bs_bs_banner

doi:10.1111/jog.12052 J. Obstet. Gynaecol. Res. Vol. 39, No. 6: 11901199, June 2013

Evaluation of a 5-year cervical cancer prevention project

in Indonesia: Opportunities, issues, and challenges

Young-Mi Kim1, Fransisca Maria Lambe3, Djoko Soetikno3, Megan Wysong1,

Ana Isabel Tergas2, Presha Rajbhandari3, Abigael Ati3 and Enriquito Lu1
1
Jhpiego/USA, Johns Hopkins University, 2Johns Hopkins Medical Institute, Baltimore, Maryland, USA; and 3Jhpiego/
Indonesia, Johns Hopkins University, Jakarta, Indonesia

Abstract
Aim: The Cervical and Breast Cancer Prevention (CECAP) Project sought to develop a national model for
cervical cancer prevention in Indonesia based on visual inspection with acetic acid (VIA) to detect abnormal
changes in the cervix. The purpose of this study was to evaluate a pilot project introducing VIA and cryo-
therapy in Indonesia and to identify lessons learned that could be applied to the national scale-up of cervical
cancer prevention services.
Material and Methods: Fifty-four months (July 2007 to December 2011) of service records at 17 health centers
were abstracted and analyzed. The data were used to calculate the proportion of all women aged 3050 who
received VIA screening, the VIA-positive rate, the treatment rate, and the interval between screening and
treatment.
Results: The 45 050 women screened during the project included 24.4% of the total female population in the
target age group in the catchment area. Throughout the 5-year project, 83.1% of VIA-positive women sought
cryotherapy. During the last 18 months of the project, after data collection tools were revised to more accurately
reflect when cryotherapy was received, 13% of women were treated on the same day that they were screened.
Among the 74% of women treated within 1 month of screening, the mean interval between screening and
treatment was 7.2 days.
Conclusion: As cervical cancer prevention services are scaled up throughout Indonesia, changes in the service
delivery model and program management are needed to increase screening coverage, promote a single-visit
approach, and ensure the quality of services.
Key words: cancer prevention, cancer screening, cervical cancer, cryotherapy, Indonesia.

Introduction Prevention (CECAP) Project in January 2007, in part-

Cervical cancer is the second leading cause of cancer
deaths among women in developing countries,
although it is preventable when detected and treated in
its early stages.1 In Indonesia, there were over 13 700
new cases of cervical cancer and almost 7500 deaths
due to the disease in 2008. In response, the Ministry of
Health (MoH) launched the Cervical and Breast Cancer
nership with Jhpiego and the Ford Foundation. The
goal of this 5-year project was to develop a national
model for cervical cancer prevention and breast cancer
awareness. Cervical cancer prevention was based on
implementing low-cost but effective methods of early
detection at public health centers (or puskesmas). From
the start, the CECAP Project worked at the national
level toward the development and dissemination of

Received: May 11 2012.

Accepted: November 8 2012.
Reprint request to: Dr Young-Mi Kim, Jhpiego, an affiliate of Johns Hopkins University, 1615 Thames Street, Baltimore, MD 21231,
USA. Email: ymkim@jhpiego.net

1190 2013 The Authors

Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology

policy, service delivery, and training guidelines on cer-
vical cancer screening and treatment that are appli-
cable nationwide.
The CECAP service delivery model relies on visual
inspection with diluted acetic acid (VIA) to screen for
abnormal changes in the cervix followed by cryo-
therapy or a referral to a hospital for further evaluation
and/or advanced care when needed. Providers were
trained to dilute a commercial brand of acetic acid with
water to produce a 5% solution. VIA offers a well-
tested and cost-effective alternative that requires less
infrastructure, training, equipment, and specialized
personnel than cytology-based screening.29 Because
VIA screening results are available immediately,
women with precancerous lesions can be treated
during the same visit rather than having to return at a
later date. A single-visit approach (SVA) that links VIA
screening with immediate cryotherapy by a trained
provider has been proven safe, feasible, cost-effective,
and acceptable to women.4,1014 It also minimizes loss to
follow-up and helps ensure that all women with pre-
cancerous lesions receive treatment.1518
The CECAP Project was implemented on a pilot
basis in Karawang District, which is located approxi-
mately 1.5 h east of Jakarta. Karawang was selected as a
demonstration site because of the high number of cer-
vical cancer cases seen at the district hospital and the
existence of multiple risk factors for cervical cancer,
including early onset of sexual activity, high incidence
of sexually transmitted infections (STI), and proximity
to commercial sexual activity.
At the end of the project in 2011, an evaluation was
conducted in Karawang to assess outcomes and iden-
tify lessons learned that could be applied to the
national scale-up of cervical cancer prevention services
in Indonesia. This report focuses on one arm of the
evaluation: the analysis of routine service statistics col-
lected at participating health centers. It answers the
following research questions:
1 What percentage of women in the target age group
(3050 years) in the community was screened?
2 What proportion of VIA-positive women received
cryotherapy?
3 How effective were service providers in screening
and treating women promptly?
Methods
Pilot activities in Karawang District
CECAP services, including VIA screening and cryo-
therapy, were implemented at 17 of Karawang Dis-
2013 The Authors
Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology
Cervical cancer prevention in Indonesia
tricts 47 public health centers. Each health center
serves from eight to 15 villages. The health centers
selected were located in both rural and urban areas and
were geographically dispersed across the district to
maximize access to cervical cancer screening and treat-
ment. CECAP services were introduced at four health
centers in 2007, followed by an additional eight health
centers in 2008 and five health centers in 2009. The
evaluation included all 17 facilities.
The service model, guidelines, and training package
developed at the national level, based on Jhpeigo pack-
ages in other countries, were implemented in
Karawang. A team of two or three physicians and mid-
wives who were the primary providers for reproduc-
tive health services at each facility were trained in VIA
and cryotherapy, using a competency-based approach.
Depending on the size of the facility, they represented
a smaller or greater proportion of all providers at the
facility. The project: (i) included refresher training,
which included a review of relevant knowledge
and classroom simulation and clinical practice to
strengthen identification of significant acetowhite
lesions; (ii) offered mentoring and coaching during
refresher training; (iii) provided essential equipment
and supplies; (iv) developed an information system for
the health center level; and (v) trained staff in docu-
menting, recording, and reporting relevant data.
Eleven of the 17 health centers implemented the
Standards-Based Management and Recognition quality
improvement process, which uses detailed standards
to guide essential tasks performed by health-care
workers and identify and address weaknesses in
service delivery.19 During the final year of the project,
midwives at eight health centers were trained to
perform cryotherapy. This marked a change from pre-
vious policy, which limited the performance of cryo-
therapy to doctors.
Advocacy and behavior change communication
formed an essential part of the CECAP Project. Activi-
ties focused on raising awareness of cervical cancer and
gaining broad support from stakeholders and the com-
munity for screening and treatment. Advocacy teams
were established at the national, district, and sub-
district levels. The project also recruited the help of
volunteer community health workers, called kaders,
who go house-to-house to promote various health
services.
To increase the number of women screened, health
centers began holding mobile outreach events once or
twice a year in each village. Kaders publicized the
events, which were held in the village midwifes
1191
Y-M. Kim et al.

house, and encouraged women to go for screening.

collected in February 2012; women who returned for treatment after that data are not included. CECAP, Cervical and Breast Cancer Prevention; VIA, visual inspection with acetic
Includes women who made a separate trip to a health facility for cryotherapy after screening, as well as women who received cryotherapy on the same day as screening. Data
Women were eligible for cryotherapy if they were VIA-positive, their lesions did not occupy more than 75% of the cervical surface, and they were not suspected of cervical cancer.
From 10 to 60 women attended each event, which

Did not seek

cryotherapy
included a group counseling session followed by VIA

Among eligible VIA-positive

(37.0)
(30.5)
(10.4)

(20.6)
(16.9)
(8.2)
women, number (%) who:
screening. Cryotherapy was not offered because of the
difficulty of transporting the CO2 tanks. Instead,

10
48
17
22
41
138
women who screened positive were referred to the
health center for cryotherapy. While health center
service statistics routinely included mobile outreach
events, they did not record the location where each

cryotherapy
woman was screened; however, providers observed

(79.4)
(63.0)
(69.4)
(89.6)
(91.8)

(83.1)
that relatively few women sought screening at health

Sought
centers. Rather, they reported that most women were

17
109
147
247
158
678
screened at outreach events.

Data collection and analysis

Fifty-four months (July 2007 to December 2011) of

having cancer
Suspected of
service records on cervical cancer screening and treat-
ment at all 17 health centers were abstracted and ana-

(0.4)
(0.4)
(0.3)
(0.3)
(0.3)
Among women screened,
number (%) who were:

(0)
lyzed. Data included the number of women who

0
21
43
43
38
145
received VIA screening and the results of that screen-
ing (normal, precancerous lesions, or suspected
cancer). For women who tested positive for precancer-
ous lesions, data included the number who pursued
cryotherapy during the same or a later visit, the results

VIA-positive
of a repeat VIA test conducted by doctors before they

(3.5)
(3.2)
(1.6)
(1.6)
(1.6)
(1.8)
performed cryotherapy, and the number who received
Table 1 CECAP service data on VIA screening and cryotherapy, 20072011

cryotherapy (if the repeat test was negative, women

27
157
164
269
199
816
were not treated with cryotherapy).
Early data collection forms did not indicate the
patients age or the timing of cryotherapy in relation to
the initial screening. The forms were changed in the
Number of

summer of 2010 to show how much time elapsed

screened
women

between screening and cryotherapy treatment.

777
4 874
10 298
16 406
12 695
45 050

To help explain the quantitative data, we sometimes

refer to findings from qualitative research conducted as
part of the CECAP evaluation. The methods and results
of that research, which explored factors affecting
womens decisions regarding cervical screening and
implementing
health centers

treatment, are fully reported elsewhere.20

Number of

CECAP

Results
4
12
17
17
17

Screening coverage
Table 1 shows that the number of women screened
annually grew sharply in the early years of the project
JulyDec 2007
JanDec 2008
JanDec 2009
JanDec 2010
JanDec 2011

as more health centers began participating. Once all 17

health centers had implemented the CECAP model,
Total

the number of women screened annually rose from

Dates

acid.

10 298 in 2009 to 16 406 in 2010, before falling to 12 695

in 2011.

1192 2013 The Authors

Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology
 Cervical cancer prevention in Indonesia

Table 2 Cumulative screening coverage among women aged 3050, 20072011, by health center
Health center Total female Number of Percent of
population women aged population
aged 3050 3050 screened screened
Ciampel 3 464 1 607 46.4
Pangkalan 4 417 1 833 41.5
Jatisari 5 218 1 807 34.6
Cilamaya 9 547 3 277 34.3
Rengas Dengklok 11 322 3 519 31.1
Telagasari 7 677 2 331 30.4
Kota Baru 4 338 1 142 26.3
Klari 7 826 1 948 24.9
Cikampek 9 931 2 078 20.9
Pedes 8 280 1 732 20.9
Karawang 6 707 1 325 19.8
Tempuran 8 734 1 678 19.2
Tirta Jaya 7 622 1 458 19.1
Tirta Mulya 5 586 1 018 18.2
Lemah Abang 8 153 1 281 15.7
Batu Jaya 8 676 1 255 14.5
Cibuaya 6 010 849 14.1
Total 123 508 30 138 24.4

Over the course of the 5-year project, a total of 45 050
women received VIA screening, including 30 138
women in the target age group of 3050 years. They
represented 24.4% of the total female population aged
3050 in the catchment area of the 17 health centers.
Cumulative screening coverage in the target age group
exceeded 40% at two health centers. Less than 20% of
the target population was screened at seven health
centers (Table 2).
Results of VIA screening
Among all women screened from 2007 to 2011, 1.8%
tested positive for cervical dysplasia (Table 1). The
VIA-positive rate was highest during the first 18
months of the project, at 3.5% in 2007 and 3.2% in 2008.
It fell to 1.6% from 2009 through 2011.
A total of 145 women, or 0.3% of those screened over
the 5-year period, were suspected of having cervical
cancer. That proportion remained stable from one year
to the next. Women suspected of cancer were referred
to the district hospital for further evaluation and
advanced care. Follow-up information, including the
number of women with a confirmed diagnosis of cer-
vical cancer and the number who received appropriate
treatment, is not available.
Loss to follow-up
According to project guidelines, VIA-positive women
are eligible for cryotherapy if they are not suspected of
having cervical cancer and if their lesions do not cover
more than 75% of the cervical surface or extend into the
endocervical canal. Women with larger lesions are
expected to be referred to a hospital for treatment;
however, there were no records of VIA-positive
women with large lesions at participating health
centers.
Over the course of the 5-year project, the majority
(83.1%) of VIA-positive women had cryotherapy
(Table 1), but not necessarily on the same day that they
were screened. Most women visited a health center at a
later date for treatment (see below for data on the inter-
val between screening and treatment). The proportion
of women who received cryotherapy rose markedly
after 2008, in large part due to a change in how cryo-
therapy was offered. During the first 2 years of the
CECAP Project, obstetrician/gynecologists at the dis-
trict hospital were responsible for performing cryo-
therapy. In 2009, general practitioners (GP) began to
perform cryotherapy at health centers. This made the
service more readily accessible to women, who no
longer had to travel to the district hospital for treat-
ment; however, the change in policy did not guarantee
that treatment was available on the same day as screen-
ing, as each health center typically has only one GP on
staff who not only serves as manager, but also has
clinical responsibilities for all primary health-care ser-
vices. In 2009 and 2010, around 90% of VIA-positive
women either received cryotherapy the same day they

2013 The Authors 1193

Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology
Y-M. Kim et al.

Table 3 Outcomes for women who came for cryotherapy after screening positive for precancerous lesions
Dates Number of women who During repeat visualization, Among women who
were VIA-positive and number (%) of women who were: were VIA-positive on a
came for cryotherapy VIA-negative VIA-positive repeat visualization,
number (%) who
received cryotherapy
JulyDec 2007 17 12 (70.6) 5 (29.4) 5 (100)
JanDec 2008 109 64 (58.7) 45 (41.3) 44 (100)
JanDec 2009 147 50 (34.0) 97 (66) 97 (100)
JanDec 2010 247 73 (29.6) 174 (70.4) 174 (100)
JanDec 2011 158 32 (20.3) 126 (79.7) 126 (100)
Total 678 231 (34.1) 447 (65.9) 447 (100)
Includes women who made a separate trip to a health facility for cryotherapy after screening, as well as women who received cryotherapy
on the same day as screening. Women who were VIA-negative on a second screening were not offered cryotherapy. VIA, visual inspection
with acetic acid.

were screened or visited a health center for treatment at

a later date. That proportion fell to 79.4% in 2011,
leaving about 20.6% of VIA-positive women who never
returned to a health center for cryotherapy by the end
of data collection in February 2012.

Cryotherapy rates
When VIA-positive women return for treatment at a
later date, national guidelines require doctors to
perform a repeat VIA test to confirm the presence of
precancerous lesions before they conduct cryotherapy.
In 70.6% of cases in 2007 and 58.7% of cases in 2008, the
repeat VIA test was negative and the women were not
treated (Table 3). That proportion fell to 34% of cases in
2009 and continued to decline to 20.3% in 2011. Every
woman who came for cryotherapy and was found to
be VIA-positive on a repeat visualization received
cryotherapy.

Interval between screening and treatment

Information on the interval between screening and
treatment is available for the 18-month period from July
2010 to December 2011, during which 155 VIA-positive
Figure 1 Interval between screening and treatment.
women received cryotherapy. Only 13% of these
women were treated on the same day that they were
screened, but another 74% received treatment within 1
month of screening (Fig. 1). Among women screened sistently available at health centers due to a lack of
within 1 month, the mean interval between screening trained providers, space, equipment, and/or supplies;
and treatment was 7.2 days. and (iii) women are required to obtain their husbands
According to interviews and focus-group discus- consent for the procedure.20
sions with providers, women, and husbands in
Karawang, there are three main reasons why VIA- Discussion
positive women do not receive treatment on the same
day as screening: (i) women must travel to the health Applying lessons learned from the CECAP pilot in
center to get cryotherapy; (ii) cryotherapy is not con- Karawang District can help improve the effectiveness,

1194 2013 The Authors

Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology

quality, and sustainability of cervical cancer prevention
services as they are scaled up throughout Indonesia.
Routine service statistics from 17 sub-districts in
Karawang point to four opportunities to improve
service delivery:
1 Intensifying community mobilization and expand-
ing the role of static service delivery sites to increase
screening coverage.
2 Incorporating continuous quality improvement to
strengthen providers skills.
3 Changing the service delivery model to expand
access to SVA.
4 Collecting and utilizing data to strengthen strategic
planning and program management.
Expanding screening coverage
Health centers in Karawang primarily relied on mobile
outreach events for VIA screening, which were held
only once or twice a year in each village. Although
mobile screening services have proven effective in
other developing countries, especially for hard-
to-reach communities,21 service statistics show that
screening coverage remained low in Karawang. The
relative infrequency of visits by mobile screening
teams may have reduced access to screening in the
community. The downward trend in the pace of
screening during the final year of the project reinforces
the need to try new approaches to increase screening
coverage in addition to continuing and even increas-
ing the frequency of mobile outreach. While this
study did not investigate alternative service-delivery
models, experience in Karawang has led program
experts to suggest some promising possibilities that
take advantage of the ability of static facilities to offer
continuing access to screening between outreach
events.
One option is to integrate VIA screening into related,
routine health services offered at health centers and
other static sites. This approach would invite every
woman aged 3050 who visits a health center, regard-
less of the reason, to be screened for cervical cancer in
a no-missed-opportunities approach.21 Another possi-
bility is for health centers to partner with private mid-
wives. For example, midwives could be encouraged to
bring women for screening and treatment on desig-
nated days. Some health centers have even begun train-
ing village midwives to perform VIA screening in
order to make the service regularly available within the
community. These midwives are expected to coordi-
nate their services with nearby health centers offering
2013 The Authors
Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology
Cervical cancer prevention in Indonesia
cryotherapy so that same-day screening and treatment
is possible.
Experience across developing countries has demon-
strated the importance of community involvement to
increase participation in cervical cancer screening.17,22
In Karawang, local advocacy teams and kaders were
supposed to meet this need, but they did not function
as well as expected, according to interviews with
health workers and advocacy team members.20 Weak
leadership, lack of coordination, limited funding, and
lack of clarity concerning the function and responsibili-
ties of advocacy teams hampered their ability to
promote cervical cancer screening, while competing
obligations to other health programs limited most
kaders commitment to CECAP activities. Changes are
needed to strengthen community mobilization efforts,
for example, by arranging stronger leadership and a
clear scope of work for local advocacy teams or by
offering kaders greater recognition. Partnering with
other potential spokespersons in the community, such
as religious leaders and high school teachers, could
also help disseminate CECAP messages.
Improving the quality of services
While providers met performance standards during
refresher training, three findings raise questions about
their technical skills:
1 Only 1.8% of women screened positive, which is low
compared to reports in other countries. Elsewhere in
Asia, studies have recorded VIA-positive rates of
4.8% in Bangladesh,23 7.0% in Laos,14 9.9% in Tamil
Nadu, India,8 and 13.3% in rural Thailand.12 In addi-
tion, the MoH has reported a VIA-positive rate of
4.3% in other parts of Indonesia. This raises the ques-
tion of whether midwives are missing lesions during
the testing process or the base prevalence for cervical
precancer is low in Karawang.
2 No VIA-positive women in Karawang were reported
to have large lesions. It is not clear whether mid-
wives and doctors do not recognize large lesions, are
misreporting them, or are failing to report them.
3 Doctors did not always confirm the presence of cer-
vical lesions in women found VIA-positive by mid-
wives, although differences in test results decreased
over time, presumably due to the normal learning
curve. One cannot assume that the doctors were
more accurate than the midwives.
Based on current data, it is impossible to determine
whether the lower-than-expected rate of cervical
lesions, including large lesions, reflects the true rate of
1195
Y-M. Kim et al.
dysplasia in Karawang or is an artifact of poor provider
skills. Examinations conducted during refresher train-
ing and mentoring activities found that providers were
able to accurately assess the results of VIA tests. Hence,
a clinical study is needed to determine the true rate of
cervical dysplasia and cervical cancer in Karawang.
Additionally, a robust quality assurance mechanism,
such as a video link allowing experts to check diag-
noses made in the field, could ensure that providers are
performing according to standards. If there was evi-
dence that the skills of some or all providers were
weak, retraining would be indicated.
Experience in other countries shows that it is not
difficult to train mid-level providers to perform VIA
screening to a high standard,2426 although nurses and
midwives may need more practice than doctors and
may find it more challenging to make clinical judg-
ments about the need for treatment.27 Training alone is
insufficient, however. Consistent, on-the-job coaching
and mentoring by experienced supervisors, as well as
peer-to-peer learning, are needed to strengthen provid-
ers skills and maintain the accuracy and consistency of
VIA screening. Unlike the coaching and mentoring
provided by the CECAP Project at training workshops,
on-site coaching and mentoring as part of supportive
supervision offers providers immediate feedback on
their skills and also enables coaches to address other
aspects of the work environment that affect perfor-
mance, such as protocols, equipment, supplies, moti-
vation, and management support. The government
health system in Indonesia already offers this kind of
on-the-job coaching and mentoring for other maternal
and neonatal health interventions; it could be extended
to CECAP services at little additional expense.
Cervical cancer prevention programs in other low-
resource settings have instituted a range of quality
assurance procedures. A variety of tools including
supportive supervision, peer feedback, weekly meet-
ings to review cases, periodic refresher courses, flash
cards featuring photos of healthy and unhealthy cer-
vixes washed with vinegar and other job aids, and
regular monitoring with performance checklists have
been shown to help providers achieve high
performance.16,2730 This gives program managers an
extensive toolkit from which to select the approaches
most appropriate to the setting. In Indonesia, the most
pressing need is for ongoing supportive supervision.
Clinically competent supervisors, who have been
trained on program standards, could check whether
providers are correctly interpreting the results of VIA
tests, reinforce guidelines regarding large lesions, and
1196
Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology
determine which provider is correct when test results
are not confirmed. Once supervisors identify a
problem, they could offer providers coaching, on-the-
job training, and close monitoring to correct it, drawing
on some of the tools listed above, as needed.
Promoting SVA
During the final year of the CECAP Project, less than
14% of VIA-positive women received cryotherapy the
same day, while 21% had not returned for treatment by
February 2012. Others faced delays in seeking treat-
ment. The solution is SVA. Indeed, same-day screening
and treatment is one of the primary benefits of using
VIA rather than Pap smears; however, the CECAP
Project was not able to offer SVA to most women
because mobile outreach events lacked the equipment
and, in most cases, the trained providers needed to
perform cryotherapy. Raising the SVA rate in Indonesia
will require more trained providers (and an acceptance
that lower-level cadres can perform cryotherapy),
additional equipment, and arrangements to offer cryo-
therapy outside of health centers.
To make SVA more readily available, the CECAP
Project began training midwives in cryotherapy during
its final year. Experience in Bangladesh, Ghana, India,
Thailand, and South Africa has demonstrated that, with
careful training, nurses and midwives are capable of
providing cryotherapy safely and effectively.1012,3033
Midwives in Karawang were well trained, as demon-
strated by high scores on post-tests. Mid-level provid-
ers are also acceptable to and sometimes even
preferred by women receiving cryotherapy.34 This is
likely to be true in Indonesia as well, given womens
preference for female providers for most procedures,
particularly more intimate ones, such as VIA screening
and cryotherapy. In Indonesia, task shifting offers the
additional advantage of training a cadre of providers
who are less mobile than doctors and therefore more
likely to remain at the health center where they were
originally trained.
Task shifting in Indonesia faces challenges, however.
Regulatory changes are needed to ensure that any
trained and qualified provider, regardless of cadre, can
operate and freely utilize cryotherapy equipment. In
addition, trained midwives must be offered ongoing
support and a chance to practice their skills. In
Karawang, midwives had little opportunity to perform
cryotherapy after they were trained because of the low
caseload and the reluctance of some doctors to allow
midwives to perform cryotherapy if they were avail-
able instead.20 Ensuring doctors cooperation and
2013 The Authors

arranging for trained midwives to provide cryotherapy
at multiple sites will be essential to the success of task
shifting.
Offering cryotherapy at mobile outreach events and
village locations wherever minimum safety stan-
dards can be ensured is critical to SVA. A project in
Thailand has demonstrated that it is feasible for mobile
teams to transport CO2 tanks and equipment between
sites and offer cryotherapy services along with screen-
ing;12 however, providers in Karawang are concerned
about the efficiency of using portable CO2 tanks
because their small size limits the number of proce-
dures that can be conducted.20 A program in the Phil-
ippines takes a different approach: it permanently
stations full-size CO2 tanks at churches, schools, and
health posts, so that providers have somewhere to take
and treat VIA-positive women immediately after
mobile screening events (Lu E, 2012, unpublished
data). Because limited resources make it impossible to
supply every health facility and outreach site in Indo-
nesia with cryotherapy equipment, it is crucial to place
these units strategically so as to maximize access and
coverage. It is also important to encourage sharing of
the equipment available, for example, by designating
certain health centers to provide cryotherapy for mul-
tiple sub-districts.
Collecting and utilizing data
Routinely collecting service data and tracking key indi-
cators is essential for effective planning and manage-
ment of cervical cancer prevention programs; it enables
managers to monitor performance and improve
ongoing service delivery.21 In Guyana, Cte dIvoire,
and Tanzania, regular review of service data has
enabled managers to overcome barriers to screening
and treatment and to systematically improve out-
comes; each quarter, they compare service statistics
against standards set for screening coverage, the VIA-
positive rate, and the SVA rate (Wysong MW, 2012,
unpublished data).
Our evaluation revealed numerous weaknesses in
data collection at study sites in Karawang District. For
example, forms initially did not record the patients age
or the interval between screening and treatment, pro-
viders did not report large lesions, and no further
information was collected on women suspected of cer-
vical cancer, including whether cancer was confirmed
and treatment given. In addition, the limited data avail-
able were not routinely or effectively utilized for
program management, such as changing intervention
strategy.
2013 The Authors
Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology
Cervical cancer prevention in Indonesia
Conclusion
The MoH has introduced cervical cancer screening and
treatment services based on the CECAP model in 14
provinces across Indonesia, using the guidelines, train-
ing modules, and other materials tested in Karawang
District. District governments provide all of the sup-
plies and equipment needed and also pay to train pro-
viders in VIA and cryotherapy. As a result of these
efforts to scale up the CECAP approach, over 291 000
women in 68 districts across Indonesia received VIA
screening from 2007 to 2010; however, only 39.3% of
VIA-positive women received cryotherapy. It is impor-
tant to note that the effectiveness of the services
offered outside of the Karawang District have not been
evaluated, and other districts may face a unique set of
barriers to implementation, which may result in lower-
quality services. Lessons learned in Karawang will help
cervical cancer prevention programs across Indonesia
increase screening coverage, improve the quality of
services, expand SVA, and utilize service data for
program management.
Acknowledgments
Financial support for this evaluation came from the
Ford Foundation and the Union for International
Cancer Control. The authors are grateful to Dr H. Yuska
Yasin, MM, Dr Rasim, Dr Hj. Rina Hasriana, Mkes, and
Haryanto, SKM from the Karawang District Health
Office, Dr Fita Rosemary, Agus from Provincial Health
Office, and Dr Basalama Fatum, MKM from MoH/
Indonesia for their contributions. We thank the data
collectors, Maulana Hasan and Haryanti Koostanto.
Special thanks to Anne Hyre, Alain Damiba, Linda
Fogarty, Sharon Kibwana, Jean Sack and Katherine
Naugle at Jhpiego for their guidance and review of the
report. Thanks to Richard Embry for his collaboration.
Special thanks to Adrienne Kols who helped the team
with writing and editing the report. We also thank the
service providers and CECAP clients who participated
in the study.
Disclosure
No author has any potential conflict of interest.
References
1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM.
Estimates of worldwide burden of cancer in 2008: GLOB-
OCAN 2008. Int J Cancer 2010; 127: 28932917.
1197
Y-M. Kim et al.
2. Almonte M, Ferreccio C, Winkler JL et al. Cervical screening
by visual inspection, HPV testing, liquid-based and conven-
tional cytology in Amazonian Peru. Int J Cancer 2007; 121:
796802.
3. Belinson JL, Pretorius RG, Zhang WH, Wu LY, Qiao YL, Elson
P. Cervical cancer screening by simple visual inspection after
acetic acid. Obstet Gynecol 2001; 98: 441444.
4. Goldie SJ, Gaffikin L, Goldhaber-Fiebert JD et al. Cost-
effectiveness of cervical-cancer screening in five developing
countries. N Engl J Med 2005; 353: 21582168.
5. Mandelblatt JS, Lawrence WF, Gaffikin L et al. Costs and
benefits of different strategies to screen for cervical cancer in
developing countries. J Natl Cancer Inst 2002; 94: 1469
1483.
6. Megevand E, Denny L, Dehaeck K, Soeters R, Bloch B. Acetic
acid visualization of the cervix: An alternative to cytologic
screening. Obstet Gynecol 1996; 88: 383386.
7. Sankaranarayanan R, Nene BM, Dinshaw KA et al. A cluster
randomized controlled trial of visual, cytology and human
papillomavirus screening for cancer of the cervix in rural
India. Int J Cancer 2005; 116: 617623.
8. Sankaranarayanan R, Esmy PO, Rajkumar R et al. Effect of
visual screening on cervical cancer incidence and mortality in
Tamil Nadu, India: A cluster-randomised trial. Lancet 2007;
370: 398406.
9. University of Zimbabwe, JHPIEGO Cervical Cancer Project.
Visual inspection with acetic acid for cervical cancer screen-
ing: Test qualities in a primary care setting. Lancet 1999; 353:
869873.
10. Blumenthal PD, Gaffikin L, Deganus S et al. Cervical cancer
prevention: Safety, acceptability, and feasibility of a single-
visit approach in Accra, Ghana. Am J Obstet Gynecol 2007; 196:
407.e1407e.9.
11. Denny L, Kuhn L, De Souza M, Pollack AE, Dupree W,
Wright TC Jr. Screen-and-treat approaches for cervical cancer
prevention in low-resource settings: A randomized con-
trolled trial. JAMA 2005; 294: 21732181.
12. Gaffikin L, Blumenthal PD, Emerson M, Limpaphayom K,
Royal Thai College of Obstetricians and Gynaecologists
(RTCOG)/JHPIEGO Corporation Cervical Cancer Preven-
tion Group. Safety, acceptability, and feasibility of a single-
visit approach to cervical-cancer prevention in rural
Thailand: A demonstration project. Lancet 2003; 361: 814820.
13. Mathers LJ, Wigton TR, Leonhardt JG. Screening for cervical
neoplasia in an unselected rural Guatemalan population
using direct visual inspection after acetic acid application: A
pilot study. J Low Genit Tract Dis 2005; 9: 232235.
14. Phongsavan K, Phengsavanh A, Wahlstrm R, Marions L.
Safety, feasibility, and acceptability of visual inspection with
acetic acid and immediate treatment with cryotherapy in
rural Laos. Int J Gynaecol Obstet 2011; 114: 268272.
15. Goldhaber- Fiebert JD, Denny LE, De Souza M, Wright TC Jr,
Kuhn L, Goldie SJ. The costs of reducing loss to follow-up in
South African cervical cancer screening. Cost Eff Resour Alloc
2005; 3: 11.
16. Luciani S, Winkler J. Cervical Cancer Prevention in Peru: Lessons
Learned from the TATI Demonstration Project. Washington, DC:
Pan American Health Organization, 2006.
17. Nene B, Jayant K, Arrossi S et al. Determinants of womens
participation in cervical cancer screening trial, Maharashtra,
India. Bull World Health Organ 2007; 85: 264272.
1198
Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology
18. Perkins RB, Langrish SM, Stern LJ, Burgess JF, Simon CJ.
Impact of patient adherence and test performance on the
cost-effectiveness of cervical cancer screening in developing
countries: The case of Honduras. Womens Health Issues 2010;
20: 3542.
19. Necochea E, Bossemeyer D. Standards-Based Management and
Recognition: A Field Guide. Baltimore, MD: JHPIEGO, 2005.
20. Kim YM, Ati A, Kols A et al. Influencing womens actions
on cervical cancer screening and treatment in Karawang
District, Indonesia. Asian Pac J Cancer Prev 2012; 13: 2913
2921.
21. Bradley J, Barone M, Mah C, Lewis R, Luciani S. Delivering
cervical cancer prevention services in low-resource settings.
Int J Gynaecol Obstet 2005; 89 (Suppl 2): S21S29.
22. Agurto I, Arrossi S, White S et al. Involving the community in
cervical cancer prevention programs. Int J Gynaecol Obstet
2005; 89 (Suppl 2): S38S45.
23. Nessa A, Hussain MA, Rahman JN, Rashid MH, Muwonge R,
Sankaranarayanan R. Screening for cervical neoplasia in
Bangladesh using visual inspection with acetic acid. Int J
Gynaecol Obstet 2010; 111: 115118.
24. Levine LD, Chudnoff SG, Taylor K, Baganizi M, Banks E. A
5-day educational program for teaching cervical cancer
screening using visual inspection with acetic acid in low-
resource settings. Int J Gynaecol Obstet 2011; 115: 171
174.
25. Masch R, Ditzian LR, April AK, Maza M, Peralta E, Cremer
ML. Cervical cancer screening and treatment training course
in El Salvador: Experience and lessons learned. J Womens
Health (Larchmt) 2011; 20: 13571361.
26. Sangwa-Lugoma G, Mahmud S, Nasr SH et al. Visual inspec-
tion as a cervical cancer screening method in a primary
health care setting in Africa. Int J Cancer 2006; 119: 1389
1395.
27. Blumenthal PD, Lauterbach M, Sellors JW, Sankaranarayanan
R. Training for cervical cancer prevention programs in low-
resource settings: Focus on visual inspection with acetic acid
and cryotherapy. Int J Gynaecol Obstet 2005; 89 (Suppl 2):
S30S37.
28. Mwanahamuntu MH, Sahasrabuddhe VV, Pfaendler KS et al.
Implementation of see-and-treat cervical cancer prevention
services linked to HIV care in Zambia. AIDS 2009; 23: N1
N5.
29. Ramogola-Masire D, de Klerk R, Monare B, Ratshaa B, Fried-
man HM, Zetola NM. Cervical cancer prevention in HIV-
infected women using the see and treat approach
in Botswana. J Acquir Immune Defic Syndr 2012; 59: 308
313.
30. Sanghvi H, Limpaphayom KK, Plotkin M et al. Cervical
cancer screening using visual inspection with acetic acid:
Operational experiences from Ghana and Thailand. Reprod
Health Matters 2008; 16: 6777.
31. Ahmed T, Ashrafunnessa, Rahman J. Development of
a visual inspection programme for cervical cancer pre-
vention in Bangladesh. Reprod Health Matters 2008; 16: 78
85.
32. Nene BM, Hiremath PS, Kane S, Fayette JM, Shastri SS,
Sankaranarayanan R. Effectiveness, safety, and acceptability
of cryotherapy by midwives for cervical intraepithelial neo-
plasia in Maharashtra, India. Int J Gynaecol Obstet 2008; 103:
232236.
2013 The Authors
 Cervical cancer prevention in Indonesia

33. Sankaranarayanan R, Rajkumar R, Esmy PO et al. Effective- 34. Bradley J, Coffey P, Arrossi S et al. Womens perspectives on
ness, safety and acceptability of see and treat with cryo- cervical screening and treatment in developing countries:
therapy by nurses in a cervical screening study in India. Br J Experiences with new technologies and service delivery
Cancer 2007; 96: 738743. strategies. Women Health 2006; 43: 103121.

2013 The Authors 1199

Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology