Authored by Shreya Bhatt
January is Cervical Cancer Awareness Month in the United States, and we’re excited to feature the experiences of nurses, supervisors and patients from our mHealth cervical cancer screening project in India. Cervical cancer is one of the most common, preventable, and treatable cancers affecting women globally, and like many other diseases, its burden is most pronounced in low and middle-income countries. Over 20% of all new cases are diagnosed in India, where our tools have been used by nurses since May 2016 to screen for cervical cancer in low-resource communities in Tamil Nadu, Chhattisgarh and Madhya Pradesh. In a recent visit, we spent some time with field teams using our tools in Mungeli (Chhattisgarh) and Padhar (Madhya Pradesh) to hear their experience of screening, referring and following up for cervical cancer in last-mile settings with basic mobile phones. Close to 100 cervical cancer screenings have been conducted using Medic Mobile tools across the three sites. Here are some of things we heard. (Quotes from community service providers, nurses and nursing assistants were translated from Hindi into English by Shreya Bhatt.)
“The phones have helped us become quicker and more efficient in our work. I also feel more self-confident that I’m able to use phones and do my work well.” - Mohan, Community Service Provider, Padhar Hospital.
“Our families like that we are using mobile phones for our work. My husband proudly tells others that I received a phone from the hospital.” - Narmada, Community College Nursing Assistant, Christian Hospital Mungeli.
“Even others in the community are impressed that we use phones for cervical cancer screening instead of paper.” - Samiksha, Nurse, Padhar Hospital.
Not only did users share positive feedback on the tool and the efficiency it has enabled in their work, but they also shared anecdotes revealing the perceived social benefit of using mobile phones to deliver health care and the resulting boost to their confidence and self-esteem.
CHM’s Mobile Clinic team with Gayatri Ganesh (4th from right), Mungeli, Chhattisgarh. Photo Credit: Christian Hospital Mungeli
"The notion of preventive care doesn’t exist here. Patients often seek care only when they are on their deathbed." - Gayatri Ganesh, Director of Development at Christian Hospital Mungeli
In addition to positive user experiences, we also heard about challenges that the field teams face in screening and following up with patients for treatment. Health care in many low-resource settings around the world is still reactive rather than preventive. Lack of disease awareness and poor health literacy is a key challenge to changing this status quo. When it comes to cancer, particularly cervical cancer, people living in poverty often associate myths with the condition and fear it as a death sentence. Screening is a new concept for women in such settings, and increasing the uptake of cervical cancer screenings means winning hearts and minds by changing long-held perceptions, behaviors and attitudes. Our partners at Christian Hospital Mungeli, Padhar Hospital and Christian Medical College Vellore achieve this by conducting extensive and culturally-appropriate community education programs using mediums such as puppet shows, folk songs, posters, flyers and peer education.
Community outreach team with Bappa Mukherjee (centre), Padhar, Madhya Pradesh. Photo Credit: Padhar Hospital
“The women in our community don’t have any money of their own. Money is often controlled by their husbands. Even if they are willing to come to the hospital for treatment, they can’t. This is the hard truth.” - Bappa Mukherjee, Head of Department - Community Initiatives Department, Padhar Hospital.
Financial barriers continue to hinder patients from seeking treatment. These barriers typically include the cost of transportation to and from the facility and home, the cost of investigations and treatment, the opportunity cost of a day’s wages lost to visit the facility, and other consequences such as task-shifting of home chores to other members of the family. In low-resource communities, these are very real challenges that patients face and bear throughout their illness, often waiting until the late stages of their cancer to seek treatment.
Despite these and other challenges, we were excited to hear several patient experiences. One of the first patients to be treated as part of this project in Mungeli is Sangeeta Varma (name changed to protect privacy). Sangeeta hails from a small village roughly 30 kilometres from Mungeli. She is thirty years old, has one child and has completed primary education (up to grade 8). Several weeks ago, Sangeeta visited the USAID ASHA mobile clinic run by Christian Hospital Mungeli (CHM), with a complaint of irregular menstruation and several other symptoms. The doctor at the mobile clinic performed a vaginal examination using a colposcopy and a visual inspection with acetic acid (VIA) which tested positive for precancerous lesions. The doctor and nurses counseled Sangeeta to return for free cryotherapy treatment the following week when the mobile clinic was due to return to the village.
“We were unsure whether she would return to the clinic. Loss to follow up is an issue with most patients here,” noted Gayatri. However, the following week, Sangeeta returned with her husband and successfully received cryotherapy treatment. When asked to share what motivated her to seek treatment, Sangeeta replied, “I thought it is better to come for a smaller procedure than let it grow and have surgery later. I am scared of surgery.”
Sangeeta reported that her decision was also driven by financial considerations - treatment is free at CHM while it would have cost her thousands of rupees at other hospitals. Proximity to the point of care also influenced her decision to seek treatment, as the mobile clinic makes weekly visits to a village close to her own. Throughout her journey to care, Sangeeta did not need to visit the main hospital at all as her screening, diagnosis and treatment took place on the mobile clinic directly at the community.
Sangeeta is one of several women who have been screened, diagnosed with precancerous lesions, received follow up, and have been treated at facilities or community-based points of care across the three project sites. In the absence of this project, it is likely that Sangeeta’s condition would have remained undiagnosed until an advanced stage.
Cervical cancer is often preventable and treatable if detected early, and our intervention shows that simple and low-cost mobile technology can serve to strengthen care coordination for cervical cancer screening, early diagnosis and treatment follow-up in last-mile settings. Our brief visit with the field teams mid-project was both informative and inspiring, and we hope to share more learnings and updates soon.