University of Gondar

College of Medicine and Health Science

Institute of Public Health
Department of Health System and Policy
MPH in monitoring & Evaluation Proposal Defense

By: Ketemaw Tsegaye (BSc)

March, 2021
Evaluation of visual inspection with acetic acid cervical cancer
screening program implementation at Gondar town
administration health centers, Northwest Ethiopia, 2021.
 Background


Estimated 570,000 new cases diagnosed, and 311,000 women die in 2018 (1,2).


Approximately 90% of the cases occurring in low-and middle-income resource setting

countries (1,2).


Sub-Saharan region, the highest disease burden, the second most common cancer &

leading cause of cancer-related death in women(1, 3).


Ethiopia, one of developing countries, the cervical cancer burden is high, an estimated

7095 new cases & 4732 women die from the disease annually(4).
 con…

Possibilities of cervical cancer prevention, like cervical screening,

which is testing of all women at risk of cervical cancer.

In developed nations, well-organized cervical screening program

contribute to significant reduction of incidence & mortality rates (6,7).

Scaling up cervical screening in LMICs, even to achieve coverage of

majority of women once or twice lifetime, historically very
challenging (5).
 Statement of the problem

Cervical cancer affects the cells of the lower part of uterine cervix. It is a major
public health threat to women’s health and lives (9)

Globally, for every two minutes one woman dies of cervical cancer (9).

Disproportionately high burden of cervical cancer incidence and mortality in

LMICs settings that lack organized screening and prevention programs (9).

Majority of cervical cancer (>80) are detected at advanced stage, which is

associated with low survival rates (11).
Con…

A study in 2015 on cervical screening concludes literature in LMIC focuses mainly
on prevention and detection, largely without implementation considerations (13).

In spite of three screening modalities are available for the program, there remains
low cervical screening coverage worldwide, Gakidou et al. reports a coverage rate
of 36.9% globally and only 18.5% in the least developed countries (12)

Therefore, evaluating the program performance of availability and compliance and
the participants satisfaction is important to improve the program go ahead.
 Significance of the evaluation

Many researchers and policy makers are now calling for process evaluation to provide a better

understanding of an intervention.


There is no a comprehensive evaluation for cervical screening implementation in Ethiopia, thus the

finding is expected to contribute in decision making.


An integrated set of intervention operates with appropriate allocation of available resources through

implementation of evidence-based intervention, can be used as a source (reference).


Closely monitored and evaluated program performance basis for next step toward improving

cervical cancer prevention programs.

 Program description
Stakeholders of the program


The stakeholders identified were involved in direct program operation and implementation, served or

affected by program, primary users and those who have an interest in the program.


These are Amhara regional health bureau, Central Gondar Zone health department, Gondar town

administration, service users, healthcare providers, religious leader and media (Fana FM) .


The stakeholders provided information on program performances during the evaluability assessment,

and they identified and prioritized the area of the program that will be addressed during the evaluation.
 Goal and objectives of the program

Goal: to prevent and control of cervical cancer in Ethiopia.

Objectives:

To reach 50% of the population with cervical cancer prevention

awareness information by 2020.

To achieve 80% coverage of VIA to detect precancerous cervical

lesions among non-symptomatic women aged 30-49.
 Logical framework
 Program development

Cervical cancer official recognition is as early as 1886. Since then

much research done to decrease cervical cancer incidence.

Pap smear was developed 1930s, contributes to significant reduction

of the incidence and mortality rates in some developed countries.

Challenges of implementing high quality cytology-based services,

especially in developing countries.
Con…
Harald Zur Hausen discovered HPV in the 1970s, concluded that infected with types 16 & 18 were
increased risk of developing cervical cancer.

Visual inspection with acetic acid technique was endorsed by WHO in 2010.

Many aspects of VIA make it a promising approach for use in low-resource settings.

FMOH decided in 2013 to begin developing the implementation of National Cervical Cancer
Prevention and Control program.

Currently, Ethiopia uses visual inspection with acetic acid as the cervical cancer screening method
 Conceptual framework
Evaluation questions

Is the program being implemented as intended? If yes, how and if no, why?

Specific evaluation questions


Are the required resources available to provide cervical cancer screening services? If yes, how and

if no, why?

Is the program implemented according to the national cervical cancer screening guidelines? If yes,

how and if no, why?


What are the factors that affect the satisfaction of mothers with cervical cancer screening services?
 Objectives of evaluation
General objectives
To evaluate visual inspection with acetic acid program’s implementation in
Gondar town administration health centers, Northwest, Ethiopia, 2021.

Specific objectives

To assess the availability of resources required to provide visual inspection with
acetic acid services.
To describe healthcare workers’ compliance to the national guideline.

To determine the level of target groups satisfaction/acceptability.

 Evaluation methods and materials

Evaluation area and period

The study will be conducted at Gondar town administration health centers.

Gondar city is found in the Amhara Regional State of Ethiopia in Central Gondar
Zone, 727 km from Addis Ababa, the capital of Ethiopia.

To evaluate the program worth, evaluability assessment was conducted from
January 05-15, 2021.

 The evaluation will be conducted from Mar 17– Apr 17, 2021.
 Evaluation design, approach and focus
A multiple case study with mixed method will be conducted among targeted
women, to describe the process and examine factors that influenced the
implementation process.

Qualitative and quantitative data were collected separately, analyzed separately,

and integrated during the interpretation of findings.

A process evaluation approach will be used, as the program is on the operation

of existing program.
Con…

The focus of evaluation is for understanding and describing a program’s process

theory.

These are the types and quantities of services delivered, target beneficiaries,
resources used to deliver the services, the practical problems encountered and the
ways such problems were resolved.
 Evaluation dimensions

Availability: measures the extent to which the provider has the requisite resources,
such as personnel, supply and technology, to meet the needs of the client.

Compliance: evaluation will be assessed the compliance of HCWs providing VIA

services in line with the national guideline.

Acceptability/satisfaction: reflects the extent to which people receiving

intervention consider it appropriate.
 Sample indicators

Availability indicators


The proportion of HCPs trained in Visual Inspection with Acetic acid (VIA).


The proportion of resource availability, yes to the total resource.


The distribution of health workers, who work on VIA by sex.


The proportion of health facilities having at least one national guideline.
Con…

Compliance indicators


Proportion of HCPs great and welcome participants


Proportion of clients who get pre-test counselling for procedure.


Proportion of clients get routine (pelvic) physical examination


Proportion of VIA+ clients who get tested for HIV


The proportion of positive women who are linked to diagnosis and treatment
Con…

Satisfaction indicators


Percentage of clients saying waiting times were acceptable.


Proportion of women who were satisfied with counseling services they received.


Proportion of women who perceive visiting time to receive service is good


Proportion of women who perceive service healthcare providers are competent


Proportion of women who perceive the waiting area of clinic are clean & appropriate.
 Population and sampling

Source populations: all women age 30-49 live in Gondar town, all healthcare

workers, and all documents of screening service at Gondar town

administration health facility.

Study population: all VIA screening receiver clients, all healthcare workers

providing cervical cancer screening service, and all cervical cancer screening

documents at Gondar town administration health center.

Con…

Study unit: selected VIA screening receiver clients during the data collection
period, selected cervical cancer screening documents, and selected healthcare
workers available during data collection period.

Sampling unit: VIA screening receiver clients, healthcare workers and participant
documents.

Primary unit of analysis: VIA screening service receiver individual, HCPs, and
document.

Secondary unit of analysis: health centers

 Sample size determination
•Quantitative:
  client exit interview for satisfaction. P=76.4% (non-published screen & treat
acceptability study in AA.), CL=95%, MOE=5%, *0.76(1-0.76)/ =281

Assume 10% non-response rate, final sample size = 310

Qualitative:

Document review: a minimum of 30 registries will be reviewed, based on saturation.

Key informant interview: a total of 17 key informant interviews will be included.

Observation: a total of 30 observations will be taken to assess provider client interaction and
service implementation.
 Sampling procedure
Quantitative: since <9 HCs, will include all HCs. Estimate sample size based on allocation proportion formula,

by using the last two quarterly report of HCs. Then consecutive sampling technique will be used.

Qualitative:


Key informant interview: purposive sampling procedure will be employed in order to answer “how and why”.


Observation: will be done every third day by using systematic random sampling. HCPs & client interaction

observation will be done for two cases per day by selecting charts with simple random sampling.


Document review: total number of registries will be counted, then use serial number for simple random

sampling.
 Data collection tool and procedure
For quantitative:

Structured interview questionaries will be used to study participant satisfaction.

Checklist will be used for observation and compliance assessment.

For qualitative:

Semi-structured questionaries for HCPs, observation and document review will be

used.
 Matrix of analysis and judgment


The analysis and judgment matrix were developed and agreed with HCP stakeholders


The weight of dimensions and the respective indicators were given depending on their

level of relevance to the program.


The weight given to each indicator sum up the value of dimensions.


Sum of all dimensions was attributed to the service’s implementation status. So that by

convention, we give availability 30%, compliance 35%, and satisfaction 35%.

 Ethical issues

The University of Gondar college of medicine and health science ethical clearance committee will

approve the ethical clearance.


The principle of ethics i.e., autonomy, beneficence, non-maleficence & justice will be respected.


Respondent’s name & specific identification will not mention maintaining confidentiality &

privacy.


Informed verbal and written consent will be obtained from the study subjects, following a clear

understanding of the study.

 Evaluation dissemination plan

First the evaluation finding will be communicated with program stakeholders.

Then after will be presented to UOG, college of medicine and health science.

After presentation the hard and soft copy of the finding will be provided to
stakeholders timely.
 Meta evaluation
The joint committee standards comprised a set of 30 evaluation standards under four core standards.

Utility standards: ensure that information needs of evaluation users are satisfied. 7 sub-standards.

Feasibility standards: ensure that the evaluation is realistic & diplomatic. 3 sub-standards.

Propriety standards: ensures evaluation will be conducted legally & ethically. 8 sub-standards.

Accuracy standards: ensure that the evaluation produces findings that are considered correct.
Twelve accuracy sub-standards

The steps and standards are used together throughout the evaluation process.
 Work plan
•.
 Budget
 Reference
1. Arbyn M, Weiderpass E, Bruni L, de Sanjosé S, Saraiya M, Ferlay J, et al. Estimates of

incidence and mortality of cervical cancer in 2018: a worldwide analysis. The Lancet Global

Health. 2020;8(2):e191-e203.

2. Ginsburg O, Bray F, Coleman MP, Vanderpuye V, Eniu A, Kotha SR, et al. The global burden

of women’s cancers: a grand challenge in global health. The Lancet. 2017;389(10071):847-60.

3. Jedy-Agba E, Joko WY, Liu B, Buziba NG, Borok M, Korir A, et al. Trends in cervical

cancer incidence in sub-Saharan Africa. British journal of cancer. 2020;123(1):148-54.

Con…

4. Heyi WD, Bekabil TT, Ebo GG. knowledge, attitude and practice of cervical cancer
screening among women aged 15-49 years in Bishoftu town, East Shewa zone,
Oromia region, Ethiopia, 2016. Ethiopian Journal of Reproductive Health.
2018;10(2):10-.

5. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer
statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36
cancers in 185 countries. CA: a cancer journal for clinicians. 2018;68(6):394-424.
 Acknowledgment
•I am great full for the University of Gondar Institute of Public Health Department
of Health System and Policy for giving me this chance to do this study.

•I would like to give my deepest gratitude to my advisers for their unreserved

comment and support throughout the proposal work starting from the concept note
to the final proposal.
 THANK
YOU