Improving rural health care reduces illegal logging and conserves carbon in a tropical forest

Tropical forest loss currently exceeds forest gain, leading to a net greenhouse gas emission that exacerbates global climate change. This has sparked scientific debate on how to achieve natural climate solutions. Central to this debate is whether sustainably managing forests and protected areas will deliver global climate mitigation benefits, while ensuring local peoples' health and well-being. Here, we evaluate the 10-y impact of a human-centered solution to achieve natural climate mitigation through reductions in illegal logging in rural Borneo: an intervention aimed at expanding health care access and use for communities living near a national park, with clinic discounts offsetting costs historically met through illegal logging. Conservation, education, and alternative livelihood programs were also offered. We hypothesized that this would lead to improved health and well-being, while also alleviating illegal logging activity within the protected forest. We estimated that 27.4 km2 of deforestation was averted in the national park over a decade (∼70% reduction in deforestation compared to a synthetic control, permuted P = 0.038). Concurrently, the intervention provided health care access to more than 28,400 unique patients, with clinic usage and patient visitation frequency highest in communities participating in the intervention. Finally, we observed a dose-response in forest change rate to intervention engagement (person-contacts with intervention activities) across communities bordering the park: The greatest logging reductions were adjacent to the most highly engaged villages. Results suggest that this community-derived solution simultaneously improved health care access for local and indigenous communities and sustainably conserved carbon stocks in a protected tropical forest.

Addressing Family Planning Access Barriers Using an Integrated Population Health Environment Approach in Rural Uganda

Recent studies recommend FP initiatives in rural sub-Saharan Africa operate in more context-specific ways to reduce inequities. In 2011 such a project, HoPE-LVB, was implemented by Pathfinder International and local partners among Ugandan Lake Victoria fishing communities using a Population, Health and Environment approach. Among other objectives, the project aimed to increase support for FP and women's involvement in decision-making by linking FP benefits to community needs including income generation from nature-based livelihoods. Improved FP access was measured by the project using qualitative methods and the project's indicator database in terms of five barriers: service quality, community knowledge, physical access, finances, and social acceptability. Through coordinated interventions representing multiple sectors, the project helped communities move more towards a -tipping point‖ whereby FP use has now become more an acceptable and accepted social norm. Central to this has been improving service quality and physical access as well as facilitating women's involvement in income-generation, thereby increasing their agency and contribution to decision-making including pregnancy timing.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution.

METHODS

Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol.

FINDINGS

All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa.

INTERPRETATION

Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition

BACKGROUND

The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development.

METHODS

We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time.

FINDINGS

Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries.

INTERPRETATION

Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

FUNDING

Bill & Melinda Gates Foundation.

Effects of land use on plague (Yersinia pestis) activity in rodents in Tanzania

Understanding the effects of land-use change on zoonotic disease risk is a pressing global health concern. Here, we compare prevalence of Yersinia pestis, the etiologic agent of plague, in rodents across two land-use types-agricultural and conserved-in northern Tanzania. Estimated abundance of seropositive rodents nearly doubled in agricultural sites compared with conserved sites. This relationship between land-use type and abundance of seropositive rodents is likely mediated by changes in rodent and flea community composition, particularly via an increase in the abundance of the commensal species, Mastomys natalensis, in agricultural habitats. There was mixed support for rodent species diversity negatively impacting Y. pestis seroprevalence. Together, these results suggest that land-use change could affect the risk of local transmission of plague, and raise critical questions about transmission dynamics at the interface of conserved and agricultural habitats. These findings emphasize the importance of understanding disease ecology in the context of rapidly proceeding landscape change.

Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occured since the Millennium Declaration.

METHODS

To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010-13) of incidence, drug resistance, and coverage of insecticide-treated bednets.

FINDINGS

Globally in 2013, there were 1·8 million new HIV infections (95% uncertainty interval 1·7 million to 2·1 million), 29·2 million prevalent HIV cases (28·1 to 31·7), and 1·3 million HIV deaths (1·3 to 1·5). At the peak of the epidemic in 2005, HIV caused 1·7 million deaths (1·6 million to 1·9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19·1 million life-years (16·6 million to 21·5 million) have been saved, 70·3% (65·4 to 76·1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7·5 million (7·4 million to 7·7 million), prevalence was 11·9 million (11·6 million to 12·2 million), and number of deaths was 1·4 million (1·3 million to 1·5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7·1 million (6·9 million to 7·3 million), prevalence was 11·2 million (10·8 million to 11·6 million), and number of deaths was 1·3 million (1·2 million to 1·4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64·0% of cases (63·6 to 64·3) and 64·7% of deaths (60·8 to 70·3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1·2 million deaths (1·1 million to 1·4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31·5% (15·7 to 44·1). Outside of Africa, malaria mortality has been steadily decreasing since 1990.

INTERPRETATION

Our estimates of the number of people living with HIV are 18·7% smaller than UNAIDS's estimates in 2012. The number of people living with malaria is larger than estimated by WHO. The number of people living with HIV, tuberculosis, or malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.

METHODS

We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.

FINDINGS

292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland.

INTERPRETATION

Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.

FUNDING

Bill & Melinda Gates Foundation.

Avoiding verification bias in screening test evaluation in resource poor settings: a case study from Zimbabwe

Background Verification bias occurs when the percentage of subjects receiving disease verification differs according to the test result. Statistical adjustment yields unbiased sensitivity and specificity under a missing at random (MAR) assumption.

Purpose To use an example from an international study to show how the assumptions needed for unbiased statistical adjustment for verification bias can be undermined by conditions on the ground, and that accuracy of estimates is also compromised by too low a sampling fraction of subjects who test negative.

Methods A study in Zimbabwe assessed the accuracy of a screening test for cervical cancer screening, visual inspection with acetic acid (VIA). The study was conducted in two phases, Phase I, where only 10% of subjects with negative tests received verification, and Phase II, in which nearly all subjects were verified. Unadjusted, simple- and covariate-adjusted estimates were compared to investigate factors affecting differences. Bootstrap simulations were used to illustrate the effect of varying test negative sampling fractions.

Results Phase I unadjusted sensitivity and specificity were 0.66 (0.61—0.70) and 0.34 (0.31—0.36), respectively. Simple-weighted adjusted estimators accounting only for VIA status were 0.20 (0.17—0.23) and 0.80 (0.78—0.81), respectively, suggesting the test to be useless. It was found that verification (colposcopy) capacity in-country had been exceeded, and that random selection of test negative patients for colposcopy had been compromised. Phase II estimates of sensitivity and specificity were 0.77 and 0.64, respectively. With 9% disease prevalence, a VIA test-negative sampling fraction >50% was necessary for the confidence intervals for sensitivity to have more than a 90% probability of including the true value. Limitations Phase I statistical adjustment was not made for MAR deviations unexplained by the two auxiliary factors, Pap results and STD history. Adjustment was not possible for other unmeasured co-factors.

Conclusions While there are standard formulae for correcting for verification bias, these will be biased if the MAR assumption is not met, which can occur through the actions of study personnel or subjects. Design of such studies in low resource environments needs to either require 100% verification, or employ procedures ensuring that the sample of test negatives who receive verification is indeed random. In addition, required test negative sampling fractions need to incorporate information on both disease prevalence and overall sample size. Clinical Trials 2008; 5: 496—503. http://ctj.sagepub.com

Poverty reduction and Millennium Development Goals: recognizing population, health, and environment linkages in rural Madagascar

The Millennium Development Goals (MDGs), committed to by all 191 United Nations member states, are rooted in the concept of sustainable development. Although 2007 (midway) reports indicated that programs are under way, unfortunately many countries are unlikely to reach their goals by 2015 due to high levels of poverty. Madagascar is one such example, although some gains are being made. Attempts of this island nation to achieve its MDGs, expressed most recently in the form of a Madagascar Action Plan, are notable in their emphasis on (1) conserving the country's natural resource base, (2) the effect of demographic trends on development, and (3) the importance of health as a prerequisite for development. Leadership in the country's struggle for economic growth comes from the president of the Republic, in part, through his "Madagascar Naturally" vision as well as his commitment to universal access to family planning, among other health and development interventions. However, for resource-limited countries, such as Madagascar, to get or stay "on track" to achieving the MDGs will require support from many sides. "Madagascar cannot do it alone and should not do it alone." This position is inherent in the eighth MDG: "Develop a global partnership for development." Apparently, it takes a village after all - a global one.

Visual inspection with acetic acid as a cervical cancer test: accuracy validated using latent class analysis

Background

The purpose of this study was to validate the accuracy of an alternative cervical cancer test – visual inspection with acetic acid (VIA) – by addressing possible imperfections in the gold standard through latent class analysis (LCA). The data were originally collected at peri-urban health clinics in Zimbabwe.

Methods

Conventional accuracy (sensitivity/specificity) estimates for VIA and two other screening tests using colposcopy/biopsy as the reference standard were compared to LCA estimates based on results from all four tests. For conventional analysis, negative colposcopy was accepted as a negative outcome when biopsy was not available as the reference standard. With LCA, local dependencies between tests were handled through adding direct effect parameters or additional latent classes to the model.

Results

Two models yielded good fit to the data, a 2-class model with two adjustments and a 3-class model with one adjustment. The definition of latent disease associated with the latter was more stringent, backed by three of the four tests. Under that model, sensitivity for VIA (abnormal+) was 0.74 compared to 0.78 with conventional analyses. Specificity was 0.639 versus 0.568, respectively. By contrast, the LCA-derived sensitivity for colposcopy/biopsy was 0.63.

Conclusion

VIA sensitivity and specificity with the 3-class LCA model were within the range of published data and relatively consistent with conventional analyses, thus validating the original assessment of test accuracy. LCA probably yielded more likely estimates of the true accuracy than did conventional analysis with in-country colposcopy/biopsy as the reference standard. Colpscopy with biopsy can be problematic as a study reference standard and LCA offers the possibility of obtaining estimates adjusted for referent imperfections.

Cervical cancer prevention: safety, acceptability, and feasibility of a single-visit approach in Accra, Ghana

OBJECTIVE

The purpose of this study was to assess the safety and acceptability of a single-visit approach to cervical cancer prevention combining visual inspection of the cervix with acetic acid wash (VIA) and cryotherapy.

STUDY DESIGN

The study was observational. Nine clinicians were trained in VIA and cryotherapy. Over 18 months 3665 women were VIA-tested. If positive and eligible, cryotherapy was offered immediately. Treated women were followed-up at 3 months and 1 year.

RESULTS

The test-positive rate was 13.2%. Of those eligible, 70.2% and 21% received immediate or delayed treatment, respectively. No major complications were recorded, and 5.6% presented for a perceived problem post-cryotherapy. Among those treated over 90% expressed satisfaction with their experience, and 96% had an indentifiable squamo-columnar junction. Only 2.6% (6/232) were test positive, 1-year posttreatment.

CONCLUSION

A single-visit approach using VIA and cryotherapy proved to be safe, acceptable, and feasible in an urban African setting.

Cost-effectiveness of cervical-cancer screening in five developing countries

BACKGROUND

Cervical-cancer screening strategies that involve the use of conventional cytology and require multiple visits have been impractical in developing countries.

METHODS

We used computer-based models to assess the cost-effectiveness of a variety of cervical-cancer screening strategies in India, Kenya, Peru, South Africa, and Thailand. Primary data were combined with data from the literature to estimate age-specific incidence and mortality rates for cancer and the effectiveness of screening for and treatment of precancerous lesions. We assessed the direct medical, time, and program-related costs of strategies that differed according to screening test, targeted age and frequency, and number of clinic visits required. Single-visit strategies involved the assumption that screening and treatment could be provided in the same day. Outcomes included the lifetime risk of cancer, years of life saved, lifetime costs, and cost-effectiveness ratios (cost per year of life saved).

RESULTS

The most cost-effective strategies were those that required the fewest visits, resulting in improved follow-up testing and treatment. Screening women once in their lifetime, at the age of 35 years, with a one-visit or two-visit screening strategy involving visual inspection of the cervix with acetic acid or DNA testing for human papillomavirus (HPV) in cervical cell samples, reduced the lifetime risk of cancer by approximately 25 to 36 percent, and cost less than 500 dollars per year of life saved. Relative cancer risk declined by an additional 40 percent with two screenings (at 35 and 40 years of age), resulting in a cost per year of life saved that was less than each country's per capita gross domestic product--a very cost-effective result, according to the Commission on Macroeconomics and Health.

CONCLUSIONS

Cervical-cancer screening strategies incorporating visual inspection of the cervix with acetic acid or DNA testing for HPV in one or two clinical visits are cost-effective alternatives to conventional three-visit cytology-based screening programs in resource-poor settings.

A critical assessment of screening methods for cervical neoplasia

The objective of cervical cancer screening is to reduce cervical cancer incidence and mortality by detecting and treating precancerous lesions. Conventional cytology is the most widely used cervical cancer screening test. Although cytology has been effective in reducing the incidence of and mortality from cervical cancer in developed countries in both opportunistic and--more dramatically--organized national programs, it has been less successful and largely ineffective in reducing disease burden in low-resource settings where it has been implemented. Liquid-based cytology, testing for infection with oncogenic types of human papillomaviruses, visual inspection with 3-5% acetic acid, magnified visual inspection with acetic acid, and visual inspection with Lugol's iodine have been evaluated as alternative tests. Their test characteristics, and the applications and limitations in screening, are discussed with an emphasis on the work of the Alliance for Cervical Cancer Prevention over the past 5 years.

Advocating for cervical cancer prevention

Cervical cancer is a significant health problem among women in developing countries. Contributing to the cervical cancer health burden in many countries is a lack of understanding and political will to address the problem. Broad-based advocacy efforts that draw on research and program findings from developing-country settings are key to gaining program and policy support, as are cost-effectiveness analyses based on these findings. The Alliance for Cervical Cancer Prevention (ACCP) has undertaken advocacy efforts at the international, regional, national, and local levels to raise awareness and understanding of the problem (and workable solutions), galvanize funders and governments to take action, and engage local stakeholders in ensuring program success. ACCP experience demonstrates the role that evidence-based advocacy efforts play in the ultimate success of cervical cancer prevention programs, particularly when new screening and treatment approaches-and, ultimately, radically new approaches such as a human papillomavirus vaccine-are available.

Screening test accuracy studies: how valid are our conclusions? Application to visual inspection methods for cervical screening

While the basic concepts associated with screening are simple, studying the value of new tests requires a very strict methodology. This paper summarizes lessons learned regarding appropriate methodologies to assess the value of new screening approaches using visual inspection with acetic acid (VIA), a screening test for cervical pre-cancerous lesions, as an example. In addition to being convenient to, safe for and acceptable by target community members, a screening test should be reliable and have good test characteristics (i.e. be able to discriminate well between early disease and non disease). Test reliability assesses the degree to which repeated measurements of the test yields the same result. To ensure reproducibility of study findings, test reliability should be assessed before any evaluation of test accuracy. The accuracy of a test (specificity and sensitivity) is measured using cross-sectional studies with adequate sample size. Several basic features are necessary to ensure internal validity for such studies: (a) final disease status data should be obtained for all subjects, (b) all tests results must be determined independently of previous results, (c) the reference standard used to determine the disease status should be accurate, (d) the full "spectrum" of the disease should be included in the study. The study results should also have external validity to be applicable to other populations to which the test will be applied. All these consideration are exemplified by 17 very heterogeneous studies published to date assessing VIA test accuracy. The assessment of a new screening test is the first step in researching a new cancer prevention strategy. For this reason, this step should be carefully addressed through rigorous studies.

Occupational health and gorilla conservation in Rwanda

The design and implementation of an employee health program for people who work with mountain gorillas in Rwanda is described. This program aims to improve worker health and to reduce human-to-gorilla transmission of infectious disease. The program covered approximately 111 workers, generally healthy men and women 25-45 years old, including essentially all people in Rwanda who have regular contact with gorillas. Initial assessment included a questionnaire, medical examination, and local tests. U.S. laboratory facilities were utilized to confirm some results and for serologic testing for zoonotic (simian) viruses. Initial interventions included STD/HIV prevention health education, tetanus immunization, and anthelminthic treatment. Local physicians continue to provide health services, including follow-up testing and treatment. Mountain Gorilla Veterinary Project (MGVP) veterinarians assist in planning and implementing continuing program components in collaboration with local health authorities and the other employing organizations.

How research can affect policy and programme advocacy: example from a three-country study on abortion complications in sub-Saharan Africa

OBJECTIVE

To provide a basis for continued policy dialogue and reform to address the problem of death due to abortion complications among the ECSA Health Community countries. The anticipated short-term outcome of this study was increased awareness among African health officials about the problem of incomplete abortion in SSA, especially CRHCS/ECSA countries.

DESIGN

The study undertaken in 1993/1994, involved primary data collection of abortion-related morbidity and mortality statistics, the cost of treating patients with abortion complications and provider and abortion patient perspectives. Data were collected via one on one interviews and reviews of logbook data. A computerized literature review on abortion in the region covering the years 1980-1994 complemented the primary data collection.

STUDY SETTING

Primary data collection was conducted in three countries (Zambia, Uganda and Malawi) at selected districts and tertiary care hospitals.

SUBJECTS

Nurses and physicians providing care to women with complications of abortion in participating hospitals were interviewed as well as hospital administrators. Women receiving care in the selected hospitals during the data collection period also were interviewed.

MAIN OUTCOME MEASURES

This analysis focused on cross-country comparisons of nurse and doctor attitudes and knowledge about abortion and family planning-related issues.

INTERVENTIONS

At a 1994 CHRCS conference, Health Ministers from 12 Commonwealth countries reviewed and endorsed the results of this study. In a 1995 ECSA Director Joint Consultative Committee meeting, participants discussed the study findings and developed regional action plans which were subsequently endorsed by the Health Ministers' at their 1995 annual conference.

RESULTS

Abortion complication patients in the three countries were on average 24-26 years old with two children. Patients experienced long hospital stays while receiving care for complications. The average monthly number of post-abortion patients was substantially higher in urban facilities as compared to mixed/rural ones. Opinions regarding factors that led to the abortion, access to abortion services and the legal provisions surrounding abortion were inconsistent between doctors and nurses. Patients were aware that complications of abortion were a major cause of maternal mortality. Overall, provider opinion about access to family planning (FP) information among abortion complication patients was also inconsistent between doctors and nurses but there was agreement on factors influencing use of FP. Opinions regarding access to FP services both before and after the abortion varied from easy to very difficult to obtain.

CONCLUSIONS

These data represent the situation as it was in the region some years ago and the paper describes important implications of the findings for policy and programme development. This research provided some impetus for stakeholders in these countries to put safe abortion and management of abortion complications on their health agenda. Ensuring that research results will be shared with appropriate decision-makers is key to maximizing the extent to which research findings may affect policy and programme advocacy.

Uso de contracepção por adolescentes de escolas públicas na Bahia

OBJETIVO: O interesse sobre o comportamento contraceptivo de adolescentes vem crescendo, especialmente pela relevância social conferida à gravidez nessa faixa etária. Assim, realizou-se estudo para investigar fatores associados ao uso de métodos anticoncepcionais entre adolescentes escolares. MÉTODOS: Estudo transversal que utilizou um questionário auto-aplicado em 4.774 alunos de ambos os sexos, entre 11 e 19 anos. Calcularam-se as prevalências de uso de contraceptivos na primeira e na última relação sexual e em ambas as situações (uso consistente). A regressão logística foi utilizada para a análise simultânea dos fatores e cálculo de medidas ajustadas. RESULTADOS: Entre 1.664 estudantes com iniciação sexual, os fatores associados positivamente ao uso consistente de contraceptivos pelos rapazes incluíram a iniciação sexual mais tardia, com parceria estável, contar com a família como fonte potencial de contraceptivos e acesso a serviços de saúde; entre as moças, ter iniciado a vida sexual há pouco tempo e ter o pai como fonte de informação sobre sexualidade, contracepção e prevenção DST/Aids. A gravidez foi relatada por 6,4% dos rapazes e 18,1% das moças, sendo sua ausência associada ao uso consistente de contraceptivos por elas (OR=3,83; 2,06-7,15). CONCLUSÕES: Os resultados confirmam a complexidade da determinação do comportamento contraceptivo entre adolescentes e a necessidade de que os programas educativos incorporem as múltiplas dimensões da questão para que tenham efetividade.

Performance of visual inspection with acetic acid for cervical cancer screening: a qualitative summary of evidence to date

Developing countries often lack the necessary resources to use the Papanicolaou (Pap) smear as a screening tool for cervical abnormalities. Because the burden of cervical cancer is highest in such low-resource settings, alternative techniques have been sought. Recently, interest in visual inspection with acetic acid (VIA) has increased. Numerous studies have been conducted on its accuracy and its ability to detect cervical lesions when compared with other techniques, both conventional and nonconventional. This review summarizes key findings from the literature to provide researchers and policymakers with an up-to-date summary on VIA. PubMed was used to identify relevant journal articles published between 1982 and 2002. Key words were cervical cancer screening, visual inspection, VIA (visual inspection with acetic acid), DVI (direct visual inspection), AAT (acetic acid test), and cervicoscopy. Studies were eligible for review only if they involved analysis of primary VIA data (ie, not review articles); studies involving magnification devices were excluded. Fifteen studies were reviewed in total; key results were extracted and a summary analysis was performed for sensitivity and specificity parameters. When reported, sensitivity ranged between 66% and 96% and specificity between 64% and 98%. Authors comparing VIA with cytology noted that the overall usefulness of VIA compares favorably with that of the Pap test. The reported findings reviewed here suggest that VIA has the potential to be a cervical cancer screening tool, especially in low resource settings.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to describe how visual inspection of the cervix for cervical cancer screening (VIA) is performed, to summarize the current literature on VIA, and to list potential advantages of VIA.

Safety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project

BACKGROUND

To increase screening and treatment coverage, innovative approaches to cervical-cancer prevention are being investigated in rural Thailand. We assessed the value of a single-visit approach combining visual inspection of the cervix with acetic acid wash (VIA) and cryotherapy.

METHODS

12 trained nurses provided services in mobile (village health centre-based) and static (hospital-based) teams in four districts of Roi-et Province, Thailand. Over 7 months, 5999 women were tested by VIA. If they tested positive, after counselling about the benefits, potential risks, and probable side-effects they were offered cryotherapy. Data measuring safety, acceptability, feasibility, and effort to implement the programme were gathered.

FINDINGS

The VIA test-positive rate was 13.3% (798/5999), and 98.5% (609/618) of those eligible accepted immediate treatment. Overall, 756 women received cryotherapy, 629 (83.2%) of whom returned for their first follow-up visit. No major complications were recorded, and 33 (4.4%) of those treated returned for a perceived problem. Only 17 (2.2%) of the treated women needed clinical management other than reassurance about side-effects. Both VIA and cryotherapy were highly acceptable to the patients (over 95% expressed satisfaction with their experience). At their 1-year visit, the squamocolumnar junction was visible to the nurses, and the VIA test-negative rate was 94.3%.

INTERPRETATION

A single-visit approach with VIA and cryotherapy seems to be safe, acceptable, and feasible in rural Thailand, and is a potentially efficient method of cervical-cancer prevention in such settings.

Risk factors as the basis for triage in low-resource cervical cancer screening programs

OBJECTIVES

Several studies have shown impressive sensitivity and specificity of visual inspection using acetic acid wash (VIA) in detecting cervical dysplasia. This study examines how risk-factor based triage, using clinical history-taking to limit the testing to those at highest risk of disease, improves the clinical utility of VIA.

METHODS

The study population included 2206 woman aged 25-56 from peri-urban primary care clinics in Zimbabwe. Three risk factors variables [age, lifetime number of sexual partners and history of a sexually transmitted infection (STI)] were selected as the basis for computer-simulated patient triage. Criteria for selecting risk factors were biological relevance, programmatic feasibility, historical evidence in the scientific literature as a risk factor for cervical cancer and a significant (P<0.05) predictor of dysplasia in this study population. Predictive values for VIA were calculated on subgroups of women with combinations of the three risk factors and then compared with the predictive value of VIA calculated on the full study population.

RESULTS

The positive predictive value (PPV) among women with all three risk factors (30.2%) was 1.6 times higher than that of all study women and 4.5 times higher than women with none of the three risk factors (4.1%). Additionally, the PPV was slightly (30%) higher than that obtained from computer-simulated serial testing using VIA as the primary test followed by HPV testing (27.4%).

CONCLUSION

Clinical history-taking could provide the basis for patient triage to increase the clinical utility of VIA. Such an approach could also serve to prioritize who gets tested first in low-resource countries with high disease prevalence that are struggling to strengthen national cervical cancer prevention programs.

Costs and benefits of different strategies to screen for cervical cancer in less-developed countries

BACKGROUND

About 80% of cervical cancers occur in less-developed countries. This disproportionate burden of cervical cancer in such countries is due mainly to the lack of well-organized screening programs. Several cervical cancer screening strategies have been proposed as more cost-effective than cytology screening. We compared the costs and benefits of different strategies and their effectiveness in saving lives in a less-developed country.

METHODS

We used a population-based simulation model to evaluate the incremental societal costs and benefits in Thailand of seven screening techniques, including visual inspection of the cervix after applying acetic acid (VIA), human papillomavirus (HPV) testing, Pap smear, and combinations of screening tests, and examined the discounted costs per year of life saved (LYS).

RESULTS

Compared with no (i.e., not well-organized) screening, all strategies saved lives, at costs ranging from 121 US dollars to 6720 US dollars per LYS, and reduced mortality, by up to 58%. Comparing each strategy with the next least expensive alternative, VIA performed at 5-year intervals in women of ages 35-55 with immediate treatment if abnormalities are found was the least expensive option and saved the greatest number of lives, with a cost of 517 US dollars per LYS. HPV screening resulted in similar costs and benefits, if the test cost is 5 US dollars and if 90% of women undergo follow-up after an abnormal screen. Cytology (Pap smear) was a reasonable alternative if sensitivity exceeds 80% and if 90% of women undergo follow-up. Compared with no screening, use of a combination of Pap smear and HPV testing at 5-year intervals in women of ages 20-70 could achieve greater than 90% reduction in cervical cancer mortality at a cost of 1683 US dollars per LYS, and VIA could achieve 83% reduction at 524 US dollars per LYS.

CONCLUSIONS

Well-organized screening programs can reduce cervical cancer mortality in less-developed countries at low costs. These cost-effectiveness data can enhance decision-making about optimal policies for a given setting.

Impact of an integrated adolescent reproductive health program in Brazil

An impact evaluation of an integrated school- and health-clinic-based adolescent reproductive health initiative was undertaken by the State Secretariats of Health and Education in Bahia, Brazil during 1997-99. The project was initiated in response to continued high pregnancy rates among adolescents and growing numbers of new HIV infections among young adults. It sought to promote responsible sexual and health-seeking behaviors among public secondary-school students, including the use of public health clinics. The study design included a matched control group used to measure project impact. The findings indicate that the project was successful in increasing the flow of sexual and reproductive health information to secondary-school students and that it had an impact on adolescents' intentions to use public health clinics in the future. No effects on sexual or contraceptive-use behaviors or on use of public clinics were observed, however. Client exit-interview data from a subset of project clinics indicate that adolescents who use clinic-based services are overwhelmingly female and considerably older on average and much more likely ever to have been pregnant than are adolescents in the target population for the project.

Adjunctive testing for cervical cancer in low resource settings with visual inspection, HPV, and the Pap smear

OBJECTIVE

To test whether the performance of visual inspection using acetic acid (VIA) could be improved through adjunctive testing and to determine whether the combination of visual inspection of the cervix and HPV testing could prove useful for identifying those at highest risk of cervical precancer.

METHODS

Between October 1995 and August 1997, 2199 women willing to be screened for cervical cancer in peri-urban clinics in Harare, Zimbabwe received VIA, Pap smear and HPV as screening tests. The presence or absence of (pre)cancer was confirmed via colposcopy with biopsy as indicated for >97% of all women. Computerized simulations of sequential testing scenarios provided estimates of the joint (net) test qualities of different paired combinations of the three tests and allowed for comparisons with the individual test qualities.

RESULTS

Using HGSIL/CIN II-III as the reference threshold of disease, the net sensitivity and specificity of VIA and HPV when used sequentially were 63.6 and 81.9%, respectively, compared to 43.3 and 91%, respectively, when Pap smears were followed by HPV testing. VIA followed by the Pap smear yielded a net sensitivity of 37.5% and net specificity of 94.3%.

CONCLUSIONS

For programs with limited resources but with the capacity for HPV testing, sequential testing involving the use of VIA followed by HPV could yield fewer false positives than the use of VIA alone at a cost of relatively few additional false negatives.

The American College of Nurse-Midwives' Domestic Violence Education Project: evaluation and results

From October 1994 through September 1998, the American College of Nurse Midwives conducted a nationwide Domestic Violence Education Project. The project aimed to encourage universal screening for domestic violence among all women being seen for care. A four-pronged set of objectives was used, including policy, basic education, continuing education, and advocacy/activism. A description of the project and the results of the project evaluation, including replicable features, are presented. Process and outcome evaluations were performed using both quantitative and qualitative data. Surveys, interviews, and site visits formed the basis for the evaluation of the policy reform, education program, and advocacy components. Pretests and posttests of training participants formed the basis of the evaluation of the continuing education component. All project objectives were met. Policy reform occurred as expected. Changes were noted in education programs in both didactic content and clinical exposure. Changes in clinical behavior as assessed by the pretests and posttests look promising, although numbers of respondents at 12 and 24 months after training are small. Participants reported an increase in advocacy and activism. The Domestic Violence Education Project seems to be a successful and somewhat replicable model for changing attitudes about a health topic (among providers) with possible implications for clinical practice.

HPV-based cervical cancer screening in a population at high risk for HIV infection

We determined the utility of an assay for 13 cancer-associated HPV types in primary cervical cancer screening of Zimbabwe women at high risk of HIV infection. HIV antibody status was determined by ELISA of oral mucosal specimens, and HPV DNA in the genital tract was identified by hybridization of cervical scrapes with probe B of Hybrid Capture II. Among the 466 women investigated, the prevalence of HPV, low-grade squamous intraepithelial lesions (LGSIL) and high-grade SIL (HGSIL) were 47.2%, 13.9% and 12%. Fifty-three and one-half percent of the women were HIV-seropositive. As compared with HIV-seronegative women, HIV-infected women had a greater than 2-fold HPV prevalence (64.3% vs. 27.6%), a greater than 7-fold amount of HPV DNA (RLU of 82.6 vs. 10.7) in HPV(+) women assessed as normal on the reference standard, and a nearly 3-fold greater HGSIL prevalence (17.3% vs. 5.9%). The strong link between HGSIL and HPV DNA positivity was seen in both HIV-infected and HIV-seronegative women. The amount of HPV DNA increased with disease severity in both HIV-seronegative and HIV-infected women. The sensitivity and specificity of the HPV test for HGSIL were, respectively, 90.7% (95% confidence limit 77.9-97.4%) and 41.3% (34.5-48.3%) in HIV-infected women and 61.5% (31.6-86.1%) and 74.5% (68.0-80.3%), respectively, in HIV(-) women. The usefulness of the HPV test as a screening test for cervical cancer in areas of high HPV prevalence will depend upon local health resource availability, disease priorities and policies regarding clinical case management.

Evaluation of a human papillomavirus assay in cervical screening in Zimbabwe

OBJECTIVE

To determine the utility of an assay for high risk genital human papillomavirus (HPV) in cervical screening in Zimbabwe, Africa.

DESIGN

Cross-sectional study.

SETTING

Harare, Zimbabwe.

POPULATION

Zimbabwe women (n = 2,140), 25 to 55 years old, recruited in clinics in Chitungwiza and Greater Harare.

METHODS

Genital specimens were assessed for HPV, using the HPV DNA test Hybrid Capture II (probe B). Further assessment of the women was conducted using colposcopy and biopsy as indicated. High grade squamous intraepithelial lesions were diagnosed in 215 women. Colposcopy and/or biopsy showed low grade lesions in 346 women.

RESULTS

The overall prevalences were: 42 x 7% for HPV, 10% for high grade squamous intraepithelial lesions and 16% for low grade lesions. Prevalence for HPV decreased significantly with increase in age (P for trend < 0 x 0001) and increased significantly with increasing disease severity, from 35% in normal women, to 53% in women with low grade lesions and 81% in women with high grade lesions (P for trend < 0 x 001). In specimens positive for HPV, the amount was 14-fold higher in women with high grade lesions compared with normal women. In screening for high grade lesions the assay for HPV had a sensitivity of 81% (CI 75%-86%); sensitivity for low grade lesions was 64% (CI 60%-68%). Specificity was 62% (CI 59%-64%) for high grade lesions and 65% (CI 62%-67%) for low grade lesions. The positive predictive value was 19% (CI 17%-22%) for high grade lesions and 39% (CI 36%-42%) for low grade lesions.

CONCLUSION

For high grade squamous intraepithelial lesions the sensitivity of the Hybrid Capture II HPV DNA test was high, but the specificity was relatively low. The test may therefore be most useful in conjunction with other screening tests.

Provider attitudes toward IUD provision in Zimbabwe: perception of HIV risk and training implications

This study was conducted to assess providers' attitudes toward the provision of long-term methods of contraception, in particular the IUD, and provider concerns about human immunodeficiency virus (HIV) in the context of family planning (FP) services. The data were collected using self-administered structured questionnaires. Between 65% and 80% of the public and private providers thought that the IUD is a good contraceptive method for Zimbabwean women. In addition, the majority of these two provider groups felt that neither the IUD nor tubal sterilization (TL) posed much risk of HIV infection to the client. A significant number of providers (especially the public nurses), however, thought that the provision of TL put the provider at high risk of HIV infection and a significant proportion of public nurses were also concerned about provider risk associated with providing IUD and injectables. To address such concerns, future training interventions should emphasize appropriate infection prevention practices associated with surgical FP method provision. Nurses, in particular, should be informed about the magnitude of risk associated with FP service provision and ways to protect themselves. Logistic activities also need to be strengthened so that legitimate concerns among providers regarding lack of adequate infection prevention supplies (e.g. gloves) in the field can be addressed.

Training for Norplant implant removal: assessment of learning curves and competency

OBJECTIVE

To determine the learning curves and rapidity with which clinicians become competent in implant removal using two Norplant removal techniques.

METHODS

Twenty-four physicians, none of whom were experienced in the use of Norplant implants, were randomly assigned to learn either the "U" removal technique or the standard technique. The physicians in the two groups received identical training in all other respects. Each physician then performed ten supervised removals. Removal times, procedure problem rates, and the number of procedures performed by the clinicians before they were judged "competent" were assessed for both groups.

RESULTS

Data from 240 removals were analyzed. Mean removal times were 38% faster in the "U" group than in the standard group. None of the "U" group procedures took longer than 20 minutes, compared with 11% of removals in the standard group (P < .001). The mean number of cases required before the provider consistently performed all steps adequately was significantly (P < .02) higher in the standard group (5.8 cases) than in the "U" group (3.9 cases).

CONCLUSIONS

Using competency-based training methods, the "U" removal technique was learned easily by inexperienced clinicians. It appears to offer significant improvements in speed and achievement of proficiency over the standard technique recommended by the manufacturer. Large-scale programs should consider using competency-based training and the "U" technique as the removal method of choice when providing training in implant removal.

Complications of unsafe abortion in sub-Saharan Africa: a review

The Commonwealth Regional Health Community Secretariat undertook a study in 1994 to document the magnitude of abortion complications in Commonwealth member countries. The results of the literature review component of that study, and research gaps identified as a result of the review, are presented in this article. The literature review findings indicate a significant public health problem in the region, as measured by a high proportion of incomplete abortion patients among all hospital gynaecology admissions. The most common complications of unsafe abortion seen at health facilities were haemorrhage and sepsis. Studies on the use of manual vacuum aspiration for treating abortion complications found shorter lengths of hospital stay (and thus, lower resource costs) and a reduced need for a repeat evacuation. Very few articles focused exclusively on the cost of treating abortion complications, but authors agreed that it consumes a disproportionate amount of hospital resources. Studies on the role of men in supporting a woman's decision to abort or use contraception were similarly lacking. Articles on contraceptive behaviour and abortion reported that almost all patients suffering from abortion complications had not used an effective, or any, method of contraception prior to becoming pregnant, especially among the adolescent population; studies on post-abortion contraception are virtually nonexistent. Almost all articles on the legal aspect of abortion recommended law reform to reflect a public health, rather than a criminal, orientation. Research needs that were identified include: community-based epidemiological studies; operations research on decentralization of post-abortion care and integration of treatment with post-abortion family planning services; studies on system-wide resource use for treatment of incomplete abortion; qualitative research on the role of males in the decision to terminate pregnancy and use contraception; clinical studies on pain control medications and procedures; and case studies on the provision of safe abortion services where legally allowed.

Institutionalizing fertility management/human sexuality training in Colombian nursing schools

While there is no universally applied definition of the terms, 'institutionalization', 'capacity', 'capability' and 'commitment' have been suggested as subindicators of a self-sustained program. This paper describes efforts to measure these terms in the context of a fertility management/human sexuality (FM/HS) education program for student nurses in Colombia. Interviews with 19 school deans formed the basis of measuring progress towards institutionalization. All the deans supported the idea of having FM/HS instruction, although resource commitment to effectively carry out the instruction varied. Focus groups with professors from participating schools provided insights into the effect of the project on both the students and course teachers. Professors found that students who had taken the course were more effective FM/HS counselors in later practical courses. Responses from interviews with a random sample of students who had or had not attended the course were compared to assess the effect of the course on the nursing students. Although attitudes between the two groups did not differ significantly, knowledge levels about FM/HS were significantly higher among nursing students who had attended the course. In general, the results indicate that the participatory educational approach used in teaching the FM/HS topics was effective in sensitizing both students and teachers to this subject area.

Usefulness of a clinical scoring system to anticipate difficulty of Norplant removal

OBJECTIVES

Removal of contraceptive implants (e.g. Norplant) is an issue affecting its worldwide acceptability. Reports of difficult, painful removals have resulted in lawsuits and reduced demand. To improve quality of care, we developed a scoring system to anticipate difficult removals. We report on the usefulness of such a system and present client perspectives about the removal experience.

METHODS

A 9-point scoring system based on the visibility, arrangement, and position (VAP) of Norplant capsules was used to assess the anticipated difficulty of removal in 53 consecutive patients. The VAP score was then correlated with removal time and related parameters.

RESULTS

Mean removal time was 14.74 min (range 4.75-47). In 20% of patients, the VAP score indicated a potentially difficult removal and the VAP score correlated significantly with removal time (r = 0.3, p = 0.05). Patients expected removal to be moderately difficult (mean visual analog score 4.7 out of a possible 10), but after removal they rated the actual removal experience as relatively easy (mean score 2.6/10). Before the removal, only 48% of patients said they would recommend Norplant to a friend but after removal, 70% said they would do so.

CONCLUSIONS

A scoring system such as the VAP score can help identify potentially difficult removals so that an experienced remover can be present at the time of removal or an appropriate referral made. However, the VAP score cannot predict variables such as the density of the subcutaneous fibrous tissue "envelope". Although patient anxiety concerning removal may be high, the presence of a competent remover and an easy removal experience reduces this anxiety and encourages patients to be more positive about this method. The value of having properly trained, competent personnel available to perform removals cannot be over-emphasized.

Materials, methods and results of the Norplant training program

Norplant subdermal implants for contraception were introduced into UK clinical practice in October 1993. Use of Norplant requires providers to learn additional skills. A training program designed to give providers to opportunity to obtain these skills was designed and implemented through the co-operation of Hoechst Roussel, JHPIEGO and members of the UK medical profession. Uptake of training for Norplant provision has been widespread and Norplant has been established as a realistic contraceptive choice for women in the UK. Introduction of Norplant in the UK has raised many issues that go beyond clinical considerations.

Problem visits to a family planning clinic

In order to obtain information necessary for optimum delivery of services, data were collected on the nature of the services provided at a family planing clinic. Clinic visits were divided into initial, annual, routine, problem, supply, educational and unknown. An analysis of the "problem" visits was undertaken to assess various epidemiologic aspects of such visits and to identify areas of clinic efficiency that could be improved. Problem visits were defined as any visits for which the patient had a presenting complaint. Age, level of education, method of contraception and parity were statistically associated with problem visits. When compared to Pill users, diaphragm users, intrauterine device users and non-users had a higher-than-expected number of problem visits. Less educated women and teenagers had a lower-than-expected number of problem visits when compared to more educated and older women. Socioeconomic status and problem visits were not statistically associated. Problem visits required more time, utilized more medical services and resulted in more referrals to the gynecology clinic than did other visit types. As a result of this analysis, we have increased our educational efforts for patients at high risk of problem visits and have instituted a special problem-oriented family planning clinic in which a full complement of house staff and ancillary personnel are available. This arrangement makes the uncomplicated family planning clinic run more smoothly and efficiently and obviates the need for time-consuming and cost-ineffective referrals.