Major challenges to scale up of visual inspection-based cervical cancer prevention programs: the experience of Guatemalan NGOs

Staff Turnover

Twenty-four interviewees working with 13 of 20 NGOs reported turnover of staff trained in VIA was a problem—either among former trainees or their own programs' practitioners. Specific concerns with staff turnover differed based on interviewee involvement with training versus service provision.

Turnover of trainees in the MOH. NGOs offering training courses encountered difficulties with turnover of trainees, and especially MOH trainees. Central American Ministries of Health rotate personnel between services every few years, particularly with electoral changes in political leadership. NGO program directors reported that MOH nurses they had trained in VIA offered the exam in their posts in reproductive health for 1–2 years but then were rotated into a new service with no VIA component (for example, child nutrition, labor and delivery). Staff turnover within the MOH also results from changes of administration, which can lead to supervisors' decisions to lay off personnel performing VIA and reduce or eliminate VIA program budgets. As one VIA training course instructor reported:

[The MOH] would send us women, nurses, doctors [they] wanted us to train. We trained them. We even gave some of them [cryotherapy] guns. But inevitably, more than half of them, the doctor left to go somewhere else, the nurse got fired, or whoever was in charge of the department, their interest disappeared.

This instructor estimated that only about 50% of the nurses and physicians that his NGO trained in VIA ended up using the skill after the course. Program administrators of another NGO, which had performed a study with former trainees, noted that fewer than one-third of the MOH nurses they had trained over 4 years (2008–2011) were still practicing VIA in 2012. Indeed, the MOH reported that, in 2008, only 50–85 of 1,211 personnel previously trained in VIA (about 4%–7%) still actively provided the service.³²

One Guatemalan training course instructor feared that lower-level providers would lose their clinical observation skills if not in constant practice:

During the course, many people are trained, and afterwards, they rotate through other services and forget it. If you don't use the skill and just do Pap smears, you will not be able to do [VIA] because it's hard to do. It's often hard to see.

Staff turnover results in temporary or permanent discontinuation of VIA programs when posts remain unfilled. As a result, training course instructors felt that monetary and human resource investments were being used sub-optimally.

Staff turnover among MOH administrators also disrupted long-term VIA collaborations with NGOs. A Guatemalan program administrator stated:

We made contacts with government officials to train people from the MOH. We began very well and all, but the lines of communication break pretty easily with them. They change personnel every 4 years, every time there is another election, and then whatever you've been doing with them goes downhill.

Some interviewees expressed frustration over expending resources on travel and meetings with MOH representatives when VIA collaborations fell through due to MOH leadership changes. Other interviewees, however, reported building relationships successfully in 2 departments, whose health directors expressed great enthusiasm for VIA and popularized the method among other staff and their successors.

Turnover in NGOs. Changes in leadership and staff turnover frequently affected not only NGO–MOH training collaborations but also internal NGO VIA programs. NGO programs were particularly vulnerable to unexpected shifts in funding streams and strategic mission. One European VIA provider voiced frustration that the NGO she worked for tended to “take on a lot of projects” but not follow through with them. VIA became one such project, and shortly after sending her to training, administrators had a “change of heart”: “They decided not to do VIA-cryo for no apparent reason.”

Job shopping and leveraging salary differentials were also major sources of VIA staff turnover in NGOs. In Guatemala, NGOs and the private sector offer health practitioners higher salaries than the public sector,³³ and salaries vary widely between NGOs of differing sizes. As a result, “internal brain drain” is a common problem. One NGO administrator observed that MOH nurses trained in VIA market this skill and leave their government posts to earn higher wages elsewhere. Similar job switching from less to more lucrative NGO posts was also common. As one NGO administrator from the United States related:

Right now, we are not doing VIA. This was not a strategic decision, but rather bad happenstance. There used to be a community health worker who did community screenings. She got trained in [VIA], and between her and another doctor who got trained in the method, they were able to bring people in. Unfortunately, we lost both staff members [to other NGOs], and so we lost capacity to offer the programming.

Several interviewees remarked that funding constraints prevented them from responding to this “brain drain,” since they had not budgeted to send new staff to VIA training courses. In contrast, one NGO director reported accounting for staff turnover in yearly programming budgets: “That's not a problem for us. We pay to train new providers.”

Training Quality

Twenty-two interviewees working for 11 of 20 NGOs described ensuring VIA training quality as a serious challenge. Interviewees endorsed the quality of VIA courses delivered by 2 large and well-known NGOs, as well as those offered in some health districts of Guatemala with strong leadership among local MOH administrators. These courses rigorously adhered to VIA educational materials developed by Jhpiego, the organization that designed and pioneered the global gold standard of VIA training courses.⁸

Commonly, however, interviewees described visiting or participating in shorter courses that offered only didactic training with no clinical supervision. For example, while MOH officials at the national level report offering week-long courses,¹⁴ an interviewee with a part-time MOH affiliation alleged:

[The MOH] was trying to form courses, but with many deficiencies…. [They] offer a 2- or 3-day course that is purely theoretical, with no practicum.

Similarly, an NGO physician and former MOH employee noted that the MOH scheduled its courses with so little advance notice that participants did not receive or review materials prior to training. Furthermore, she reported, the MOH did not recruit enough women to serve as screening subjects for the training courses, with the result that trainees lacked opportunities for clinical training.

Also, some NGOs and short-term medical missions use non-standard curricula. A Guatemalan nurse related that she had participated in 2 VIA training courses sponsored by U.S. physicians. The first was with an NGO that offered a one-time 3-day VIA course and another with a well-established NGO that had been offering 5-day courses following Jhpiego standards for several years. She contrasted her experiences in the 2 courses:

In the first one, they just told us how to do it, and then we went off on our own and attended the women, but [the instructors] were not there with us. The second time, they were there with us, and it was harder because there were exams.

Because of variations in the length and perceived quality of VIA training courses, several interviewees feared that deficient training might result in low-quality services and negative publicity surrounding VIA. “The problem is that even those who do not pass the course can go on to practice VIA, because there is no regulation to stop them,” a Guatemalan training course instructor lamented. An NGO director from the United States described receiving reports from a relatively small and recently formed North American NGO in eastern Guatemala that had experienced both high false positive and false negative rates in a VIA pilot program. This group, she explained, had offered its practitioners minimal and inadequate training before beginning to offer services:

I'm afraid that some of these smaller groups are out there doing VIA, but there's not any quality control, and they aren't doing it well. And that worries me, because that can give a bad name to the procedure … Pretty soon people are going to say, “Well, that procedure doesn't work.”

Continued Supervision

Twenty-two interviewees working for 11 of 20 NGOs reported concerns about a lack of continued on-site supervision and long-term support for health care providers after VIA training. Most NGOs and MOH trainers lack resources to offer continued mentoring to former trainees. One training course instructor, a Guatemalan physician, expressed concerns about this as she described visiting a group of Guatemalan nurses and health promoters who had been certified in VIA by a one-time U.S.-sponsored medical mission. These VIA providers had difficulty distinguishing between positive and negative exams, but they did not have the means to communicate with their international trainers for ongoing guidance.

Interviewees described a lack of continued mentoring for MOH-trained providers, as well. A Guatemalan nurse and course instructor reported witnessing problems at government-run VIA clinics, such as examiners using inadequate light sources or no light source at all during exams, sniffing acetic acid to determine its concentration, manipulating the cervix with tongue depressors that obstructed their vision, and performing cryotherapy incorrectly.

Pointing out the implications of such lack of oversight, several interviewees drew attention to an incident in which a group of women were severely burned by undiluted acetic acid during VIA exams gone awry in Guatemala City.³⁴ As a Guatemalan VIA training course instructor remarked:

Now [the MOH is] having to remove staff that they trained in VIA from their posts, because this year complications arose. In some public clinics in Guatemala City, they burned patients because they used pure acetic acid without diluting it … So people lost faith; they don't go to that health center anymore.

A U.S. physician working for another NGO reported that, because of this incident, some of her patients resisted VIA exams, which they referred to as “acid Paps,” and demanded “real Paps.”

Program directors often asserted that their own staff could benefit from continuing supervision and refresher courses, as over time some employees had strayed from protocol. For example, some administrators said that their staff performed cryotherapy on women under the age of 25, even though it is recommended that the test be performed only on women ages 25–50.^35,36 Additionally, one U.S. program director found that trained local staff treated women with “a little touch” (toquecito) of the cryotherapy probe rather than following guidelines to freeze, thaw, and refreeze lesions for 3, 5, and 3 minutes, respectively³⁵:

Sometimes I wonder what we're doing. It's like, are you kidding me? Someone gave a 22-year-old a “little touch” of cryo? What does that mean? What does that do? What are we doing? Okay, so now we're doing “little touches” of cryo to all these 20-something-year-old Guatemalan women?

This program director subsequently sent local staff to a refresher course.

Cryotherapy Referrals

Seventeen interviewees working for 12 of the 20 NGOs mentioned concerns about contact with MOH facilities or other NGO programs in which VIA and cryotherapy are not performed together, within a single visit. As one program director stated:

VIA is not being done here in the way it is proposed in international medical journals. VIA is supposed to be see-and-treat.

In part, this is because some MOH facilities and NGOs in Guatemala have materials to perform VIA exams, but they lack equipment or run out of supplies to perform cryotherapy. While the MOH does not report problems with gas supply at the national level,³² interviewees explained that local-level MOH facilities in which providers had been trained in VIA-cryotherapy often lack funds for replenishing gas supplies. Furthermore, there is no national system for maintenance of cryotherapy equipment.³²

Training in VIA but not cryotherapy. Another reason that VIA and cryotherapy are not coupled is that some providers are trained in VIA but not cryotherapy. For instance, in 2008, the MOH reported that only 252 of 1,211 VIA-trained providers (about 21%) were also trained in cryotherapy.³² Similarly, some NGOs reported certifying only a subset of VIA trainees in cryotherapy. Training course instructors aim to supervise trainees during 5–10 cryotherapy procedures, in line with Jhpiego recommendations.³⁵ This generally limits the number of cryotherapy trainees to 1 to 2 practitioners per 100 women screened. However, NGO administrators sometimes enroll more students (for example, 10–20) in their courses than can be trained in cryotherapy, feeling that they can benefit from learning VIA alone until they are eventually trained in cryotherapy in a subsequent course. As a result, about 20%–25% of trainees participating in these courses received training in both VIA and cryotherapy. Not all interviewees agreed with this strategy. One U.S. NGO director familiar with large training courses stated, “I'm scratching my head wondering why they would train you in one and not the other.” This NGO had limited the size of its course to 5 trainees so that all would have the opportunity to learn cryotherapy.

Because of shortages of cryotherapy equipment and trained personnel, NGO and MOH providers may refer women who test positive to other NGOs or larger MOH facilities for treatment. For example, one NGO director reported forming a relationship with the MOH:

The MOH, they're doing VIA, but they don't have the capability to do cryo, so they're referring cryotherapy patients to us.

NGO staff also made contact with other NGOs to overcome inability to offer cryotherapy. As one NGO administrator described it:

We did the screening, but what are we going to do to help them [screening-positive women]? We made an alliance with [another NGO]. They give us treatment when we refer patients directly to them … And that's how we're working, because we haven't been trained to do the VIA and the cryotherapy.

Loss to follow-up. Nine interviewees working in 7 of 10 NGOs participating in cryotherapy referral networks reported challenges with ensuring follow-up care for VIA-positive women. While interviewees regarded the emergence of NGO–MOH referral networks as a practical solution to resource scarcity, they highlighted 2 major problems with these systems. First, VIA-positive women often did not complete cryotherapy referrals because of economic, transportation, and childcare barriers. One Guatemalan NGO auxiliary nurse, trained in VIA but not cryotherapy, described the case of a woman she had referred for a later cryotherapy appointment at the same facility:

We gave her an appointment so that she would come back to the health center to get her cryotherapy. But she didn't come. So what I was doing was calling and calling … I told her that when she comes, they're going to give her the treatment free, because she'd have spent money on getting there. And she says, “Yes, I'm going to go.” But she doesn't come.

Interviewees who received cryotherapy referrals reported the same problems. At one VIA–cryotherapy campaign we attended, only 2 of 16 women who had been referred for cryotherapy after prior VIA testing arrived for their appointments. The nurse charged with their treatment remarked, “This makes us feel as if we are not really doing anything [with VIA].” A program administrator, exasperated with the situation, stated: “If you can't follow-up on the whole package, I'm not sure how much value there is [in doing VIA].” Some NGOs overcame referral problems by directly organizing and financing transportation for women to complete referrals or working with local MOH facilities and municipal offices to do so.

Coordination problems. A second concern with cryotherapy referrals related to the difficulties of inter-institutional coordination. One NGO director reported that her organization had the resources to offer free treatments to women in need of follow-up but had troubles establishing reliable contacts with MOH personnel and staff of another NGO with “broken” cryotherapy equipment willing to coordinate referrals. Rather, many VIA-positive women learned of her clinic on their own, through word-of-mouth. This problem was not as salient in other health districts, where NGOs had established strong relationships with active MOH leaders.

Limitations

This study has 3 primary limitations. First, as we relied on a convenience sample of NGOs, results may not be generalizable to other NGOs operating VIA programs in Guatemala or in Latin America. However, because the NGOs involved varied widely in terms of size, program models, and extent of collaboration with the MOH, the study likely describes the full range of challenges in NGO-sponsored VIA programming in Guatemala. Second, since the study focused exclusively on NGOs' roles in VIA programs, MOH personnel were not interviewed. Undoubtedly, MOH personnel would describe additional challenges not discussed here. This is an area for future research. Third, given the qualitative nature of the study, we cannot specify the absolute frequency of reported phenomena such as the breakdown of the “see-and-treat” paradigm. Further quantitative research is needed to assess this issue.