This September is one of double celebrations for the Pink Ribbon Red Ribbon program in the Republic of Botswana; commemorating Pink Ribbon Red Ribbon’s fifth year anniversary globally and Botswana’s Golden Jubilee as an independent country. Since 2012, Pink Ribbon Red Ribbon has partnered with the Government of Botswana to reduce morbidity and mortality from cervical cancer.
This month, we highlight screening outreaches as a novel implementation approach for the cervical cancer screening and treatment programs in Botswana. It is a well-known public health strategy that in order to reach underserved communities, the services must be taken to where people live and work. For the first time, screening outreaches are conducted in the districts of Botswana for cervical cancer screening and treatment.
Below is a guest blog from Jhpiego, Pink Ribbon Red Ribbon’s implementing partner in Botswana:
Botswana’s small population of just over two million people has struggled with numerous health challenges over the past several decades, notably one of the most severe HIV/AIDS epidemics in the world (Botswana currently ranks second in HIV prevalence globally). Growing in pace with the burden of HIV is an expanding epidemic of non-communicable diseases, especially cervical cancer which presents a synergistic threat to women living with HIV and is the leading cause of cancer-related deaths among women in the country.
With a territory of almost 600,000km2, comparable in size to France or the U.S. state of Texas, ensuring the population has access to routine health services for cervical cancer screening is a challenge. With the endorsement of the “See-and-Treat” strategy in 2015 based on WHO recommendations, Botswana has actively moved to expand access to routine preventive screening for cervical cancer by making it accessible to all women at the primary healthcare level through the visual inspection with acetic acid (VIA) technique, a low-cost, highly effective method which can be conducted by a nurse and yields immediate results. “See-and-Treat” allows health providers to respond immediately if a woman has pre-cancerous lesions by providing onsite cryotherapy treatment to remove the lesions. Quick access to treatment is critical to winning the fight against cervical cancer, if caught early. Botswana’s goal is that all women between the ages of 30 and 49 years be screened at least once in their lifetime.
Following national and international guidelines, increasing the number of women who come forward to be screened for the first time is a major part of the Ministry of Health’s efforts to tackle cervical cancer. Working with the Ministry’s National Cervical Cancer Prevention Program (NCCPP), as part of national efforts, Jhpiego is partnering with district health managers and clinic staff in Mahalapye District to increase the number of health clinics offering VIA through the support of Pink Ribbon Red Ribbon and the U.S. Centers for Disease Control and Prevention (CDC), building on the existing PEPFAR platform.
In order to increase the number of women screened, the clinics in the district started conducting mobile outreaches in the communities, providing information and “on-the-spot” screening services to women in a familiar setting close to their homes. The work to build a foundation for cervical cancer prevention in Mahalapye district is paying off: between November 2015 and June 2016, Mahalapye had the highest number of women screened of any district nationwide, reporting a total of 1,016 (42%) of all 2,401 new screenings. Based on modest targets set during the national roll-out phase, the district has aimed to screen at least 61 new women each month, in addition to routine and follow-up screenings. Between January and June 2016, this target was exceeded every month with the exception of May when they were 6 clients short of the target.
A large part of this success can be attributed to the outreach activities conducted by the enthusiastic staff at the Mahalapye District Hospital’s “See-and-Treat” clinic, especially two passionate nurses, Senyana and Morebodi. The clinic is the only facility in the district that is currently offering VIA screening. Between January and March 2016, the nurses led 12 outreach campaigns in Mahalapye district: 406 women were screened, 256 (63%) of whom were screened for the first time. Nine women screened positive, and of them 7 (100% of those eligible) were treated with cryotherapy on the same day and 2 were referred for treatment of large lesions.
The Mahalapye nurses appreciate the eagerness of women to be screened for cervical cancer in their communities during the outreach campaigns: “…they are many, and that’s where we catch them [women]” explained the nurses, noting that due to the large distances between treatment sites, the outreach campaigns offer an important avenue for reaching women. To meet the demand, the two nurses try to conduct at least four outreach sessions a month. They are an inspiration to their colleagues at the Mahalapye District Hospital to keep up the fight against cervical cancer, as their Hospital Superintendent and Head of the District, Dr. Bose enthusiastically shared, “the team is very motivated and encourages even me to support their initiatives, so we don’t disrupt their momentum”.
During the outreach sessions, the team from the “See-and-Treat” Clinic in Mahalapye Hospital uses a van to transport the necessary equipment such as the cryotherapy machine and supplies, including a nitrous oxide gas cylinder, screening packs, and speculums. The health clinics in the outreach communities provide the space and beds for the screening. The team offers immediate cryotherapy treatment for eligible VIA-positive clients. The nurses liaise with the outreach health facility to make appointments for clients that need referral for further care, in cases of large lesions that require treatment with the loop electrosurgical excision procedure (LEEP), and ensure that they are assisted to reach the nearest facility.
At the village outreach event in Chadibe, the Jhpiego staff supporting Mahalapye witnessed firsthand the drive of the Malahapye staff, who together with Jhpiego, screened 59 women in one day, of which 50 (85%) were screened through VIA. Of these, 46 (92%) were either screening for the first time or had previously done a Pap smear but had not received results. Three women were found to be VIA-positive, and all received same-day treatment, either through cryotherapy or LEEP as there was a doctor on-site to perform LEEP. The client turnout demanding screening was higher than the providers expected, clearly demonstrating the need for intensified and more frequent outreaches. Clients like Ms. Gofaone expressed gratitude to the health care providers as knowing the status of her cervical health made her more comfortable. The last client of the day, Ms. Popego expressed no regret after waiting the whole day to be screened at 19.00 hours, “It was worth the wait… I will sleep [well] tonight” she said with a sigh of relief.
The enthusiasm for cervical cancer screening is growing in Botswana, as is the awareness by women that screening is a critical step they can take to keep themselves healthy. Through expanded outreach and increased availability of services, Botswana will continue moving closer to achieve the goal of reducing cervical cancer deaths.The outreach activities have the potential to be enormously useful, when well planned and managed. The NCCPP and Jhpiego’s “See-and-Treat” teams continue to improve and refine the outreach strategies.
Written by: Rosinah Dialwa and Toun Olateju.
Rosinah is the Monitoring and Evaluation Advisor for Jhpiego in Botswana, and directly supports improving “See-and-Treat” facilities’ data collection and analysis with the NCCPP as part of data for decision making priorities.
Toun is the Country Program Manager for Botswana at Pink Ribbon Red Ribbon.