Epidemiological studies have clearly established Human Papilloma Virus (HPV) infection as the central cause of invasive cervical cancer. HPV is a sexually transmitted agent that infects cervical cells and slowly causes cellular changes that can result in cancer (Jan et al. 1999).
According to Clifford et al. (2003), cervical cancer can be effectively controlled by screening unlike many malignant tumours. Papanicolau (Pap) smear screening (which was developed in the 1930s and named after inventor Dr. George Papanicolaou) can identify potentially precancerous changes and immediate treatment can prevent the development of cancer.
EPIDEMIOLOGY OF CERVICAL CANCER
Cervical cancer is the fifth most common cancer in women worldwide with approximately 466,000 new cases diagnosed each year (Parkin 2007). Studies by Arbryn et al. (2003), revealed that 34,000 new cases and >16,000 deaths due to cervical cancer are reported annually in the European Union.
Similarly, the Cancer Research UK (2009) reported that In the United Kingdom, 2,900 women are diagnosed with cervical cancer and as many as 1,100 die from the disease each year.
Eighty percent of new cases occur in the developing world where screening programs are not well established or are minimally effective and about 231,000 women die each year because of this malignancy (Pisani et al. 1999).
CERVICAL CANCER CYTOLOGICAL SCREENING
Cervical screening Is a method of preventing cancer by detecting cytological abnormalities through microscopic examination of PAP smears and subsequent treatment if necessary (Clifford, 2003).
Cytological screening at the population level every 3-5 years can reduce cervical cancer incidence by up to 80%. This benefit can only be achieved if quality is optimal at every step in the screening process; from information and invitation of eligible target population to performance of the screening tests, follow up and treatment of detected abnormalities (IARC, 2005).
Deaths from cervical cancer have fallen over the last 20 years in the United Kingdom. The reduction is mainly due to the NHS cervical screening programme, which may detect changes in the cells of the cervix at a pre cancerous stage (BUPA 2009). Similarly, studies by Kamar et al. in 2007 revealed that the wide spread use of cervical screening programmes have reduced the incidence of invasive cancer and mortality rates by 50% or more in developed countries.
CERVICAL CANCER IN NIGERIA
Nigeria has a population of about 40.43 million women who are at risk of developing cervical cancer. It is the commonest gynaecological malignancy and current estimates indicate that every year, 9922 women are diagnosed with cervical cancer and 8030 die from it (WHO 2010).
The National Cervical Cancer Coalition (2008) stated that the main reason for the sharply higher cervical cancer incidence is the lack of effective screening programs aimed at detecting precancerous conditions and treating them before they progress to invasive cancer.
The current wisdom about cervical cancer control is the critical importance of early detection. Most women in Nigeria present with advanced disease when radiotherapy and hysterectomy is of no benefit. Olukoya (1989), noted several reasons for late presentation and these are; ignorance about the condition and symptoms, fatalistic attitudes, embarrassment, readiness to attribute neoplastic disease to supernatural causes, fear of confirmation of suspicion and the perennial problem of low coverage of the population by health care services especially the rural areas.
It has been estimated that only 5% of women in Nigeria have been screened for cervical dysplasia in the past 5 years compared to 40 - 50% seen in developed countries. (National Cervical Cancer Coalition 2008)
EVALUATION OF PREVIOUS POLICY AND RATIONALE BEHIND PROPOSED POLICY CHANGE
Nigeria has not had a great deal of success in implementing effective cervical cancer screening until date. The delivery of cervical cancer screening in Nigeria is usually conducted in an opportunistic manner, whereby screening depends on the initiative of the woman and/or her health care provider. This may lead to inappropriate screening utilization and inadequate follow-up of abnormal results. (Cristina 2000). There is currently no mass screening program for the detection of cervical cancer in Nigeria. Services are only available in teaching hospitals and are not adequately utilized. Constraints against underutilization were found to be poverty, ignorance and system failure (Anderson 1988).
In this regard, this literature will advocate for a population-based screening program, which conforms to evidence based standards and procedures
AIM
The aim of this policy is to reduce the incidence, morbidity and mortality of cervical cancer among women between the ages of 30 and 50 years in Nigeria. This can be achieved through enlightenment campaigns, screening the target population and treating every diagnosed case.
POLICY GOALS
To have an impact on cervical cancer incidence and mortality, programs must achieve the following goals:
Increased awareness of cervical cancer and preventive health-seeking behaviour among women between the ages of thirty and fifty. (This age range is a reasonable for a cervical cancer prevention program with limited resources).
Screen all women aged 30-50 at least once before expanding services to other age groups or decreasing the interval between screenings.
Treat women with high-grade dysplasia, refer those with invasive disease where possible and provide palliative care for women with advanced cancer.
Disseminate summary information and key research papers on cervical cancer to medical establishments so that they will understand the rationale for screening and treatment recommendations
Collect service delivery statistics that will facilitate ongoing monitoring and evaluation of program activities and outputs (Miller 1992; and Cristina et al 2000).
HEALTH POLICY TRIANGLE (ANALYSIS FOR POLICY)
THE ACTORS:
According to Walt (2005), actors are at the centre of the health policy framework and they play major roles in the influence of policy process. The actors involved in policy change of cervical cancer screening, try to influence the policy process at local, national and international levels. These actors apply different levels of power in the policy process and they all have different preferences. The actors identified in this policy include:
Health care Providers (Gynaecologists, physicians, General practitioners)
Technical and Scientific community
Pharmaceutical companies (Pfizer)
Cancer Research Centre
National Institute of Social and economic research of Nigeria
Government ( Federal Ministry of health, Ministry of Women Affairs)
International organization ( World Health Organization, The World Bank)
Non-governmental organizations
Pressure/interest groups
Mass media
CONTEXT
SITUATIONAL FACTORS: After the second “Stop Cervical Cancer in Africa†took place in July 2008. The stakeholders were sensitized on the increasing incidence of cervical cancer and it was agreed that all African governments through their ministry of health must fund and implement national cervical cancer prevention programs.
STRUCTURAL FACTORS: The alarming increase in mortality due to cervical cancer was made public by the media. This was initiated by various NGOs working to improve the quality of lives of Nigerian women.
INTERNATIONAL FACTORS: A lot of Non-governmental organization and international organizations like WHO and World Bank are willing to assist the country financially to reduce the incidence of cervical cancer in the country.
CONTENT
There are various methods of reducing cervical cancer incidence and mortality through screenings. They include:
Pap Smears (Cytological screening tests)
Visual Approach (Visual inspection of cervix with unaided eyes, magnification, lugol’s iodine, acetic acid etc)
Human Papilloma Virus diagnostics.( Laboratory-based analysis of samples taken from the cervix, vaginal tampons and swabs)
The Pap smear program is encouraged because it has achieved impressive results in reducing cervical cancer incidence and mortality in some developed countries. Cervical cancer incidence can be reduced by as much as 90% where screening quality and coverage are high (Cristina 2000).
THE POLICY MAKING PROCESS
PROBLEM IDENTIFICATION AND ISSUE RECOGNITION:
The Ministry of Health currently has many health issues that need attention so the first step is getting the proposed issue on the policy agenda. The Hall model of agenda setting (1975) suggests that the odds of an issue getting on the policy agenda and faring well is increased when it is legitimate, feasible and have immense public support.
For the program to succeed as far as the policy process in Nigeria is concerned, the role of the media in agenda setting cannot be over emphasized. The media is expected to play an important role in the dissemination of health problems to the public as well as ensuring that the government tackles these challenges. For this reason, relevant literatures and reports on cervical cancer which have been prepared by a multidisciplinary team of experts (cytopathologists, epidemiologists, general practitioners, gynaecologists, urologists etc) will be made available to the media and press for publication.
The issues will be presented to influential individuals or groups and top officials in the federal ministry of health in a compelling way so that they will realize that a real need exist. Some decision makers may lack the political will to support or draw attention to a health subject that is deemed controversial because it is associated with sexual activity. To handle this, a case for cervical cancer prevention will be built by a team of experts from various disciplines and evidence- based reports on the issues of cervical cancer and its preventive measures will be given. Key information will include current data on the on the disease and its precursors among defined populations, the availability and utilization of prevention and treatment services and policies currently in place that affect access to and use of services.
A broad coalition that includes key leaders, individuals from a range of organizations, women from target population etc will be established. Together, several plans of action to actively increase public awareness, capture the attention and support of key decision makers, opinion leaders, the public, the media and respond to opposition etc. Will be developed.
POLICY FORMULATION
Policy formulation involves setting objectives and options analysis. It also involves assessing many areas of potential policy impacts to reduce the chances of unintended consequences (Walt 2005).
According to Cristina (2000), when deciding whether to initiate cervical cancer prevention services, decision makers must compare information on existing capabilities/ infrastructures with the estimated inputs needed to achieve the minimum service-delivery goals for a given population.
The policy makers and stakeholders will need to agree on a public health approach to cervical cancer prevention; whether through screening for abnormal cells, HPV or HPV vaccination programs.
There will also be a need to consider whether the screening program should be incorporated into health care service, piggy backed on other health care programs (e.g. HIV and family planning clinics), or a established independently in every local government area.
A target age group will need to be identified for provisions to be made for the necessary logistics, staffing needs, equipments and facilities to be quantified and budgeted for. To establish this, service providers like gynaecologists, cytopathologists, nurses, doctors etc should be consulted.
Finally, a program guideline should be drawn. This will include; screening frequency, follow up requirements, target population, treatment approach etc
POLICY IMPLEMENTATION
During the policy implementation, the top-down and bottom-up approach will be incorporated as suggested by Walt (2005). Considering the political dynamism in Nigeria, neither of them can be expected to work independently. The first step in the policy implementation is ensuring my goals are well defined and understood. Other steps include making sure health infrastructures, financial, technical and administrative resources are available. A chain of command from the centre of the screening program to its periphery, should be established to ensure the screening program is on course. The actors and stakeholders should be incorporated into the implementation process and their opinions/activities will be duly considered.
When policies are executed the following should be considered:
Sustainability can be of the program can be increased by building on existing health system
The public, community leaders, religious leaders, media, stake holders etc. Should be involved
The screening program should be integrated into existing programs that offer similar services to the target population.
Health care providers should be well trained in counselling and screening of women
Bottle necks should be identified and removed for an effective service delivery
POLICY EVALUATION
The monitoring and evaluation of a policy-operation and impact is essential to determine whether the program is meeting its objectives effectively and efficiently. A positive evaluation can be used to mobilize continued financial and political support for the program (Cristina 2000).
The policy evaluation in this study will follow the pattern of the work published by cristinna, in her work, the following were done Based on studies done by ristina in 2000, I will effectively evaluate the program by
Identifying measurable evaluation indicators (both process and impact indicators)
Developing an appropriate evaluation strategy (for example comparing performance against set targets for a given time period)
Gathering information about selected indicators
Analyzing the information and reporting findings
Recommending corrective actions to the appropriate program personnel.
The aforementioned above can be achieved using a reliable Information technology system well- functioning information system by this individual women can be tracked over time. An established national cancer registry can be used to monitor changes in cervical cancer incidence rate.
MONITORING AND EVALUATION OF THE EFFECTIVENESS OF PROPOSED CERVICAL SCREENING PROGRAM
Monitoring and evaluation of a cervical cancer prevention program’s operations and impact are essential in determining whether the program is meeting its objectives effectively and efficiently (cristina 2000).
The purpose of establishing performance indicators is to promote high quality screening which ultimately will lead to a reduction in the incidence, morbidity and mortality of cervical cancer while minimizing any associated risks. (Canada).For the set goals to be achieved, the screening pathway from coverage and participation to diagnosis and treatment of cervical cancer must be properly carried out.
PROGRAM PERFORMANCE INDICATORS
COVERAGE
PARTICIPATION RATE
DEFINITION: Percentage of eligible women in the target population with at least one Pap test in a three-year period.
RATIONALE: A significant decrease in the incidence of cervical cancer and mortality is expected when all eligible women have access to regular Pap test (Laara 1987). Factors that can influence participation rate includes; acceptability, accessibility, screening interval, promotion of screening among others.( Hakama 1997).
RETENTION RATE:
DEFINITION: percentage of eligible women rescreened within three years after a negative Pap test in a 12-month period.
RATIONALE: To optimise the benefits of screening, regular participation is essential. Factors that influence retention rates include; socio-economic status, access to health care provider, availability of a reminder notification system, etc.
CYTOLOGY PERFORMANCE INDICATORS
SPECIMEN ADEQUACY
DEFINITION: Percentage of Pap tests reported as unsatisfactory in a 12-month period.
RATIONALE: Pap tests are classified in the laboratory based on their adequacy for interpretation. The unsatisfactory rate may be influenced by several factors including specimen collection, sample collection, sample preparation and observer variation in the interpretation of test slides, etc.
SYSTEM CAPACITY INDICATORS
CYTOLOGY TURN AROUND TIME
DEFINITION: The average time from the date the specimen is taken to the date the finalized report is issued over a 12-month period.
RATIONALE: Cytology turnaround time is not necessarily a quality indicator but an indicator of system capacity for reporting of Pap tests. Lengthened turnaround times may indicate insufficient personnel or resources.
TIME TO COLPOSCOPY
DEFINITION: Percentage of women with a positive Pap test who had a follow up colposcopy within 6-12 months after the index Pap test.
RATIONALE: Time to colposcopy is a measure of timely compliance to follow up which is necessary to ensure the detection and treatment of cervical abnormalities.
FOLLOW UP
BIOPSY RATE
DEFINITION: Percentage of women with a positive screening test who received a histological diagnosis in a 12-month period.
RATIONALE: Biopsies are used to confirm cervical abnormalities. A low biopsy rate is indicative of a poor follow up.
OUTCOME INDICATORS
CANCER INCIDENCE
DEFINITION: Age standardized incidence rate (per 1000 women) of invasive squamous carcinoma or adenocarcinoma of the cervix per year.
RATIONALE: As organized screening programs become established, the age-standardized incidence rates for invasive squamous carcinoma and adenocarcinoma of the cervix are expected to decrease. Evidence of effectiveness should preferentially be based on reduction of cancer morbidity and mortality.
SCREENING HISTORY IN CASES OF INVASIVE CANCER
DEFINITION: Percentage of women diagnosed with invasive squamous carcinoma or adenocarcinoma by time since previous Pap test in a 12-month period.
RATIONALE: The screening history of women who are diagnosed with invasive cervical cancer offers insight into program effectiveness.
Cervical cancer incidence rate is affected by many factors including screening uptake in the population, sensitivity of the screening program sensitivity of tests to identify pre-cancerous lesions, effectiveness of treatment for lesions and other patient-based factors.
