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The Sexual and Reproductive Health and Rights (STARS) - Cervical Cancer Screening and Treatment module allows nurses, midwives, clinical officers, and medical officers to become confident and competent in performing visual inspection with acetic acid (VIA), and thermal ablation of cervical pre-cancer lesions as part of cervical cancer screening and treatment procedures performed in primary health care facilities and mobile units in resource-constrained settings.

Overview[edit | edit source]

Global Impact[edit | edit source]

Cervical cancer is a leading cause of mortality among women.[1] In 2020, an estimated 604,000 women were diagnosed with cervical cancer worldwide and about 342,000 women died from the disease. Cervical cancer is the most commonly diagnosed cancer in 23 countries and is the leading cause of cancer death in 36 countries. The vast majority of these countries are in sub-Saharan Africa, Melanesia, South America, and South-Eastern Asia.[2] Demographic shifts and inaction means the annual global number of preventable deaths from cervical cancer is predicted to reach 460,000 by 2040.[3]

In May 2018, Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO), issued a call to action for the elimination of cervical cancer.[1] A WHO global strategy to accelerate the elimination of cervical cancer as a public health problem was presented and unanimously endorsed by the Seventy-third World Health Assembly in August 2020. Subsequently, WHO officially launched the global strategy to accelerate the elimination of cervical cancer on 17 November 2020.[4]

The targets of the global strategy are, by 2030:

  • to vaccinate 90% of eligible girls against Human Papillomavirus (HPV);
  • to screen 70% of eligible women at least twice in their lifetimes; and
  • to effectively treat 90% of those with a positive screening test or a cervical lesion, including palliative care when needed.

Cervical cancer is an AIDS-defining illness and the leading cause of cancer death in the 20 million women with HIV globally.[5][6] HIV infection is associated with an earlier onset of invasive cervical cancer and higher mortality risk in cervical cancer patients.[6][7][8]

Uganda has one of the highest cervical cancer rates globally due to inadequate prevention, screening, and treatment infrastructure, especially in rural regions.[9][10][11] In 2021, there were 6,959 new cases of cervical cancer and 4,607 cervical cancer deaths, which is the most commonly diagnosed cancer and the leading cause of cancer death in Uganda.[12]

Performing visual inspection with acetic acid (VIA) and ablative therapy for cervical pre-cancer lesions is one of the 44 essential surgical procedures identified by the World Bank.[13] An open-source, comprehensive, self-assessed, and evaluated training module designed for task sharing cervical cancer screening and treatment procedures with nurses, midwives, clinical officers, and medical officers would prevent needless suffering and deaths worldwide and accelerate the global elimination of cervical cancer.

Frugal Simulation Technologies for Cervical Cancer Screening and Treatment Procedural Skills[edit | edit source]

The specific psychomotor skills that this module teaches are:

  • Identification of Acetowhite Lesions Suitable for Thermal Ablation on Visual Inspection with Acetic Acid (VIA)
  • Thermal Ablation of Cervical Pre-Cancer Lesions Using a Thermocoagulator with a Cold Probe
  • Thermal Ablation of Cervical Pre-Cancer Lesions Using a Thermocoagulator with a Hot Probe

The Gynecologic Simulator is made out of locally available, inexpensive materials. The Thermocoagulator Simulator uses readily available, low cost materials and a smartphone. No tools, specialized equipment, or technical expertise is required to construct the two simulators.

The Gynecologic Simulator is designed with removeable cervixes so the learner can practice visual inspection with acetic acid (VIA), and thermal ablation on pre-cancer lesions on nulliparous and parous cervixes. The drawback of the Gynecologic Simulator is that it does not simulate the pelvic speculum insertion and removal steps of cervical cancer screening and treatment. We require that learners have prior experience in pelvic examinations to address the shortcoming of the Gynecologic Simulator in teaching the performance of the pelvic speculum exam.

The learner will practice identifying cervical lesions suitable for thermal ablation using Jhpiego Flashcards.

The Thermocoagulator Simulator is designed with removeable probes so the learner can practice thermal ablation with hot and cold probes. This simulator has an augmented feedback circuit to alert the user when a heated probe is touching the vaginal sidewalls of the Gynecologic Simulator.

The insertion and removal of the thermocoagulator probe is a critical step of the thermal ablation procedure. Depending on the product's design, thermocoagulator probes are inserted and removed unheated ("cold") or heated ("hot") into the vagina. This module trains learners on how to apply cold and hot probes for thermal ablation because using both types of thermocoagulator probes does not happen frequently enough for practitioners or trainees to experience them in their practice, which can result in an increased risk of patient morbidity.

The user's learnings on the Gynecologic Simulator, Jhpiego Flashcards and Thermocoagulator Simulator will directly translate into clinical performance of VIA, and thermal ablation with hot and cold probes of cervical pre-cancer lesions on nulliparous and parous cervixes.

Phase 1: Knowledge Review[edit | edit source]

The learner should study the content of knowledge pages below and then take the practice quiz and readiness test. It is highly recommended that the learner be familiar with this content before proceeding to the skill pages.

Phase 2: Simulator Build[edit | edit source]

Phase 3: Skills Practice[edit | edit source]

Phase 4: Self-Assessment[edit | edit source]

This module uses the following methods for self-assessment of the quality of the skill acquisition:

  • Jhpiego Flashcards and checklist to confirm the identification of acetowhite lesions that are suitable for thermal ablation (coming soonǃ)
  • Step-by-step procedural checklists to verify proper technique for thermal ablation with "cold" and "hot" probes
  • Augmented feedback in the form of an auditory tone to alert the user if a heated probe touches the vaginal sidewalls
  • Visual inspection, pre- and post-treatment photos, and written documentation to confirm the treated area on the cervix

The Gynecologic Simulator and Thermocoagulator Simulator are designed to include a mechanism for the user to self-generate targeted feedback which enables the user to: ensure they are practicing the appropriate skills; modify their performance to improve competence; and determine when they have practiced to a sufficient level of mastery to perform the procedure in a patient.

Innovation[edit | edit source]

The STARS - Cervical Cancer Screening and Treatment module is better than and more effective than traditional approaches available in LMICS for nurses, midwives, clinical officers, and medical officers because it enables cervical cancer screening and treatment skills acquisition with innovative, locally reproducible, high fidelity, lower cost, and cruelty-free simulators and self-assessment outside of training courses.

The traditional in-person teaching approach to training VIA, and thermal ablation skills requires access to courses, trainers, expensive mannequins, and costly thermal ablation devices.[14] The WHO recommends using the ZOE® Gynecological Skills Trainer, which costs $2,695 USD.[14][15] One FDA-approved thermocoagulator device costs ̩$1,500 USD.[16]

This module is designed to reach and support as many nurses, midwives, clinical officers, and medical officers in LMICs as possible. This self-assessed module does not require access to training centers, course workshops, teachers, expensive mannequins, or costly thermal ablation devices.

The Gynecologic Simulator is made out of locally available, inexpensive materials.

The VIA Positive Nulliparous and Parous Cervix Models provide a higher fidelity, hygienic, and humane training alternative to using animal meat products which makes them suitable for the 1.2 billion followers of Hinduism, over 520 million followers of Buddhism, 4.5 million followers of Jainism, and ethical vegans who refrain from using any animal products.[17][18][19][20] No animal should be harmed from using this training module in accordance with the principles of ahimsa (non-violence or non-injury to all living beings), no killing of any living being under the Right Action Factor of The Eightfold Path of Buddhism, and the recognition of consciousness of all mammals outlined in The Cambridge Declaration on Consciousness.[18][19][21][22]

The Thermocoagulator Simulator is made using readily available, low cost materials and a smartphone.

Our innovative Thermocoagulator Simulator Mobile App, programmed in MIT App Inventor by Jude Barnabas, an Ugandan Medical Maker, simulates the Liger Medical HTU-110 Thermocoagulator™ user interface, light illumination feature, and sounds heard during thermal ablation. This mobile app also uses the cellphone's camera to allow the user to take pre- and post-treatment photos of the cervix for the self-assessment framework.

This module offers an unique augmented feedback feature (in the form of an auditory tone) to alert the learner if the Thermocoagulator Simulator heated probe touches the vaginal sidewalls of the Gynecologic Simulator.

Evaluation[edit | edit source]

Below is a description of how we developed and iterated our original prototype design following user testing throughout the development of our prototype.

1
The STARS prototype Gynecologic Simulator, Thermocoagulator Simulator, and Thermocoagulator Simulator Mobile App.
Simulator Build
  • When possible, we removed the use of acronyms (like SCJ for squamocolumnar junction and TZ for transitional zone) in case these acronyms would not be understood by learners when the module is translated into other languages.
  • Based on user testing conducted in Uganda by the Team Lead on September 23, 2021, the build instructions were modified to specify using corrugated cardboard (instead of just cardboard) to construct the Thermocoagulator Simulator.
  • Our user testing taught us that the cervix should be made of water-based, softer clay and not stiffer oil-based clay to permit the Thermocoagulator Simulator probe tip to leave an outline in the cervix so the learner can identify the treated area.
  • Our user testing showed that the clay cervix could complete the augmented feedback circuit. The vaginal canal was re-designed to not have conductive aluminum foil at a 3.0 cm distance from the proximal end of the vaginal canal closest to the cervix.
  • Our user testing showed that it's important to tape down the front and back of the base, and triangular supports for stability. We added an additional tongue depressor to permit convenient taping of the base, angled plane, and triangular supports.
  • Our user testing showed that a tongue depressor would support the vaginal canal better than a friction fit between the two support pillars. We redesigned the support pillars to be spaced 4.5 cm apart (the diameter of the vaginal canal) and repositioned the upper tongue depressor at a different height in the support pillars to directly support the vaginal canal.
  • Our user testing led to the re-design of the cutout pattern of the cold probe tip to permit a sharper outline to allow the learner to better identify the treated area on the cervix.
  • Our user testing showed that we needed to add tape over the cardboard edge of the probe tip of the Thermocoagulator Simulator contacting the clay cervix to prevent adhesion of the clay to the cardboard which caused the cervix to lift off the angled plane of the Gynecologic Simulator when the Thermocoagulator Simulator was removed from the treatment area.
  • Our user testing identified taping methods for the Thermocoagulator Simulator to ensure that all tape on the probe tip would be underneath the aluminum foil to avoid insulating the conductive material.
  • Our user testing identified that the probe shaft needed reinforcement to maintain the proper angle when it is inserted into the Thermocoagulator Simulator. We redesigned the Thermocoagulator Simulator with two additional cardboard folded layers to support the probe shaft. Our user testing in Uganda on February 5, 2022 confirmed that these additional folded layers provided the necessary support for the probe shaft.
  • Our user testing identified that the three types of audible beep sounds in the Thermocoagulator Simulator Mobile App needed to be corrected. These corrections were performed by recording and isolating the audible beep sounds of the Liger Medical HTU-110 Thermocoagulator™, uploading these audio files, and reprogramming coding blocks in MIT App Inventor.
2
Nigeria User Testing of Gynecologic Simulator and Thermocoagulator Simulator
Skills Practice
  • To maximize learner safety, we now clip an alligator clip to a small length of non-insulated metal wire looped around the proximal probe shaft of the Thermocoagulator Simulator to avoid having the learner directly touching the exposed wire in a potentially live electrical circuit during the simulation training.
  • Our user testing in Uganda and Nigeria found that the Gynecologic Simulator and Thermocoagulator Simulator builds are feasible and the Vaginal Canal with Augmented Feedback circuit is functional. The major challenge is purchasing a soft clay product, like Play-Doh. The users were able to make VIA Positive Cervix Models with a homemade recipe using flour, food colouring, salt, and water. We are working on refining this homemade clay recipe.
3
Uganda User Testing of Gynecologic Simulator and Thermocoagulator Simulator
Self-Assessment
  • Our user testing in Uganda and Nigeria confirmed that it is important that the vaginal canal be increased to 4.5 cm in diameter because using a smaller diameter vaginal canal would make it very difficult for the learner to practice thermal ablation without setting off the augmented feedback circuit.
  • On October 16, 2021, we trialed the NASA Task Load Index for Nigerian and Ugandan users of the module but observed that learner compliance with completing the forms was poor. We opted to remove the NASA Task Load Index from our self-assessment frameworks because it did not add any additional training value to the learner and this would reduce the administrative burden on the learner.
  • Our user testing of our prototype Thermocoagulator Simulator Mobile App that is now available in the Google Play Store showed that the smartphone camera light function is no longer turning on automatically when taking pre-treatment and post-treatment photos. Our mobile app developer will work on fixing this bug.
  • Our user testing has observed that the Thermocoagulator Simulator Mobile App is not saving the pre-treatment and post-treatment cervix photos to the cellphone. Our mobile app developer will work on fixing this bug. In the interim, the learner's documentation of the pre-treatment VIA-positive lesion and post-treatment area on the cervix in the Training Logbooks will suffice until we can get this bug repaired.

Design for Extreme Accessibility in Low Resource Settings[edit | edit source]

This module applies user-centered, reproducible, and accessible design choices to maximize adoption in resource-constrained settings.

User-Centered Design[edit | edit source]

Our intended users are nurses, midwives, clinical officers, and medical officers working in primary health care facilities and mobile units in resource-constrained settings and who have prior experience in conducting pelvic examinations.

Performing visual inspection with acetic acid (VIA) and ablative therapy for cervical pre-cancer lesions is one of the 44 essential surgical procedures identified by the World Bank.[13] This module teaches thermal ablation skills because this procedure can be provided in community healthcare facilities (including mobile units) and can be safely performed by a variety of healthcare practitioners without the need for anesthesia in resource-constrained settings.[3] The advantages of training nurses, midwives, clinical officers, and medical officers to perform thermal ablation over cryotherapy are that thermal ablationː

  • uses simple, lightweight (< 2 kg) and portable devices instead of bulky, and heavy refrigerant gas containers
  • uses rechargeable batteries (each fully charged battery for the Liger Medical HTU-110 Thermocoagulator™ can last for about 50 applications) instead of frequent refills of expensive refrigerant gas (N2O or CO2)
  • treatment times are 20 to 40 seconds per application (multiple if needed) which is much shorter than cryotherapy minimum total treatment times of 11 minutes using the WHO's recommended 3–5–3 minute double freeze technique.[3][14][23]

Practitioners in resource-constrained settings may not have access to costly mannequins and thermocoagulators for training. This module provides instructions to the learner on how to build the Gynecologic Simulator and fully reusable Thermocoagulator Simulator out of readily available, low cost materials and a smartphone.

Learners need access to safe simulation training. To maximize safety and minimize the risk of the learner touching any conductive material in a live electrical circuit during simulation training:

  • we added an extra insulated alligator clip to minimize the length of non-insulated metal wire for the Thermocoagulator Simulator
  • we revised the simulator build and use instructions to re-emphasize and explain the safety rationale for the mandatory use of gloves during training.

Nurses, midwives, clinical officers, and medical officers in LMICs have busy work schedules and typically do not have a technical background. We tailored the design of the surgical training module prototype to meet their training needs by designing the Gynecologic Simulator and Thermocoagulator Simulator to not require any tools, specialized equipment, or advanced technical expertise to build, install, operate and maintain these simulators within the intended place of use.

Over 4 billion people do not have access to the Internet.[24] The penetration of high-speed Internet connectivity (broadband, 3G, or better mobile connections) is less than 30% in rural regions.[25] In 2021, nearly 711 million people were in extreme poverty, which is defined as living on less than $1.90 per day.[26] To enhance adoption of this surgical training module in low resource settings, we:

  • Created frugal simulators made from low cost, locally available materials and readily available items, including a smartphone
  • Designed the Thermocoagulator Simulator to be fully reusable and most of the Gynecologic Simulator to be reusable to minimize the use of consumables and maximize their lifespan in the place of use
  • Innovated VIA Positive Cervix Models for the Gynecologic Simulator that can be easily and inexpensively replaced with a homemade recipe using flour, food colouring, salt, and water
  • Developed an Appropedia module which does not require the creation of an account, inputting of a username and password, or paying journal or other subscription fees to access the training content
  • Provided step-by-step instructions and labelled images (instead of only videos) and published our self-assessment frameworks directly in Appropedia so the module content can be available in multiple languages and exported for offline access, and
  • Programmed our prototype Thermocoagulator Simulator Mobile App for the Android operating system because Android is the leading mobile operating system globally with over 2.5 billion users across 190 countries.[27][28]

Reproducible Design[edit | edit source]

The frugal simulators are made from readily available and inexpensive materials and are designed to be fully reproducible in the intended place of use.

The demand for this module will be greatest in regions with little or no access to the Internet, smartphones, or grid electricity. When possible, we have provided step-by-step instructions and labelled images (instead of only videos) and published our self-assessment frameworks directly in Appropedia so the module content can be exported in pdf format for offline access.

Once constructed, the Thermocoagulator Simulator is fully reusable to maximize its lifespan in the place of use.

The assembled Gynecologic Simulator is also reusable except for the colored clay used to make the VIA Positive Cervix Models, which will occasionally need to be replaced.

Cost of Gynecologic Simulator Materials Locally Purchased in Nigeria and Uganda
Item Quantity Cost in USD in Nigeria Cost in USD in Uganda
Corrugated Cardboard 5 pieces with dimensions of 19.0 cm x 16.5 cm; 13.0 cm x 16.5 cm; 9.0 cm x 9.0 cm; 13.0 cm x 3.0 cm; and 13.0 cm x 3.0 cm Readily available in place of use or locally available as a free recycled item Readily available in place of use or locally available as a free recycled item
Ruler 1 Readily available in place of use Readily available in place of use
Pencil 1 Readily available in place of use Readily available in place of use
Tongue Depressors 4 Readily available in place of use Readily available in place of use
Scissors 1 Readily available in place of use Readily available in place of use
Knife 1 Readily available in place of use Readily available in place of use
Tape Multiple strips Readily available in place of use Readily available in place of use
Paper 1 sheet Readily available in place of use Readily available in place of use
Aluminum Foil 1 piece with estimated minimum dimensions of 11.0 cm by 30.0 cm (size may vary) Readily available in place of use Readily available in place of use
Marker 1 Readily available in place of use Readily available in place of use
Pink Clay 2 pieces weighing approximately 57 grams (2 ounces) Can be locally made with flour, food colouring, salt, and water or by mixing red and white Playdoh together purchased at a cost of $1.58 USD if available (each 57 gram container costs $0.79 USD)[29] $3.07 USD
White Clay Small amount Can be locally made with flour, food colouring, salt, and water or can use locally purchased Playdoh if available (see above) Covered above
Red Clay Very small amount Can be locally made with flour, food colouring, salt, and water or can use locally purchased Playdoh if available (see above) Covered above
Jhpiego Flashcards 1 set Can be printed on a color printer in place of use Can be printed on a color printer in place of use
Cost of Thermocoagulator Simulator Materials Locally Purchased in Nigeria and Uganda
Item Quantity Cost in USD in Nigeria Cost in USD in Uganda
Corrugated Cardboard 6 pieces Readily available in place of use or locally available as a free recycled item Readily available in place of use or locally available as a free recycled item
Scissors 1 Readily available in place of use Readily available in place of use
Pencil 1 Readily available in place of use Readily available in place of use
Ruler 1 Readily available in place of use Readily available in place of use
Elastic Bands 2 Readily available in place of use Readily available in place of use
Toothpicks 2 Readily available in place of use Readily available in place of use
Aluminum Foil 2 pieces with dimensions of 7.0 cm by 30.0 cm and 2 pieces with dimensions of 9.0 cm by 30.0 cm Readily available in place of use Readily available in place of use
Tape Multiple strips Readily available in place of use Readily available in place of use
Android Mobile Phone with Thermocoagulator Simulator Mobile App 1 Readily available in place of use Readily available in place of use
Optionalː Wire Stripper 1 Not used Not used
Buzzer 1 $11.28 USD Not used
Alligator Clips 4 $19.20 USD (each alligator clip costs $4.80 USD in Nigeria) $4.19 USD
Battery 1 $12.72 USD Covered above
Non-Insulated, Small Gauge Wire Short length (~8.0 cm or less) $3.84 USD Covered above
Optional: Light Bulb Lamp 1 Not used Covered above

No tools, specialized equipment, or technical expertise is required to construct, operate and maintain the two simulators within the intended place of use.

This module offers significant value for money in comparison to existing approaches for cervical cancer screening and treatment simulation training.

  • The Gynecologic Simulator costs $1.58 USD or less to make in Nigeria and $3.07 USD to make in Uganda and is 877 to 1706 times cheaper than the ZOE® Gynecological Skills Trainer.[15]
  • The VIA Positive Cervix Models for the Gynecologic Simulator can be easily replaced with a homemade recipe using flour, food colouring, salt, and water.
  • The fully reusable Thermocoagulator Simulator costs $4.19 USD to make in Uganda and $47.04 USD to make in Nigeria and is 32 to 358 times cheaper than an FDA-approved thermocoagulator.[16]
  • The learner also saves on customs dues, processing fees, and international shipping costs that would be incurred when purchasing the ZOE® Gynecological Skills Trainer and an FDA-approved thermocoagulator which are not locally made.
  • This self-assessed module also permits the learner to save on the costs of course fees, travel, lodging, and missing work.

Accessible Design[edit | edit source]

This self-assessed module does not require access to teachers, training centers and courses.

This Appropedia-based module is available in the 6 official languages of the United Nations, Kiswahili, the lingua franca of the East African Community, and other languages to help ensure that practitioners from anywhere in the world will be able to engage with the content without barriers or gatekeeping.

We published our self-assessment frameworks directly in the Appropedia module (instead of a downloadable pdf) to provide automatic translations of the Training Logbooks in multiple languages to learners around the world.

We provided step-by-step instructions and labelled images (instead of only videos) so the module content can be available in multiple languages and exported for offline access.

We are adding a grid background for graphics with labelled measurements for the simulator build instructions. Because the graphic's labelled measurements will only be available in English, we will include an image caption informing the viewer that each grid square is 1.0 cm by 1.0 cm which will be automatically translated by the Appropedia platform into multiple languages. The graphic's grid background and caption plus text instructions will clarify for the learner what the labelled measurements are to build the simulator.

We are creating line drawings (black lines and white backgrounds) of our digital photos in case colour printers are not locally available and to save on printing ink costs for learners in LMICs.

Our Thermocoagulator Simulator Mobile App that simulates the Liger Medical HTU-110 Thermocoagulator™ user interface, light illumination feature, and sounds heard during thermal ablation is freely available for download in the Google Play Store and does not require the creation of an individual account or a login password to use.

This module does not require the creation of an account, inputting of a username and password, or making a journal or other subscription payment to access the training content.

Follow-on[edit | edit source]

(Optional) After completion and practice to competency, the learner may wish to continue study with these STARS courses:

  • STARS - Intrauterine Device (IUD) Insertion (in progress) for the estimated 218 million women in LMICs who want to prevent pregnancy but lack access to effective birth control and/or comprehensive family planning and sexuality education[30]
  • STARS - Postpartum Hemorrhage for the estimated 14 million women who suffer from postpartum hemorrhage globally each year (coming soon!)[31]
  • STARS - Obstetric Fistula Repair for the over 2 million women who suffer from the debilitating symptoms and social isolation from obstetric fistulas worldwide (coming soon!)[32]

References[edit | edit source]

Sections of the STARS - Cervical Cancer Screening and Treatment module are copied or adapted from: Training of health staff in VIA, HPV detection test and cryotherapy - Facilitators' guide. New Delhi: World Health Organization, Regional Office for South-East Asia; 2017. Licence: CC BY-NC-SA 3.0 IGO; Training of health staff in VIA, HPV detection test and cryotherapy - Trainees' handbook. New Delhi: World Health Organization, Regional Office for South-East Asia; 2017; and WHO guidelines for the use of thermal ablation for cervical pre-cancer lesions. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. The World Health Organization (WHO) is not responsible for the content or accuracy of any translation. The original English edition shall be the binding and authentic edition.

Page data
Part of STARS - Cervical Cancer Screening and Treatment
Type Medical course
Keywords cervical cancer, screening, treatment, human papillomavirus testing, visual inspection with acetic acid, thermal ablation, cervical pre-cancer lesions, medical courses
SDG Sustainable Development Goals SDG03 Good health and well-being
Authors Medical Makers
Published 2021
License [ CC BY-NC-SA 3.0]
Affiliations Medical Makers
Impact Number of views to this page and its redirects. Updated once a month. Views by admins and bots are not counted. Multiple views during the same session are counted as one. 1,599
  1. 1.0 1.1 WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, second edition. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. The World Health Organization (WHO) is not responsible for the content or accuracy of any translation. The original English edition shall be the binding and authentic edition.
  2. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021:71:209–49. doi:10.3322/caac.21660.
  3. 3.0 3.1 3.2 WHO guidelines for the use of thermal ablation for cervical pre-cancer lesions. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. The World Health Organization (WHO) is not responsible for the content or accuracy of any translation. The original English edition shall be the binding and authentic edition.
  4. Global strategy to accelerate the elimination of cervical cancer as a public health problem. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/9789240014107).
  5. Stelzle D, Tanaka LF, Lee KK, Ibrahim Khalil A, Baussano I, Shah ASV, McAllister DA, Gottlieb SL, Klug SJ, Winkler AS, Bray F, Baggaley R, Clifford GM, Broutet N, Dalal S. Estimates of the global burden of cervical cancer associated with HIV. Lancet Glob Health. 2021 Feb;9(2):e161-e169. doi: 10.1016/S2214-109X(20)30459-9. Epub 2020 Nov 16. Erratum in: Lancet Glob Health. 2021 Feb;9(2):e119. PMID: 33212031; PMCID: PMC7815633.
  6. 6.0 6.1 Dryden-Peterson S, Bvochora-Nsingo M, Suneja G, Efstathiou JA, Grover S, Chiyapo S, Ramogola-Masire D, Kebabonye-Pusoentsi M, Clayman R, Mapes AC, Tapela N, Asmelash A, Medhin H, Viswanathan AN, Russell AH, Lin LL, Kayembe MKA, Mmalane M, Randall TC, Chabner B, Lockman S. HIV Infection and Survival Among Women With Cervical Cancer. J Clin Oncol. 2016 Nov 1;34(31):3749-3757. doi: 10.1200/JCO.2016.67.9613. PMID: 27573661; PMCID: PMC5477924.
  7. Nega AD, Woldetsadik MA, Gelagay AA. Low uptake of cervical cancer screening among HIV positive women in Gondar University referral hospital, Northwest Ethiopia: cross-sectional study design. BMC Womens Health. 2018 Jun 7;18(1):87. doi: 10.1186/s12905-018-0579-z. PMID: 29879969; PMCID: PMC5992703.
  8. Ghebre RG, Grover S, Xu MJ, Chuang LT, Simonds H. Cervical cancer control in HIV-infected women: Past, present and future. Gynecol Oncol Rep. 2017 Jul 21;21:101-108. doi: 10.1016/j.gore.2017.07.009. PMID: 28819634; PMCID: PMC5548335.
  9. https://gco.iarc.fr/today/data/factsheets/populations/800-uganda-fact-sheets.pdf
  10. Black E, Hyslop F, Richmond R. Barriers and facilitators to uptake of cervical cancer screening among women in Uganda: a systematic review. BMC Womens Health. 2019;19(1):108.
  11. Nakisige C, Schwartz M, Ndira AO. Cervical cancer screening and treatment in Uganda. Gynecol Oncol Rep. 2017 Feb 3;20:37–40.
  12. ICO/IARC: Uganda. Human Papillomavirus and Related Cancers, Fact Sheet 2018 (2019-06-17): ICO/IARC Information Centre on HPV and Cancer. 2019. https://hpvcentre.net/statistics/reports/UGA_FS.pdf. Accessed 16 Aug 2020.
  13. 13.0 13.1 Debas, H. T., P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock, editors. 2015. Essential Surgery. Disease Control Priorities, third edition, volume 1. Washington, DC: World Bank. doi:10.1596/978-1-4648 -0346-8. License: Creative Commons Attribution CC BY 3.0 IGO
  14. 14.0 14.1 14.2 Training of health staff in VIA, HPV detection test and cryotherapy - Facilitators' guide. New Delhi: World Health Organization, Regional Office for South-East Asia; 2017. Licence: CC BY-NC-SA 3.0 IGO. The World Health Organization (WHO) is not responsible for the content or accuracy of any translation. The original English edition shall be the binding and authentic edition.
  15. 15.0 15.1 Gaumard Scientific. Zoe® S504.200 - Gynecological Skills Trainer [Internet]. Gaumard Scientific. Gaumard Scientific; 2021 [cited 2021 Nov 28]. Available from: https://www.gaumard.com/s504-200.
  16. 16.0 16.1 Liger Medical. Thermocoagulator kits: Caring for life, giving hope [Internet]. Liger Medical. Liger Medical; 2021 [cited 2021 Nov 28]. Available from: http://www.ligermedical.com/thermocoagulator-kits/.
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