Nicaragua

Context

Though it remains the second poorest country in the western hemisphere, in the last decade Nicaragua has fared better than neighboring Central American countries, which have seen an economic downturn coupled with an increase in violence. Since 2005, Nicaragua GDP per capita has risen from less than $900 to nearly $1,250 in 2011.[1]

Cervical cancer is the number one cause of cancer death in Nicaragua accounting for more than 420 deaths per year,[2] which is more than three times the number of deaths from pregnancy and childbirth.[3] About 20% of these deaths come from the northern departments of Nicaragua: Matagalpa, Jinotega, Estelí, Madriz, and Nueva Segovia. These rural, mountainous areas are also the top coffee-producing regions in the country. Although the Nicaraguan Ministry of Health (MINSA) is committed to addressing cervical cancer, there is a multitude of competing priorities for the country’s scarce health resources.

Reference

^[1] United Nations Country Profile, Nicaragua. 2014. http://data.un.org/CountryProfile.aspx?crName=NICARAGUA. Accessed 10/13/2014
[2] Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr. Accessed on February 7, 2014.
[3] MINSA. Muertes Maternas e Incidencia y Defunciones por CACU . Managua : División General de Planificación y Desarrollo-Oficina Nacional de Estadísticas, 2013.

In Nicaragua, Grounds for Health aims to establish cervical cancer prevention programs via the implementation of the following activities:

• Train community health promoters associated with coffee cooperatives to increase awareness of the importance of cervical cancer prevention and recruit women in the target group.
• Train local doctors and nurses in VIA and cryotherapy and provide supportive supervision after training to ensure continued quality of care.
• Conduct Screen and Treat campaigns with local doctors and nurses for women in coffee growing communities.
• Donate cryotherapy equipment, speculums and other essential materials for cervical cancer prevention to local clinics and provide technical assistance in its use.
• Development of a network of resources at the community, regional and national levels

Since 2007, Grounds for Health has conducted trainings, screen and treat campaigns, monitoring and supportive supervision in the departments of Jinotega (2007-2011), Matagalpa (2008-2011), Madriz (2011-2013) and Nueva Segovia (2014-present). Grounds for Health has led 14 clinical trainings and campaigns for local providers throughout the four departments in Nicaragua. These trainings have consisted of a classroom didactic section and a 3 to 4-day campaign for clinical practice. Following clinical trainings, local providers return to their posts (hospitals, health centers, and health posts) and continue to provide VIA and cryotherapy. Grounds for Health continues to support these providers via monitoring and supportive supervision as they improve clinical skills. Local ministry of health authorities and leadership play a key role in selecting local providers to be trained by Grounds for Health, and health centers where equipment donations are made to ensure on-going screening and treatment services. All partners work to ensure women requiring follow-up beyond treatment with cryotherapy receive it.

In conjunction with clinical trainings and prior to a campaign, Grounds for Health trains community health promoters (CHPs) to conduct outreach, education, and assist women in accessing services. Co-op and local health partners support and monitor community health promoters in conducting outreach activities. To date, 456 promoters have been trained, predominantly from the coffee cooperatives network and the red comunitaria, the Nicaraguan Ministry of Health’s network of community health outreach workers.

Since 2012, Grounds for Health has collaborated with the ECOM affiliate in Nicaragua, Exportadora Atlantica, to address cervical cancer in coffee growing areas. Exportadora Atlantica employs a large number of women in a range of positions for their dry processing mills and laboratories. The partnership has extended activity and programming to ECOM’s networks at their base of Sebaco, Matagalpa and northern Nicaragua. The collaboration supports training of promoters and screen-and-treat campaigns.

Currently, in Nueva Segovia, Prodecoop and the local health authorities are awaiting approval from the Ministry of Health to formalize their collaborative agreement. A separate agreement between Grounds for Health and Prodecoop was signed in September 2014 and the program kicked off with the first community health promoter training and initial clinical training and campaign in Jalapa.

The program is aiming to reach over 2,000 women from Madriz, Nueva Segovia, and Exportadora Atlantica communities between October 2014 and September 2015. Grounds for Health will also pursue opportunities to return to previously graduated sites to increase coverage in these areas.

Annual Screening and Treatment Performance – Nicaragua

Program Year (PY): October – September

Key Output Indicators – Nicaragua

The importance of community partnerships and engagement

Community partners can facilitate acceptance and access to services in hard to reach areas. By engaging coffee cooperatives in planning and implementation, community outreach and education, and using co-op vehicles for transportation when necessary, the program benefits from immediate entry and acceptance in rural communities, and ensures local ownership and commitment. The co-ops help to increase awareness and acceptability of cervical cancer prevention services among rural communities and address barriers to access. After campaigns, each partner plays an important role in ensuring that services remained accessible to women who were unable to attend, and in coordinating follow-up for women with referrals. Co-operatives often use Fair Trade premiums to support community health promoter trainings, transport women to services, provide economic support to families with women suffering from cancer, and to refill empty gas tanks to ensure timely treatment and continuation of services.

Supportive supervision is essential to ensure providers maintain competency in VIA and cryotherapy

Grounds for Health found that quality assurance was best achieved through routine supportive supervision of trained providers for a period of 6- 12 months following the initial training. Refresher trainings that brought doctors and nurses together for a review of key principles and clinical practice also provided a way to deliver continuing support and help providers develop a peer support network, share experiences, and promote continued practice.

Screening and treatment sites should be strategically selected and supported.

The data on long-term productivity of providers after training, while incomplete, underlines the importance of selecting sites and providers that will see sufficient clients to maintain skills. It has been estimated that a VIA trained provider needs to see 20 clients per month (60 per quarter) in order to maintain skills; very few of the 100 providers we trained have continued to serve this many women.

A medical records system can help to improve patient tracking and follow-up.

Most of the health facilities and hospitals that participated in the demonstration projects have systems for counting and reporting the number and type of services provided, but they do not have a system to track women who need to return for follow-up. One solution, which is used in El Salvador and other countries, may be to provide all women age 30-49 with a cervical cancer prevention card to carry with them to appointments. This card could be integrated with health facility records and used to verify screening history and ensure appropriate follow-up.

• Results & Lessons Learned – Nicaragua (PDF)
• Resultados y lecciones aprendidas – Nicaragua (PDF)