of the poorest countries in and Martha Jacob1 South America. Some 70% of Bolivians live in pov- erty, with limited access to adequate housing, sani- tation, education, and health care. Surveys indicate that the public sector in Bolivia provides health care for 40%–60% of the population, and performs 70% of all the Pap smears done in the country for cervi- cal cancer screening (5, 6). Various efforts related to cervical cancer pre- vention in Bolivia have yet to result in an apprecia- ble decrease in morbidity and mortality from the disease. These efforts have included Pap smear screening, creating the Component for the Detec- tion and Control of Women’s Cancer (Componente de Detección y Control del Cáncer de la Mujer) (the “Women’s Cancer Component”) as a unit within the Ministry of Health and Social Welfare (MHSW) (Ministerio de Salud y Previsión Social), and develop- ing national clinical norms for the prevention of Key words: cervix neoplasms; women’s health ser- cervical cancer. To identify the obstacles that have vices; preventive health services; health knowledge, impeded the effectiveness of cervical cancer pre- attitudes, practice; Bolivia. vention, three organizations joined together in 2001 to coordinate an assessment of the existing cervical cancer prevention and treatment services and the 1 EngenderHealth, New York City, New York, United States of Amer- ica. Send correspondence to: Ilana G. Dzuba; e-mail: ilanadzuba development of appropriate intervention strategies. @gmail.com The three groups were the Women’s Cancer Com- 2 Bolivia, Ministerio de Salud y Previsión Social, Componente de De- ponent, EngenderHealth (an international repro- tección y Control del Cáncer de la Mujer, La Paz, La Paz, Bolivia (currently at Hospital de Clínicas, La Paz, Bolivia). ductive health organization based in New York 3 EngenderHealth, La Paz, La Paz, Bolivia; University of Michigan City), and the Pan American Health Organization. Population Fellows Program, Ann Arbor, Michigan, United States of America (currently at Seattle & King County Department of Public These groups adapted the World Health Organiza- Health, Seattle, Washington, United States of America). tion (WHO) three-stage “Strategic Approach” for 4 Pan American Health Organization, Washington, D.C., United States of America. strategic planning and reproductive health policy 5 Pan American Health Organization, La Paz, La Paz, Bolivia. and program development (7, 8) in order to de- Rev Panam Salud Publica/Pan Am J Public Health 18(1), 2005 53 Temas de actualidad • Current topics velop evidence-based recommendations for inter- FIGURE 1. The four departments of Bolivia (Cochabamba, ventions that could strategically enhance cervical- La Paz, Potosí, Santa Cruz) where the assessment of cancer-related services and community outreach, cervical cancer prevention and treatment was carried out, 2001–2002 and thereby reduce cervical cancer rates in Bolivia. The results of the Bolivia assessment could be used to inform programming and policy by identifying management, technological, sociocultural, and eco- nomic issues that affect the quality of services and BRAZIL respect for clients’ rights. This article reports on the findings from the assessment phase of the Strategic Approach process carried out with cervical cancer prevention and treatment services in Bolivia. METHODOLOGY LA PAZ COCHABAMBA SANTA CRUZ The methodology employed was an adapta- tion of the first stage of WHO’s three-stage Strategic Approach. The first stage itself included three parts: (1) a literature review, (2) qualitative research, and POTOSÍ (3) development of recommendations for policy, POTOSÍ programming, and research. Literature review In order to assess the current status of cervical used prevention and treatment technologies. A mul- cancer prevention and treatment services and to tidisciplinary team of 15 departmental health au- identify gaps in available information in Bolivia, thorities, providers, program managers, community during March through December 2001 a consulting advocates, social scientists, and local and interna- anthropologist compiled country-specific morbid- tional researchers conducted fieldwork (in-depth in- ity and mortality statistics, information from avail- terviews with stakeholders and observations of able secondary sources on cervical cancer preven- health services) in January and February 2002. Prior tion and treatment, and details about Bolivia’s to the fieldwork, the team was oriented to qualita- sociodemographic, political, and economic context. tive research methods, the Strategic Approach, and The anthropologist reviewed general sources and the results of the literature review. The team also de- materials identified through an Internet-based liter- vised three strategic questions to guide instrument ature search and interviews with informants. Liter- development, data collection, and analysis: (1) Is it ature from the Government of Bolivia, nongovern- necessary to improve the current information sys- mental organizations (NGOs), and national and tem and cancer registry for the prevention, diagno- international research centers were included in the sis, and treatment of cervical cancer? (2) Is it neces- review. Also, in collaboration with the manager of sary to introduce new interventions for screening, the Women’s Cancer Component and the president diagnosis, and treatment of precancerous cervical of the Cancer Registry of La Paz, a list of key in- lesions? (3) Is it necessary to improve the existing country individuals and institutions related to cer- services for the management of cervical cancer? vical cancer prevention was developed. Through Fieldwork was conducted in rural, urban, and these contacts, additional documentation and pub- periurban areas of four of the nine departments of lished literature were identified and then reviewed. Bolivia. The four were Cochabamba, La Paz, Potosí, Ultimately, information from all relevant sources and Santa Cruz (Figure 1). These departments were was compiled into one text. selected purposefully to include the country’s three geographic and ecological zones and because they offered a range of cervical cancer prevention and Qualitative research treatment services. Potosí was included because of its disproportionately high rate of cervical cancer The literature review generated questions to (93.5/100 000, vs. the national rate of 58.1/100 000). explore concerning the interactions among women, The research team divided in two, with each health services and providers, and the currently group covering two departments over a period of 54 Rev Panam Salud Publica/Pan Am J Public Health 18(1), 2005 Temas de actualidad • Current topics two weeks. Existing clients of health facilities, pub- officials, program managers, oncologists, gynecolo- lic and private sector health facility personnel, lab- gists, cytologists, pathologists, and local NGO rep- oratory personnel, program managers, community resentatives from all departments of the country— members, community leaders and authorities, and including those not visited during the fieldwork— other stakeholders were selected to participate in were convened at a two-day technical input work- the assessment by convenience and snowball sam- shop. These experts reviewed the assessment re- pling. These informants’ perspectives on cervical sults and conclusions, identified evidence-based cancer and its prevention, barriers to and facilita- priorities, and, in small groups, reached consensus tors of services, and sociocultural norms were col- on recommendations for additional research, policy lected through semistructured in-depth interviews development, and programmatic interventions. based on six interview guides, which corresponded to respondent type. The interview guides were de- veloped by the 15-member research team, based on FINDINGS international standards for cervical cancer preven- tion and treatment. Literature review The fieldwork interviews were conducted in- dividually or in small groups (three to five persons), The literature review yielded 53 references and the interviewer recorded written notes in a field that were included in the final report about the so- notebook. Prior to all interviews, respondents ciodemographic, political, and economic context in granted oral consent for their involvement in the which Bolivia is situated; 16 of the 53
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