Significant inter-related barriers exist at the individual, provider, and system levels. Strategies to improve access include targeting social programs and mental health services, expanding Medicaid eligibility/enrollment, promoting community-based organizations, enforcing the use of trained medical interpreters, and improving cultural competency.

Short-term humanitarian medical volunteerism has grown significantly among both clinicians and trainees over the past several years. Increasingly, both volunteers and their respective institutions have faced important challenges in regard to medical ethics and professional codes that should not be overlooked. We explore these potential concerns and their risk factors in three categories: ethical responsibilities in patient care, professional responsibility to communities and populations, and institutional responsibilities towards trainees. We discuss factors increasing the risk of harm to patients and communities, including inadequate preparation, the use of advanced technology and the translation of Western medicine, issues with clinical epidemiology and test utility, difficulties with the principles of justice and clinical justice, the lack of population-based medicine, sociopolitical effects of foreign aid, volunteer stress management, and need for sufficient trainee supervision. We review existing resources and offer suggestions for future skill-based training, organisational responsibilities, and ethical preparation.

Objectives There is a shortage of trained healthcare personnel for cervical cancer screening in low/middle income countries. We evaluated the feasibility and limited efficacy of a smartphone-based training of community health nurses in Visual Inspection of the cervix under Acetic Acid (VIA). Methods During April-July of 2015 in urban Ghana, we designed and developed a study to determine the feasibility and efficacy of an mHealth supported training of community health nurses (CHNs) (n=15) to perform VIA and to use smartphone images to obtain expert feedback on their diagnoses within 24 hours and improve VIA skills retention. CHNs completed a 2-week on-site introductory training in VIA performance and interpretation followed by an ongoing 3-month text messaging supported VIA training by an expert VIA reviewer. Results CHNs screened 169 women at their respective community health centers while receiving real-time feedback from the reviewer. The total agreement rate between all VIA diagnoses made by all CHNs and the expert reviewer was 95%. The average rate of agreement between each CHN and the expert reviewer was 89.6% (Standard Deviation (SD)=12.8). The agreement rates for positive and negative cases were 61.5% and 98.0%, respectively. Cohen's kappa statistic was 0.67 (95% CI; 0.45-0.88). Around 7.7% of women tested VIA positive and received Cryotherapy or further services. Conclusions Our findings demonstrate the feasibility and efficacy of mHealth-supported VIA training of CHNs and has the potential to improve cervical cancer screening coverage in Ghana.

ObjectiveTo explore acceptability and feasibility of smartphone-based training of low-level to mid-level health professionals in cervical cancer screening using visual inspection with acetic acid (VIA)/cervicography.DesignIn 2015, we applied a qualitative descriptive approach and conducted semi-structured interviews and focus groups to assess the perceptions and experiences of community health nurses (CHNs) (n=15) who performed smartphone-based VIA, patients undergoing VIA/cryotherapy (n=21) and nurse supervisor and the expert reviewer (n=2).SettingCommunity health centres (CHCs) in Accra, Ghana.ResultsThe 3-month smartphone-based training and mentorship was perceived as an important and essential complementary process to further develop diagnostic and management competencies. Cervical imaging provided peer-to-peer learning opportunities, and helped better communicate the procedure to and gain trust of patients, provide targeted education, improve adherence and implement quality control. None of the patients had prior screening; they overwhelmingly accepted smartphone-based VIA, expressing no significant privacy issues. Neither group cited significant barriers to performing or receiving VIA at CHCs, the incorporation of smartphone imaging and mentorship via text messaging. CHNs were able to leverage their existing community relationships to address a lack of knowledge and misperceptions. Patients largely expressed decision-making autonomy regarding screening. Negative views and stigma were present but not significantly limiting, and the majority felt that screening strategies were acceptable and effective.ConclusionsOur findings suggest the overall acceptability of this approach from the perspectives of all stakeholders with important promises for smartphone-based VIA implementation. Larger-scale health services research could further provide important lessons for addressing this burden in low-income and middle-income countries.