Updated: Sep 7, 2019
A woman in rural Peru wakes up, makes breakfast for the family, preps her children for school, then sets out on her day of work which may consist of household chores, going to the market, preparing food, and even going to work herself. The act of seeking preventative healthcare, then, can be seen as a time consuming and resource burden. Recognizing these hurdles, the Peruvian NGO, La Liga Contra El Cancer has set out to bring care to rural areas through the use of mobile clinics. To accomplish this, mobile trucks are driven to rural checkpoints that are strategically placed near a market or other convenient convening place for the women. La Liga leverages support from community volunteers to market available services and in doing so, has increased screening uptake in rural regions.
However, if women test positive for HPV, they are then sent to a clinic that requires 2-3 buses to get to and 9 Peruvian dollars lost each way. Due to a number of reasons including, cost, fear, distance, and lack of knowledge, 71% of women who are screened at mobile clinics never return for follow up screening or care.
In an interdisciplinary team, including a medical school student, a business student, an undergraduate focused on Global Health Studies, and a head researcher from Duke’s Center for Global Women’s Health Technologies, we set out to better understand how a novel cervical cancer screening device, the Pocket Colposcope, may help to improve patient attrition rates in the cervical cancer care paradigm. To do this, we analyzed community perceptions, costs and logistics associated with the standard of care and how these factors might be affected by the implementation of the Pocket. The results of the information gathered during this Spring Break session will feed into a broader Bass Connections course initiative in which we are building a training module to this cultural context and with the goal of improving patient follow-up rates in a cost effective manner.
Key Findings from Peru Trip “It’s a fine line.” That is what one health practitioner in Peru said about delivering a cervical cancer or even a pre-cancer diagnosis when asked how results are ultimately provided to their patients. We learned that positive diagnoses have always been delivered in person for both women being referred from mobile clinics and women who are seen directly at La Liga.
But how do you encourage follow up appointments when the opportunity costs are so high for patients in rural areas? Currently, patients receive a letter in the mail followed by a call informing them they are needed for another appointment to encourage a follow up trip to the clinic. Nothing about cancer is ever mentioned in the letter or call. When asked why this is how things are done, we learned that it is a fine line in terms of how much information to give a patient right away because, in Peru, the word cancer means death to a lot of people. We learned that there are two trains of thought for Peruvians after receiving a cancer diagnosis are denial or acceptance. It is because of the possible cases of denial that La Liga has decided to be vague when asking patients to come in to be given bad news. Many patients could be so terrified by the word cancer, the overwhelming thought of treatment, and the the possible costs associated with their future care, that they would prefer not knowing their options or being fully educated about their situation.
So how can we attempt to inform patients in a way that would increase follow up rates? Through interviews, we learned that possibly, when delivered by a medical provider, could lessen the blow and make the diagnosis not as scary, therefore, making it more likely that a patient will continue the treatment process. Some midwives are currently using personal cell phones to take photos of patients’ cervixes and anecdotally cite this technique as effective in promoting follow up rates. Conclusions and Next Steps: This “fine line” observation coupled with the current behavior of showing images on cell phones has demonstrated that a clinically-rigorous, personal image counseling process could help patients better understand their own cervical pathology and the significance of the health practitioner’s diagnosis. The Pocket colposcope can strengthen this practice by linking higher quality images to electronic health records and creating personalized visit summaries for patients.
Moving forward, we would like to better understand how follow-up rate changes in clinics where the Pocket colposcope is implemented. To do this, the team is working on perfecting a Pocket Colposcope training package. This will help to facilitate optimal implementation of the device in the primary care setting and increase the possibility of image counseling success. Furthermore, the team is moving forward with clinical studies that include image counseling to better understand image counseling effectiveness in primary care settings.