1. Key interventions and primary outcomes
Table 1 summarizes the characteristics of each phase, and Table 2 presents the key educational and managerial interventions conducted at the individual, organizational, and systematic levels. Figure 1 is a conceptual framework to show guidance in implementing activities, describing how the outcomes of the project are envisioned to help reduce the burden of cervical cancer in Cambodia.
1) Phase A (Health education and screening)
To assess the baseline knowledge, attitude, and practice of the target population regarding reproductive health and cervical cancer, a cross-sectional survey was conducted in Factory A in March 2016. Among 443 female workers, their level of knowledge of women’s health and cervical cancer was low. Approximately 85% reported that their sources of information were relatives or friends, indicating that they rarely have opportunities to receive accurate knowledge from health professionals. Based on their educational needs, teaching materials and brochures on cervical cancer were developed.
2) Phase B (Diagnosis and treatment of precancerous lesions)
Situational analysis to examine the current practice at the target hospitals in November 2015 found that machines for diagnosis (colposcopy) and treatment of precancerous lesions (loop electrosurgical excision procedures (LEEP)) were already installed in all three hospitals but were often used improperly. Records regarding the number of abnormal cases detected and treated were poorly recorded.
To improve the skill of colposcopy and LEEP, a series of hands-on trainings was conducted both on-site and in Japan between 2015 and 2018. LEEP was favored over cryotherapy for the treatment of precancerous lesions because it allows the lesions to be pathologically examined for definitive diagnosis and improves surgical capacity at tertiary hospitals responsible for cancer care. To harmonize practice, a standard clinical protocol was developed to guide clinical decision-making, and it was reviewed and revised after a year. Reporting forms and a registry for HPV-positive cases were also developed for monitoring.
3) Phase C (Pathology service)
Through phase B, the obstacle to scaling up a cervical cancer screening program in Cambodia was identified as the extremely limited capacity of pathological services. When any screening program is scaled up in a country, there will inevitably be a large increase in the detection rate of cervical cancer. In 2017, however, there were only four pathologists and 15 pathology technicians actively working in the whole country. The situation was even worse than in 2014 because of the retirement of older generations.
At the target hospitals, although basic pathology equipment and supplies were available, slides were often difficult to read due to inadequate preparation. A step-by-step training was offered to technicians for quality slide preparation. Five pathology residents, enrolled in the national residency program that started in 2015 to increase the number of pathologists, were also trained for their capacity-building in diagnosis and quality management.
Under the initiative of the SCGO, a clinico-pathological conference (CPC) was introduced to improve case management. In the beginning, pathologists and gynecologists tended to criticize each other on discrepancies between clinical and pathological diagnoses, but with close mentoring by Japanese physicians, a mutual learning environment was soon created. The CPC has gradually become a routine practice for developing clinical management skills.
2. Factors contributing to optimal outcomes
The lessons learned and challenges identified in the focus group discussion are summarized in Table 3. The following factors that influenced the implementation process and contributed to optimal outcomes were identified:
1) Partnership between two professional societies
Since 1998, JSOG members have been working with the Cambodian MOH through development projects. Individual collaboration became more institutional in 2012 when an exchange program was initiated between the JSOG and SCGO. The idea for this project came from the SCGO. Throughout the project implementation, the JSOG respected the initiative of the SCGO and adopted a coaching style to provide technical and managerial guidance as a professional society that has a public responsibility. The SCGO took this opportunity to develop institutional capacity and leadership and attracted over 300 physicians across the country in 2018.
2) Strong ownership and commitment of the SCGO
With a request from the MOH and as a professional society responsible for women’s health, the SCGO took the initiatives and leadership in every step to introduce HPV test-based screening and treatment and capacity building for pathology services. Since many board members are retired or are presently high-ranking officials of the MOH with extensive clinical and administrative experience, negotiation with factory managers and national hospital directors or communication with the MOH and development partners was smooth and successful. In fact, there is no group in Cambodia other than the SCGO that is technically and professionally capable of responding to this issue.
3) A comprehensive and stepwise quality-focused approach with stakeholder involvement
Quality is essential for cancer care. The stepwise quality-focused approach taken in this project revealed opportunities and barriers in each step of the comprehensive cancer care continuum. Solutions to address the barriers were discussed and responded to on time.
In phase A, combined cervical cancer with sexuality and women’s health was revealed to be best for communicating with women and factory managers. Women showed considerable interest in learning about their own health along with the factory managers, who considered the session to be useful in maintaining a healthy workforce. Factory managers gradually became cooperative with the project, their awareness of cervical cancer increased, and mobile screening became feasible at factory.
In phase B, the involvement of national hospital directors from the initial stage made maximum utilization of existing resources possible. Finally, HPV test-based screening and treatment of precancerous lesions were introduced within a relatively small budget (Table 1). For the future development of the cancer care continuum, cervical cancer programs may serve as an entry point for strengthening pathology services in a country.
4) Socioeconomic factors
Increased demand for social welfare and quality health care pushed the SCGO to address cervical cancer as a priority agenda and to initiate this project. The National Health Insurance Scheme, introduced in January 2018, enabled formal workers to seek consultation and receive necessary treatment without copayment. Public bus service and Uber-type application service have been expanded around the city of Phnom Penh, with improved geographical access to hospitals.