Intermediate Outcome of Coordinated Pap smear Screening Program in primary care unit

Wiroj Wannapira1, Nipat Kittimanon2, Sunanta Pakdeumnat2, Patipim Yukong2, Kittiya Vijitpeung3

1 Department of Community Family and Occupational Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand 65000

2 Department of Family Medicine, Buddhachinaraj Hospital  School of Medicine, Phitsanulok, Thailand 65000

3 District Health office, Amphur Maung, Phitsanulok, Thailand 65000

Background : Cervical cancer is one of the leading cause of death among Thai women. Cervical cancer continues to be a widespread public health problem throughout the world, limited due to accessibility to screening services and delayed treatment of precancerous lesions. Incidence of cervical cancer in Thailand is highest among Asian countries, and reaches 23.4/100,000 women. The survey done in primary care networks of Buddhachinaraj Hospital in suburban area outside the Municipality in 2003 revealed very low screening coverage of only 11% of women aged 35-60.The challenging question was how to improve this screening program.

Objective: To increase screening and treatment coverage by implementing Coordinated Pap Smear Screening (Co-PAPS) Program. Material and method: This action research was carried out in 25 primary care units (PCU) with innovative approach and divided into 4 main steps; 1) setting up practical effective screening and treatment system in hospital 2) training community health care providers to increase knowledge, skills, self-confidence 3) employing tailored made screening strategy for each setting context, and 4) mobilizing community participation and setting up anti-cancer club. This research was started in October 2003, and ran step by step, from inside hospital at the beginning, and finally ended in the community. Helical approach training for community health personnel was based on the real situation, analysis from questionnaire, and knowledge management process. Both workshop and real community-based trainings were extensive and reached nearly all health personnel. After step 2, the primary care units began to implement the strategy according to local context to reach the target group. Then steps 3 and 4 ran by themselves and at each own place. Target populations were set according to the National Cancer Institute of Thailand’s guideline, as women aged 35, 40, and 45,50,55,60. Questionnaires for evaluating local health professional’s knowledge, skills, self confidence was used periodically. Data on the progress of screening program were collected and examined quarterly.  Levels of community participation, the number of anti-cancer clubs and their activities were also monitored.

Result:   Co-PAPS system was developed with consensus agreement among multidisciplinary team. The whole program was implemented after the community health personnel were trained. All three levels of Co-PAPS system; were rated as ‘Good’ on the satisfactory scale. For the health personnel’s self assessment on 3 dimensions; knowledge, skill, and self confidence remarkably increased to 81.2, 72.9, and 79.3 % respectively (at October 2005). Tailored made strategies for 4 settings were 1) mobile program for long and large area 2) zoning or pooling program for area with limited number of health personnel 3) motivated program for low-participation area, and 4) combined strategies. In people’s point of view, women’s concern increased progressively and 4 active anti-cancer clubs were founded with more to come. The main function of these clubs is was to raise awareness, to increase cooperation and to help search the target population. The club delivered self help care, partly by the patient with cervical cancer, and interestingly, the club helps other communities to set up the new clubs. The screening rate is increased, in 2004; 3,153 women were screened (coverage rate = 45.4%); eight showed precancerous lesions, other eight noninvasive cancer and one invasive cancer. In 2005; 3,756 women were screened (coverage rate = 64.6%); eight precancerous lesions, seven noninvasive cancer and one invasive cancer. Overall abnormal Pap smear for cancer is about 4.8/1000, and 94.1 percent of them were successful referred and treated.

Conclusion : Strong and practical coordinated cancer prevention program (Co-PAPS), well-trained community health care providers, and community participation were key success factors to deliver the prevention and control cervical cancer in the community and self care in a low resource, suburban and remote areas.

Key words :  Cervical cancer screening, coordinated program, community participation, primary care unit

From : The 11th International Charles Heidelberger Symposium On Cancer Research, January 26-29,2006/Naresuan University Phitsanulok Thailand, page 42-43