International Journal of Gynecology and Obstetrics (2005) 89, S46 S54

www.elsevier.com/locate/ijgo

ARTICLE

Advocating for cervical cancer prevention

J. Sherrisa,T, I. Agurtob, S. Arrossic, I. Dzubad, L. Gaffikine, C. Herdmana,
K. Limpaphayomf, S. Luciani b
a

PATH, 1455 NW Leary Way, Seattle, WA 98107, USA

PAHO (Pan American Health Organization), Washington, DC, USA
c
International Agency for Research on Cancer (IARC), Lyon, France
d
EngenderHealth, New York, NY, USA
e
JHPIEGO, Baltimore, MD, USA
f
Department of Obstetrics/Gynaecology, Faculty of Medicine, Chulalongkhorn University,
Bangkok, Thailand
b

KEYWORDS
Cervical cancer;
Prevention;
Advocacy;
Policy;
Publications;
Stakeholders

Abstract Cervical cancer is a significant health problem among women in developing

countries. Contributing to the cervical cancer health burden in many countries is a lack
of understanding and political will to address the problem. Broad-based advocacy
efforts that draw on research and program findings from developing-country settings
are key to gaining program and policy support, as are cost-effectiveness analyses based
on these findings. The Alliance for Cervical Cancer Prevention (ACCP) has undertaken
advocacy efforts at the international, regional, national, and local levels to raise
awareness and understanding of the problem (and workable solutions), galvanize
funders and governments to take action, and engage local stakeholders in ensuring
program success. ACCP experience demonstrates the role that evidence-based
advocacy efforts play in the ultimate success of cervical cancer prevention programs,
particularly when new screening and treatment approachesand, ultimately, radically
new approaches such as a human papillomavirus vaccineare available.
D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier
Ireland Ltd. All rights reserved.

1. Introduction
Cervical cancer represents a unique public health
need and opportunity. With a death toll of approxT Corresponding author. Tel.: +1 206 285 3500; fax: +1 206 285
6619.
E-mail address: [email protected] (J. Sherris).

imately 237,500 women each year, cervical cancer is

the primary cause of cancer deaths among women in
many developing countries [1]. According to recent
data, approximately 85% of the new cases of
cervical cancer (estimated at 493,000 worldwide)
and deaths from cervical cancer that occur each
year affect women in developing countries [2]. Yet,
unlike most other cancers, cervical cancer is readily

0020-7292/$ - see front matter D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.
All rights reserved.
doi:10.1016/j.ijgo.2005.01.010

Advocating for cervical cancer prevention

preventable when effective programs are implemented to detect and treat its precursor lesions.
A key barrier to the implementation of effective
cervical cancer prevention activities is the lack of
understanding and political will to address the
problem. The burden of disease from cervical
cancer is under-appreciated in many countries,
and there is a poor understanding of the principles
of effective prevention, as well as of the growing
evidence base from developing countries that
supports new approaches to cervical cancer screening and treatment. Changing this situation requires
broad-based advocacy to gain program and policy
support for effective cervical cancer prevention
interventions. Advocacy efforts are important at
the international, regional, national, and local
levels. International agencies must be convinced
to focus on cervical cancer prevention as a key
component of improving womens health worldwide; regional efforts must galvanize governments
to action and provide appropriate assistance to
national efforts; national policymakers must understand the principles of cervical cancer prevention
and build or improve national programs, policies,
and guidelines; and local stakeholders must ensure
that women, providers, and decision-makers
understand programs and that services meet individuals and communities needs.

2. Reaching out globally

A number of global health priorities compete for
the attention of the handful of organizations that
are best positioned to have worldwide impact on
public health programs and policies. Organizations
such as the World Health Organization (WHO), the
United Nations Population Fund, the U.S. Agency
for International Development, and the World Bank
can strongly influence the breadth and depth with
which a particular health issue or group of issues is
globally addressed. All of these organizations
recognize womens right to the highest attainable
standard of health, as articulated by the International Covenant on Economic, Social, and Cultural
Rights, and that the right to health includes four
interrelated featuresthe availability, accessibility, acceptability, and quality of health services [3].
The sharp inequity in cervical cancer deaths among
and within countries clearly is at odds with
womens right to health and international agencies
are increasingly exploring ways to increase womens access to appropriate and effective prevention
services.
Considerable research conducted in recent years
makes it possible to present a clear case that

S47
supporting the prioritization of cervical cancer
prevention as a global health issue can save womens
lives. Studies of screening methods that are simpler
alternatives to cytologic screening suggest that
these methods can greatly improve womens access
to effective services, even in the poorest regions of
the world [410]. Advances in the understanding of
the safety, effectiveness, and acceptability of
simple outpatient procedures to treat precancerous
lesions indicate that the approach is appropriate in
even the most remote settings [11]. Cost-effectiveness analyses of screening methods that are alternatives to cytology suggest that offering screening
to women in resource-poor areas can be a feasible
and appropriate public health intervention strategy
(see Box on cost modeling below) [12,13] and that
even a once-in-a-lifetime screening offered to
women between the ages of 35 and 40 years can
reduce lifetime risk of cervical cancer by 2536%
Table 1 [14]. Forming strategic global partnerships
and communicating these types of findings to key
international health organizationsand to the growing number of large private donors engaged in global
healthis essential to the success of global advocacy
efforts.
The Alliance for Cervical Cancer Prevention
(ACCP) took a two-stage approach to ensuring that
global health organizations obtain the best and
most timely information to help inform their
prioritization of health issues. During the initial
phase of ACCP work, as research projects were
being designed and initiated, it was clear that
general understanding of cervical cancer prevention issues was low and that there was a great need
for materials that synthesized what was known to
date about cervical cancer and prevention
approaches. Interviews conducted early in the
project indicated that key leaders and decisionmakers in several countries desired brief, nontechnical synopses of issues based on the most
current research findings [15]. The ACCP responded
to this need by developing an array of resources,
including fact sheets, program-planning materials,
and presentation materials designed to provide
accessible, up-to-date information about effective
prevention strategies. (All materials are available
at www.alliance-cxca.org).
As ACCP research projects were implemented,
study findings became available and the ACCP
moved to the second stage of disseminating information to influential global health organizations:
providing the cutting-edge findings on alternative
prevention methods for low-resource settings. In
addition to publishing findings in refereed journals
[49,16] and making presentations at regional and
international meetings, new ACCP publications,

S48

J. Sherris et al.

Box 1
Supporting advocacy efforts with cost-modeling
A new generation of models that addresses new approaches to cervical cancer prevention and the
impact of once-in-a-lifetime interventions has advanced knowledge about the likely cost-effectiveness
of cervical cancer prevention programs in developing countries. The models incorporate epidemiological patterns from developing-country populations, where cancer incidence and mortality remain
high and where women have not benefited from organized screening programs. They also incorporate
the effects of HIV and AIDS on program impact.
Recent modeling findings suggesting that new approaches to screening and treatment for
precancerous lesion can be cost-effective alternatives to reaching women and preventing deaths in
developing countries can be very powerful. For example, Goldie et al. [12] estimated the clinical
benefits and cost-effectiveness of cytology, visual inspection with acetic acid (VIA), and human
papillomavirus (HPV) DNA testing in South Africa. The model suggested that, for South African women,
a single lifetime screening with VIA (one clinic visit) or HPV testing (two clinic visits), combined with
immediate treatment for test-positive women, would reduce the incidence of cervical cancer by 26
32% and cost less than US$50 per year of life saved (Table 1). Other model-based analyses have
produced similar rankings of cost-effectiveness for different approaches [13].
A later analysis by Goldie and ACCP researchers [14] that drew on data from Kenya, Peru, Thailand,
South Africa, and India confirmed this finding, estimating that programs based on a single lifetime
screening with VIA or HPV testing (and follow up with cryotherapy for eligible women with positive
results) and targeting women between 35 and 40 years of age would reduce the lifetime risk of cervical
cancer between 25% and 35%. Although costs varied among countries, the study found that a singlelifetime screening strategy in each would be bvery cost-effectiveQthat is the cost per year of life
saved would be less than the per capita gross domestic product in each country. Cost-effectiveness was
most influenced by strategy-specific loss-to-follow-up rates, age at screening, and the direct medical
and programmatic costs associated with each screening approach. HIV prevalence had a negligible
impact on cost-effectiveness of various single lifetime screening approaches in this analysis.
Descriptions of the results of these modeling exercises are a valuable advocacy tool at the
international, regional, and national levels. Many policymakers view cervical cancer as an
extraordinarily difficult and expensive health challenge and focus instead on health problems that
seem more urgent or easily addressed. Modeling that demonstrates the cost-effectiveness and impact
of new approaches can help to overcome these biases.

such as a series of issue papers, were developed

to communicate new research and program findings and a website was created to make ACCP
Table 1 Cost-effectiveness of once-in-a-lifetime (at
age 35 years) screening strategies
Screening strategies

Reduction in
cervical cancer
incidence, %

Cost-effectiveness
ratio ($/year of
life saved)

VIA and treatment

(single visit)
HPV testing and
treatment
(single visit)
Two-visit cytology
Three-visit cytology

26

Cost saving

32

14

19
17

81
147

Note: HPV, human papillomavirus; VIA, visual inspection with

acetic acid. Based on mathematical models using data from
South Africa (Goldie et al. [12]).

progress, findings, materials, and tools accessible

to a broad audience. To ensure that ACCP
publications are meeting the needs of audiences
and being used as intended, they have been
evaluated through two reader surveys reaching
individuals in 44 countries and through keyinformant interviews in Kenya, Peru, El Salvador,
and India. The majority of the more than 100
survey and interview participantsmostly health
care providers and researchersreported that the
ACCP publications are very relevant to their work
and provided them with new information about
cervical cancer prevention.
Forming strategic partnerships with influential
organizations also has helped the ACCP advocate
effectively for increased recognition of cervical
cancer as a global health problem. For example,
collaboration between WHO, with its broad reach
and global credibility, and the ACCP, with its

Advocating for cervical cancer prevention

several large research and demonstration projects
and its strong organizational partners, leverages
the strengths of both groups. Gaining the formal
approval of WHO, the International Network for
Cancer Treatment and Research, and other organizations on ACCP documents, such as a manual for
managers [17], gives these documents greater
weight and legitimacy in the eyes of policymakers
in many countries. Likewise, ACCP is providing
input and assistance to WHO in developing practice guidelines for cervical cancer prevention.
Coauthoring vital documents, coordinating participation in global and regional meetings, and
working together to establish a broad strategy
for addressing cervical cancer have been the
hallmarks of the ACCPs partnerships with global
health organizations.

3. Reaching out regionally

Another important strategy for raising awareness
about cervical cancer prevention is through
regional advocacyworking with groups of countries that share geographic, economic, and cultural
features. Regions, however, can have high internal
diversity. Therefore, the choice of a regional
perspective for advocacy has to be flexible enough
to consider subregions or particular groups of
countries that are closely identified with each
other.
Regional advocacy efforts need to engage a
range of stakeholders who can influence decisionmaking in cervical cancer prevention. Ministries of
health and nongovernmental organizations (NGOs)
are key, as are international organizations that
provide guidance on or funding for health issues.
For example, a November 2000 regional meeting
organized by the Royal Thai College of Obstetrics &
Gynaecology and Thai Gynaecologic Oncology Society brought representatives from 20 countries
together for a symposium on cervical cancer
problems in Southeast Asia. The symposium focused
on the epidemiological, medical, and public health
aspects of cervical cancer management. Meeting
participants concluded that cervical cancer is a
major public health problem in the region and that
appropriate use of single-visit approaches (visual
inspection with acetic acid [VIA] followed immediately by cryotherapy was the primary approach
discussed) would be acceptable and feasible in
most countries of the region. The symposium also
enhanced cooperation among gynecologic oncologists in the Southeast Asia region, who play an
important role in launching effective cervical
cancer prevention services in their countries.

S49
Another regional initiative was a March 2004 meeting sponsored by the Open Society Institute in
Albania, which brought together representatives
from 12 countries in eastern and central Europe and
the Newly Independent States. Meeting participants had implemented cervical cancer prevention
activities through an ACCP small grants program
and (with a ministry of health counterpart from
their countries) shared their experiences and
developed technical and policy recommendations
related to cervical cancer prevention for the
region.
The information needs of regional audiences
vary according to their role in decision-making.
Key stakeholders might need direct, updated
technical information to help in developing a
proposal or allotting funds for a cervical cancer
prevention program, but they also may need
human-interest stories to advocate at the political
level. Information packages that are tailored for
specific audiences and that contain a range of
different materials, such as technical dossiers, fact
sheets, womens stories, presentations, and short
videos, meet a wide range of needs.

3.1. Latin American and Caribbean region

In the Latin American and Caribbean region, four
subregions are defined by sociopolitical bodies: the
Caribbean, Central American, Andean, and Southern Cone subregions. The Pan American Health
Organization (PAHO)a member of ACCPcarried
out advocacy efforts in these subregions by holding
workshops with representatives from ministries of
health, NGOs, medical and professional associations, and universities. The workshops were implemented in collaboration with the International
Union Against Cancer and the PAHO/WHO countrybased representation offices.
The subregional workshops helped build alliances between countries and stakeholders and
provide a forum for the exchange of technical
information among countries that have been implementing cytology-based screening programs for
several years. This subregional process aided advocacy efforts by:
! encouraging Latin American and Caribbean countries to give priority and allocate resources to
cervical cancer prevention programs;
! providing information about the technical and
managerial aspects of successful cervical cancer
prevention programs;
! creating new working relationships and partnerships across disciplines within countries and
between neighboring countries; and

S50
! stimulating countries to undertake critical needs
assessments and strategic planning processes to
improve their current programs.
Subsequent to the subregional workshops, more
than 10 countries in the region have critically
assessed their programs with assistance from
PAHO/WHO, devised strategic program plans, and
received seed funding to implement new strategies
for cervical cancer prevention. Through meetings
with ministers of health, joint planning and technical cooperation agendas have been established;
for instance, a meeting of the Caribbean Caucus of
Ministers of Health resulted in development of a
strategic plan for a subregional approach for
screening and treatment, which currently is being
implemented.

4. Reaching out nationally

At the national level, clear support from health
leaders, combined with supportive policy decisions,
appropriate regulations for medical services, and
bbuy-inQ from the medical and educational infrastructure, greatly affects the success of cervical
cancer prevention programs. The ACCP has worked
in more than 20 countries worldwide, with efforts
to strengthen (or initiate) cervical cancer prevention programs, often beginning with research or
demonstration projects. The success of these
programs often has hinged on engaging decisionmakers and stakeholders early and repeatedly to
ensure that supportive policies and regulations are
developed to support program expansion and that
protocols reflect the health realities and policy
environment into which findings will be translated.
By working with national bodies to explore how
cervical cancer prevention services can be integrated with existing services wherever possible,
the ACCP has avoided the creation of vertical
programs that are difficult to sustain without
significant external funding. Examples from Thailand and India illustrate the role and importance of
advocacy at the national level as part of larger
efforts to strengthen cervical cancer prevention
programs.

4.1. Thailand
Although a Pap smear-based cervical cancer prevention program has been in place for 40 years,
annual screening coverage in Thailand remains low.
One estimate suggests that fewer than 10% of
eligible women have been screened [18]. Reasons
for low coverage include insufficient numbers of

J. Sherris et al.
cytotechnicians and pathologists to process smears
and address follow-up needs. This personnel shortage can result in long waits for results, loss to
follow-up of women in need of treatment, inconsistent quality control, and reduced screening
accuracy. Low rates of treatment coverage and
screening test inaccuracy limit the potential for
measurable reduction in morbidity and mortality.
In 2000, a team of Thai professionals joined with
JHPIEGO, a partner in the ACCP, to test a singlevisit prevention approach in one rural province as
an alternative to the traditional multiple-step
strategy. This approach linked testing with the
offer of immediate treatment of suspect precancerous lesions or referral by trained nurses, using
VIA as the test and cryotherapy as the treatment
option [5].
To effectively implement the demonstration
project, policies and regulations had to be
addressed and modified so that trained nurses
could treat eligible women with cryotherapy. It
also was necessary to gain permission to treat VIA
test-positive women without further confirmatory
testing by physicians. The long-term policy objective was the inclusion of a VIA-based single-visit
approach as an option to achieve coverage targets
and morbidity and mortality reduction goals.
To achieve these advocacy objectives, a local
technical advisory board was formed, periodic
small group meetings with stakeholders from the
Ministry of Public Health and medical professional
organizations were held, and project results were
presented at national, regional, and international
meetings. All served to inform attendees of project
progress, update people about the latest evidence
(local or international), share lessons learned, and
obtain feedback about the types of evidence most
helpful in guiding policy and practice decisions.
Additionally, publication of findings in journals
respected by the medical community and media
exposure served to raise the profile of the project
and to provide a forum for public reaction to
project objectives and findings. Finally, in-country
project team members served as champions of the
alternative approach in a variety of settings.
These national advocacy efforts have helped to
garner support and guide policy decisions that have
a significant effect on program impact. Health
program decision-making and financial control is
decentralized in Thailand and the Permanent
Secretary of the Ministry of Public Health has
announced that provinces can now choose whether
to use the traditional cytology-based multiple-visit
approach or the VIA-based single-visit approach to
meet screening coverage targets. In March 2004,
the Permanent Secretary convened all of the

Advocating for cervical cancer prevention

countrys provincial health officers in Nong Khai
Province to showcase its single-visit approachbased cervical cancer prevention program. This
attracted national press coverage and generated
broader interest in use of this approach as an
alternative to cytology-based programs in areas
where the latter are not functioning effectively.
The ACCPs cervical cancer screening work is
gradually making its mark on health care information and services in Thailand. The Nursing Council
in Thailand has announced that it will include VIA
testing and cryotherapy treatment skills in the
preservice curriculum for nurses and, similarly, in
January 2004, a single-visit approach was incorporated into the residency training program of the
Department of Obstetrics and Gynecology at Chulalongkorn University. Cervical cancer prevention
activities, including VIA and Pap smear testing,
have also been included as part of the prevention
and promotion budget of the governments new 30baht per person health plan. In Roi Et Province,
where the project piloted the alternative
approach, the provision of VIA testing is now
integrated into routine health center-level performance assessments. To date, nine other provinces also have elected to use a VIA-based singlevisit approach to achieve cervical cancer screening
coverage targets.

4.2. India
Although the National Cancer Control Program in
India was initiated in the mid-1970s, no organized
screening programs for cervical cancer have been
implemented in any Indian states and financial
allocations for cancer control activities have been
very limited [19]. National consultations on cervical
cancer control agree that traditional cytologybased screening programs currently are not feasible
in India in light of technical, financial, and personnel constraints [9].
In this context, the International Agency for
Research in Cancer (IARC), a partner in the ACCP,
is working with several Indian agencies to investigate alternative screening and treatment
approaches in different parts of the country. This
effort is supported at many levels, including by a
2001 national workshop on alternative strategies for
control of cervical cancer. The workshop recommended assessment of the inclusion of visual
inspection techniques as part of a cervical cancer
prevention strategy in districts covered by the
Modified District Cancer Control Program, a national
program aimed at providing services for treatment,
prevention, and early detection of cancer in rural
communities [10]. Strategies used to achieve advo-

S51
cacy objectives in these projects included involving
major international and national research institutions in protocol design and review, keeping stakeholders informed about project progress,
disseminating preliminary results to illustrate that
reasonable coverage could be achieved through an
alternative screening project, and integrating cervical cancer prevention with efforts aimed at
preventing/controlling other types of cancer.
The largest of the ACCPs Indian studies is a fourarm cluster-randomized, controlled intervention
evaluating the comparative efficacy and costeffectiveness of once-in-a-lifetime VIA (provided
by nurses), conventional cytology, and HPV testing
in detecting cervical neoplasia and in reducing the
incidence of and mortality from cervical cancer in
Osmanabad District, Maharshtra, India[9]. This
study is a collaborative project involving the Nargis
Dutt Memorial Cancer Hospital in Barshi, the Tata
Memorial Centre in Mumbai, and the IARC.
Partnership with the Tata Memorial Centre
(Indias premier cancer center, which has been
working on cervical cancer prevention activities for
the last 20 years and has implemented the first
rural cancer registry) created a strong collaboration between project staff and Ministry of Health
officials and fostered discussion related to the
replication of the project at a programmatic scale.
Representatives of the Department of Atomic
Energy and the Ministry of Health were invited to
observe progress in the project. Each of these visits
was used to discuss the importance of cervical
cancer prevention, the different approaches to be
used in the Indian context, and the components of
the service-delivery strategy that could be replicated at a program scale. A second randomized,
controlled study in the Dindigul District of Tamil
Nadu that measured the effectiveness of once-in-alifetime VIA-based screening also has helped to
demonstrate to policymakers the acceptability and
feasibility of alternative approaches to cervical
cancer prevention [16].
The combination of these Indian studies and an
inclusive advocacy approach is making a difference. In August 2003, the Tata Memorial Centre was
awarded 44 million rupees (approximately US$1
million) by the Department of Atomic Energy,
Government of India, to implement cancer control
activities in two additional districts of Maharashtra
State (Sindhudurg and Rathapuri) through existing
primary health care centers. The Ministry of Health
will indirectly fund the project by augmenting
infrastructure for cancer screening and treatment
equivalent to 30 million rupees (approximately
US$650,000). Cervical cancer prevention (based
on VIA and visual screening with Lugols iodine)

S52
will make up a major part of the cancer control
project in these two new districts, which will build
on the experience of the Barshi project.

5. Reaching out locally

Local advocacy efforts can encompass a range of
activities, such as lobbying government authorities
and decision-makers for local policy changes,
encouraging delivery of services at local health
facilities, collaborating with womens groups to
promote screening, and conducting outreach to
encourage women to be screened. (For a related
discussion, see Agurto et al. [20] in this supplement). Regardless of the approach, local advocacy
is necessary in making the transition from scientific
investigations to public health practice.
Many elements influence the success of cervical
cancer screening and treatment at the local level.
Women often are uninformed about screening and
its importance and, consequently, there is little
consumer demand or political imperative to initiate
or enhance screening programs. Furthermore, competing health issuesmost notably HIV/AIDS in subSaharan Africahave commanded attention and
resources, not only globally and regionally but also
locally. Governments, private entities, and NGOs
can influence resource allocation and policy decisions that restrict cervical cancer prevention
activities. Involving these groups in project development from the outset to inform the process
enhances the likelihood of sustainability and promotes local ownership. ACCP partners recognize
that to have a significant impact on policy, it is
crucial to actively advocate for the cause in the
communities where ACCP projects are based.
The ACCP experience emphasizes the importance of directing advocacy efforts toward local
audiences that can influence public health. ACCP
projects in Peru and South Africa have reached out
to community health and advisory groups, church
groups, political groups, and existing health services and providers (including traditional healers).
By engaging with community groups, ACCP partners
learned about the barriers preventing women from
undergoing screening and were better equipped to
develop culturally appropriate strategies to overcome those barriers.
For example, collaboration with a range of
stakeholders in the San Martn region of Peru has
helped ensure that health promotion strategies
provide comprehensive, culturally appropriate
information and support to women who are
eligible for cervical cancer prevention services.
Community health promotion teams were key to

J. Sherris et al.
this process and included staff from the local
health center, community leaders, and representatives from the San Martn Ministry of Health.
Promotional activities have been carefully aligned
with service availability to ensure that women
who learn about the services have ready access to
them [21].
Much of local advocacy relates to achieving a
common understanding among stakeholders of the
problem of cervical cancer and how to best address
its prevention. Even when great strides toward
consensus are made, government instability and
staffing and economic changes can result in shifts in
priorities and financial allocation. Continuous
advocacy, even once agreement seems to have
been reached, is essential.

5.1. South Africa

The Khayelitsha Cervical Cancer Screening Project
is a partnership between University of Cape Town,
Columbia University in New York, and EngenderHealth, an ACCP partner. During planning and
implementation of the project, numerous steps
were undertaken to ensure local support for and
commitment to research and service-delivery
activities and to establish and maintain an open
dialogue with a variety of community organizations
and representatives.
Project staff approached and worked with several local health authorities and community-based
organizations to carry the project forward, including the local community health forum, composed of
elected representatives from the state health
sector in Khayelitsha and local politicians elected
by the community; the traditional healer association; community health service organizations (day
hospitals); local NGOs; and the Department of
Health in South Africa. The project proposal was
presented to these parties for feedback, initiating
interaction that continued throughout the project.
Project staff attended periodic meetings to provide
updates on activities and results to date, to report
on any issues that arose, and to receive input from
stakeholders. These actions resulted in greater
transparency, consensus, and collaboration as the
project moved forward.
Annual health festivals exemplified how the
project worked with other health structures, local
authorities, and respected community members
(e.g., church leaders, traditional healers, and
street committee leaders) to generate support
and momentum for improving womens health.
These celebrations of women and womens health
were held in community halls where produce was
sold, entertainment was provided, and important

Advocating for cervical cancer prevention

health messages about HIV, family planning, child
immunization, and cervical cancer prevention were
conveyed.
Other community outreach activities by project
staff that have provided an invaluable link between
the project, the community of Khayelitsha, and the
larger health sector include:
! participation in local and national call-in radio
programs;
! delivery of lectures to nurses and doctors
employed by the state and working in primary
health clinics in Khayelitsha that address a wide
range of womens health topics. Each lecture
incorporated cervical cancer screening to reiterate its importance;
! participation in meetings with local metropolitan
health authorities;
! participation on the task team for the implementation of national cervical cancer guidelines;
and
! meeting with local NGOs working in health
promotion.

6. Conclusions
Cervical cancer is a significant health problem
among women in developing countries. Contributing to the lack of effective cervical cancer
prevention programs in many countries is the lack
of understanding and political will to address the
problem. Broad-based advocacy efforts based on
research and program findings from developingcountry settings, combined with cost-effectiveness
analyses based on these findings, are key to gaining
program and policy support for prevention programs. As this article has described, these efforts
at the international, regional, national, and local
levelscan raise awareness and understanding of
the problem (and workable solutions), galvanize
funders and governments to take action, and
engage local stakeholders in ensuring program
success. Strategic, evidence-based advocacy
efforts will continue to be important in the coming
decades, as the number of older, at-risk women
grows worldwide and new cervical cancer prevention interventionsincluding HPV vaccines
become available.

Acknowledgment
Support for the development of this document was
provided by the Bill & Melinda Gates Foundation

S53
through the Alliance for Cervical Cancer Prevention
(ACCP).

References
[1] Ferlay J, Bray F, Pisani P, Parkin DM, editors. Globocan 2002:
cancer incidence, mortality, and prevalence worldwide
[database on CD-ROM]. Lyon, France7 IARC Press; 2004
[IARC CancerBase No. 5, version 2.0.].
[2] Stewart BW, Kleihues P, editors. World cancer report 2003.
Lyon, France7 IARC Press; 2003.
[3] Committee on Economic, Social and Cultural Rights (CESCR)
11/8/2000. The right to the highest attainable standard of
health: CESCR general comment 14. New York7 United
Nations; 2000.
[4] Basu PS, Sankaranarayanan R, Mandal R, Roy C, Das P,
Choudhury D, et al. Visual inspection with acetic acid and
cytology in the early detection of cervical neoplasia in
Kolkata, India. Int J Gynecol Cancer 2003;13(5):626 32.
[5] Royal Thai College of Obstetricians and Gynaecologists
(RTCOG)/JHPIEGO Cervical Cancer Prevention Group.
Safety, acceptability, and feasibility of a single-visit
approach to cervical cancer prevention in rural Thailand:
a demonstration project in rural Thailand. Lancet
2003;361(9630):814 20 [Erratum in: Lancet. 2003;
361(9373):1994].
[6] Gaffikin L, Lautervach M, Blumenthal PD. Performance of
visual inspection with acetic acid for cervical cancer
screening: a qualitative summary of evidence to date.
Obstet Gynecol Surv 2003;58(8):543 50.
[7] Denny L, Kuhn L, Pollack A, Wainwright H, Wright T.
Evaluation of alternative methods of cervical cancer
screening for resource-poor settings. Cancer 2000;89(4):
826 33.
[8] Kuhn L, Denny L, Pollack A, Lorincz A, Richart R, Wright T.
Human papillomavirus DNA testing for cervical cancer
screening in low-resource settings. J Natl Cancer Inst
2000;92(10):818 25.
[9] Sankaranarayanan R, Nene BM, Dinshaw MD, Rajkumar R,
Shastri S, Wesley R, et al. Early detection of cervical cancer
with visual inspection methods: a summary of completed
and on-going studies in India. Salud Pu blica Me x
2003;45(2):S274 81.
[10] Gupta S, Rao YN, Agarwal SP. Emerging strategies for cancer
control in women of India. In: Agarwal SP, editor. Fifty years
of cancer control in India. New Delhi7 National Cancer
Control Programme, Ministry of Health and Family Welfare,
Government of India; 2002. p. 184 95.
[11] Alliance for Cervical Cancer Prevention (ACCP). Effectiveness, safety, and acceptability of cryotherapy: a systematic
literature review. Seattle7 ACCP; 2003.
[12] Goldie SJ, Kuhn L, Denny L, Pollack A, Wright TC. Policy
analysis of cervical cancer screening strategies in lowresource settings: Clinical benefits and cost-effectiveness.
JAMA 2001;285:3107 15.
[13] Mandelblatt JS, Lawrence WF, Gaffikin L, Limpahayom KK,
Lumbiganon P, Warakamin S, et al. Costs and benefits of
different strategies to screen for cervical cancer in lessdeveloped countries. J Natl Cancer Inst 2002;94:1469 83.
[14] Goldie SJ. Alliance for cervical cancer prevention. A
comprehensive policy analysis of cervical cancer screening
in Peru, India, Kenya, Thailand and South Africa, Presented
at: 21st International Papillomavirus Conference, February
2026, 2004, Mexico City, Mexico.

S54
[15] Herdman C., Bingham A., Levin K., Boyd A.,Sherris J.
Changing minds: identifying policymakers information
needs related to cervical cancer prevention. INASP Newsletter November 2004;27.
[16] Sankaranarayanan R, Rajkumar R, Theresa R, Esmy PO,
Mahe
C, Bagyalakshmi K, et al. Initial results from a
randomized trial of cervical visual screening in rural south
India. Int J Cancer 2004;109:461 7.
[17] Alliance for Cervical Cancer Prevention (ACCP). Planning
and implementing cervical cancer prevention and control programs: a manual for managers. Seattle7 ACCP;
2004.
[18] Personal communication. KK Kimpaphayom, Department of
Obstetrics/Gynaecology, Faculty of Medicine, Chulalongkhorn University, Bangkok, Thailand, 2003.

J. Sherris et al.
[19] Luthra UK, Rengachari R. Organization of screening
programs in developing countries with reference to
screening for cancer of the uterine cervix in India. In:
Hakama M, Miller AB, Day NE, editors. Screening for
cancer of the uterine cervix. IARC Scientific Publications,
vol. 76. Lyon, France7 International Agency for Research
on Cancer; 1986. p. 273 88.
[20] Agurto I, Arrossi S, White S, Coffey P, Dzuba I, Bingham A,
et al. Involving the community in cervical cancer prevention programs. Int J Gynecol Obstet 2005;89S2:S38 45
(this issue).
[21] Bingham A, Bishop A, Coffey P, Winkler J, Bradley J, Dzuba
I, et al. Factors affecting utilization of cervical cancer
prevention services in low-resource settings. Salud Pu
blica
Me
x 2003;45:S283 91.