The impact of decentralising colposcopy services from tertiary-level to primary-level care in inner-city Johannesburg, South Africa: a before and after study

Abstract

ObjectiveTo assess whether decentralising colposcopy services to a primary care facility in inner-city Johannesburg, South Africa raises access to colposcopy.DesignBefore–after study comparing 2 years before and 2 years after decentralisation, using clinical records and laboratory data on cervical cytology and histology.Primary outcomeThe proportion of all women attending Hillbrow Community Health Centre (HCHC) with an abnormal Papanikolaou (Pap) smear who had a colposcopy post-decentralisation.SettingCharlotte Maxeke Johannesburg Academic Hospital (CMJAH) has provided colposcopy services for several decades. HCHC, located about 3 km away, began colposcopy services in 2014.ParticipantsWomen, aged above 18 years, who had a colposcopy for diagnosis and treatment of precancerous cervical lesions following a Pap smear, from 2012 to 2016 at CMJAH or HCHC.ResultsPre-decentralisation at CMJAH, 910 women had colposcopy (2012–2014). Post-decentralisation (2014–2016), 721 had colposcopy at CMJAH and 399 at HCHC, the decentralised facility. The number who had a Pap smear at HCHC and then a colposcopy rose threefold post-decentralisation (114 vs 350). Post-decentralisation, 43 women at HCHC were referred to CMJAH for colposcopy, compared with 114 pre-decentralisation. Post-decentralisation, 47.3% of women at CMJAH waited >6 months for colposcopy, while 35.5% did at HCHC (p<0.001). Across all three groups, 26.9%–30.3% of women had cervical intraepithelial neoplasia III lesions or carcinoma on colposcopy. The proportion of invalid specimens was similar at CMJAH and HCHC (1.8%–2.8%). Of 401 women who had an abnormal Pap smear at HCHC post-decentralisation, 267 had colposcopy (66.6%).ConclusionDecentralisation can decrease the time to colposcopy and reduce the workload of tertiary hospitals. Overall, more women accessed services. Colposcopy coverage at HCHC is higher than other sites, but could be further improved. Decentralisation did not appear to undermine the quality of services and this model could be extended to similar settings in South Africa and elsewhere.

Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low-income and middle-income countries: a systematic review

“…Studies were conducted in 20 LMICs across regions of Africa (8), Europe (4), Latin America (2), Middle-East Asia (1) and South-East Asia (5). Twenty were single-country studies, in which 13 countries were represented: Bangladesh (2),8 40 Botswana (2),41 42 Colombia (1),43 India (1),44 Indonesia (1),45 Iran (1),46 Malaysia (2),47 48 Nigeria (1),49 Pakistan (1),50 Rwanda (1),51 South Africa (3),52–54 Tanzania (1)55 and Zambia (3) 56–58. One study had a multicountry focus, with participants recruited from nine countries: Bosnia-Herzegovina, Costa Rica, Egypt, India, North Macedonia, Pakistan, Slovenia, Turkey and Uganda 59 Figure 2.…”

“…In terms of study design, six studies were RCT,8 40 43 45 46 51 six were before-and-after studies,42 44 48 49 52 54 one was a longitudinal (cohort-type) observational study,55 four were retrospective cohort-type studies,41 47 50 53 while the remaining four were cross-sectional studies 56–59…”

“…When categorised by the three steps of the WHO Guide to Cancer Early Diagnosis,24 eight studies reported on interventions aiming to address barriers in step 1 (promoting awareness and addressing delays in access to care)8 40 44–47 49 54; another eight focused on interventions addressing step 2 (addressing diagnostic delay by optimising clinical evaluation, diagnosis and staging)42 43 50–52 55 59 60; one study reported on an intervention targeted at both steps 1 and 253; while five studies assessed interventions targeted at all three steps (addressing access, diagnostic and treatment delays) 48 56–58 Tables 1 and 2. describe the categorisation of the interventions by the three steps of the WHO Guide to Cancer Early Diagnosis 24…”

Health outcomes in women attending with clinical guideline PROGYNE to a primary care center for cervical cancer prevention

“…In addition, a colposcopy can be a way to reduce the barrier of difficult access reducing the cost of transportation and other costs. 34,35 Non-attendance for colposcopy of women positive for high-risk HPV negatively affects CC screening in Brazil; therefore, bringing colposcopy to primary care would facilitate attendance. 36 Making use of evidence-based strategies aimed at the detection and control of CC is paramount, as well as the qualification and training of professionals.…”

“…Although colposcopy is a resource intensive diagnostic method, it requires provider training, specialized equipment, bringing it closer to the population increases the chance of attendance, consequently decreasing the delay in performance and loss to follow-up, which provides an early diagnosis of pre-cancerous lesions. [34][35][36]42 Therefore, investing in methods such as digital cervicography, VILI, and colposcopy can be an advantageous alternative to the Papanicolaou test for CC prevention in primary health care.…”