Transcript Slide 1

Risk factors for loss to follow-up after a positive visual
inspection with acetic acid test result among women in Zambia
R Magawa, A Beke, GP Parham
4th Biennial SAMEA conference on Monitoring and Evaluation
16 to 20 September 2013
Hilton Hotel Sandton, Johannesburg, South Africa
Contents
1. Global crisis of cervical cancer
2. Cervical cancer prevention in Zambia
3. Study Objective
4. Socio-demographic and economic factors
5. Loss to follow up
6. Methods
7. Analysis
8. Results
9. Conclusion
10. Recommendations
Global crisis of cervical cancer
• 2nd most common cancer among women worldwide
- 529,828 new cases; 274,000 deaths annually
- 80% occur in developing countries
• Largest burden of disease is in Africa
- 80,419 new cases, 53,300 deaths annually
- Ten countries with highest mortality rates - African
• Zambia has world’s highest burden
- 2nd highest incidence (52.8 per 100 000)
- Highest mortality rates (38.6 per 100,000)
Cervical cancer prevention in Zambia
• Pilot study conducted among 150 HIV-positive women
in 2004 revealed
− Abnormal cytology 93.8%; High-risk HPV types 85.3%
• Cervical Cancer Prevention Programme in Zambia
(CCPPZ) established 2006
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Nurse-led with distance consultation support
VIA complemented with digital photography
Treat at point-of-care with cryotherapy if VIA+
Complex cases referred to University Teaching Hospital
for biopsy
− >125,000 women screened since 2006
− High rate of Loss to Follow-Up (LTFU), <20% of HIV+
women ever return for their recommended follow-up visit
Study Objective
To investigate socio-demographic and economic factors
that influence LTFU after a positive VIA test
Socio-demographic and economic factors
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Age
−
Marital status
−
Area of residence
−
Number of lifetime sexual partners
−
Province
−
Pregnancy history
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District
−
History of cervical cancer in the family
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Level of education
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Ever smoked tobacco
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Occupation
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Ever had a pap smear
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Monthly household income
−
HIV status
Loss to follow up
• No consensus or universal definition
• Recommended definition: ≥180 days since last clinic
visit
• CCPPZ definition: ≥30 days late for missed
recommended follow-up visit
• LTFU affects the effectiveness of cervical cancer
screening programmes
Methods
• Retrospective cross-sectional study of VIA positive
patients
• Routine electronic data collected by the CCPPZ
− 01/2006 to 12/2011
− 33,980 records from 13 clinics
− Proportional and systematic random sampling of
records in each clinic
− Total sample size: 2,778 records
• Cut off date for follow-up: 01st February 2013
• Inclusion criteria
- age 15+; scheduled follow-up visit regardless of
management plan
Analysis
• Stata12
• Descriptive statistics of women LTFU
• Univariate logistic regression - to investigate the
association between factors and LTFU (Wald p-value
<0.25)
• Multivariate logistic regression - to estimate the odds
ratios (OR) for LTFU and the 95% confidence
interval (CI) according to socio-demographic and
economic factors
• Level of significance was set at p-value <0.05
• Post regression tests to assess validity of the model
Results
Descriptive statistics (N=2,778)
FACTOR
FACTOR
n (%)
Age
Range: 16 to 79 years
Mean: 35 years (SD =11yrs)
Marital status
Married
682 (63)
Area of residence
Urban
2,550 (92)
Smoking status
No
2,622 (98)
2,610 (94)
Number of lifetime sexual partners
3 or 4
798 (29)
2,550 (92)
Pregnancy history
0, 1 or 2
914 (36)
695 (39)
Ever had a pap smear
No
2,644 (97)
551 (30)
History of cervical cancer in the family
No
2,603 (96)
806 (46)
HIV status
Negative
1,094 (40)
Province
Lusaka
District
Lusaka
Education
Secondary
Occupation
Housewife
Monthly household income
High
n (%)
Descriptive statistics cont…
Among the 2,778 women:
•return visits were recommended for 2,713 (98%)
− 2,442 (90%) were lost to follow-up
•65 (2%) with complex lesions were referred for biopsy
− 38 (58%) were lost to follow-up
•Women lost to follow-up at first visit, ≥30 days: 2,480
(89%)
Univariate logistic regression (*Wald p-value<0.25)
Factor
Category
OR
p-value
Age
> 30years
1.17
0.218*
Area of residence
Urban
0.03
0.001*
Province
Southern
21.4
0.002*
District
Monze
22.01
0.002*
Education
Tertiary
0.59
0.104*
Occupation
Formal sector
0.62
0.007*
Household income
High
0.46
0.000*
Marital status
Separated/Widowed/Divorced
1.83
0.011*
Smoking status
Non-smoking
1.94
0.051*
Number of lifetime sexual partners
3 or 4
1.34
0.077*
Pregnancy history
3
0.74
0.109*
Ever had a pap smear
No
1.38
0.336
History of cervical cancer in the family
No
1.28
0.385
HIV status
Negative
0.41
0.000*
Multivariate logistic regression (*p-vale <0.05)
Risk factor
Category
OR
95 % CI
p-value
Household
income
Low
Medium
High
Referent
0.41
0.64
0.22 - 0.75
0.34 - 1.20
0.004*
0.165
Number of
lifetime sexual
partners
0–1
2
3-4
>4
Referent
0.94
2.07
1.48
0.60 - 1.50
1.29 - 3.33
0.82 - 2.63
0.807
0.003*
0.190
HIV status
Positive
Negative
Unknown
Referent
0.21
0.27
0.12 - 0.39
0.15 - 0.51
0.000*
0.000*
Conclusion
• High rate of LTFU (89%) among VIA positive women
in programme without adherence system
• Low household monthly income, high number of
lifetime sexual partners and being HIV positive are
risk factors for LTFU among Zambian women who
screen positive on VIA
Recommendations
• Implement tracking and M&E system for
who present with the risk factors for LTFU
women
• Health providers need to be aware of different
patient needs in order to mitigate LTFU and
maximize programme effectiveness
• Study adherence patterns among women LTFU in
order to obtain a broader and more in-depth
understanding of factors influencing their behaviors
- Include health system factors
“Every woman has the right to live a
life free from cancer of the cervix”
- CCPPZ
References
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2.
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6.
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8.
Human papillomavirus and related cancers: Africa, summary report update, World Health
Organisation; 2010 Sep 15.p.1-13.
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Central Statistics Office (CSO), Ministry of Health (MOH), Tropical Diseases Research
Centre (TDRC), University of Zambia (UNZA) and Macro International Inc. 2009. Zambia
Demographic and Health Survey 2007. Calverton, Maryland, USA: CSO and Macro
International Inc.
Coker AL, Eggleston KS, Meyer TE, et al. What predicts adherence to follow-up
recommendations for abnormal Pap tests among older women? Gynecol Oncol. 2007
Apr;105(1):74-80.
Parham GP, Sahasrabuddhe VV, Mwanahamuntu MH, et al. Prevalence and predictors of
squamous intraepithelial lesions of the cervix in HIV-infected women in Lusaka, Zambia.
Gynecol Oncol 2006; 103:1017–1022.
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Cancer Prevention Program in Lusaka, Zambia. PLoS Medicine 2011; 8(5):1-5
Parham GP, Mwanahamuntu MH, Sahasrabuddhe VV, et al. Implementation of cervical
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StataCorp. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP;
2011.
Use for Q&A
− Poverty is a barrier to prevention and treatment of the disease due
to financial limitations such as the cost of travel or referral
and loss of wages from hours spent in health appointments.
Similar studies have reported lower socio-economic status as
a risk factor for LTFU
− A study showed that cervical cancer (caused by a sexually
transmitted virus) is a highly stigmatised disease in Zambia
because of its association with socially condemned
behaviours such as multiple sexual partners. We hypothesise
that highly sexually active women who test VIA+ are more
likely to be stigmatised (and termed “promiscuous” ) and
subsequently lost to follow-up, as stigma is a barrier to
accessing essential health services
Use for Q&A
− Studies have shown that cervical cancer is a highly
stigmatized disease because of its association with HIV
− A combination of HIV and cervical cancer presents a
challenge of double stigma
− Stigma and discrimination against people living with HIV
have long been identified as barriers to accessing essential
health services and impact patient health outcomes
• Similar to previous studies, we failed to detect an
association between LTFU and other sociodemographic variables such as age, level of education,
occupation, marital status, smoking status and history
of pregnancy
Cervical cancer and HIV
• Cervical cancer is an HIV-associated disease
• HIV-positive women more likely to have
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persistent HPV infection
more rapid progression from HPV infection to cancer
cervical cancer diagnosed at younger ages
Recurrences