Working towards health: A model of cervical cancer screening and treatment for factory employees in Haiti

Abstract

Objective:

In Haiti, cervical cancer continues to cause high levels of mortality and morbidity due to lack of resources and political unrest. Haitian women employed in factories are especially vulnerable because they are unable to take time away from work to access health resources. We aimed to describe a low-cost intervention which successfully addressed this need.

Methods:

We present a retrospective review of data gathered through a public–private partnership, in which women working in garment factories near Port-au-Prince, Haiti, were offered health education, clinical breast exam, and free human papillomavirus (HPV) self-swab testing at their place of employment. Women testing positive for HPV were subsequently tested using visual inspection with acetic acid (VIA) to inform treatment referrals, and treated with mobile thermocoagulation in factory infirmaries. Factory-employed healthcare workers were trained on cancer screening, including VIA and clinical breast exam.

Results:

A total of 6843 out of 6983 (98%) female factory employees attended free reproductive health education sessions, and 4005 out of 4153 eligible women (97%) were screened using HPV self-swab testing; 5176 women received a clinical breast exam. Of the women screened for HPV, 1001 (25%) tested positive and 905 (90%) of HPV-positive women received VIA testing and thermocoagulation. The intervention had a total cost of US$76 000, over half of which was spent on an HPV testing machine.

Conclusions:

Innovative approaches to the prevention of cervical cancer are especially necessary in very low-resource, politically unstable environments like Haiti. Self-swab and screen-and-treat programs in the workplace were acceptable to employees and factory owners. This low-cost model was reached vulnerable women through a public-private partnership, and tracked them through screening and treatment. It could be implemented elsewhere or extended to include other health services.

1 |. INTRODUCTION

Haiti, a Caribbean nation of almost 12 million people, has long suffered from a weak public health system, rampant political instability, and limited access to economic and health resources.¹ Haiti is the poorest country in the western hemisphere due in large part to a devolving political situation.² There is extremely limited literature to date on human papillomavirus (HPV) or cervical cancer prevalence in Haiti. The true prevalence of cervical cancer is not known, but breast and cervical cancers are believed to be the most common causes of cancer in women³ and more than 65% of those diagnosed die from these diseases.⁴ While HPV infection rates are likewise not known, the prevalence of HPV was estimated to be 19% in one study.⁵

Haitian women have limited access to HPV vaccination or screening programs, due to absent health resources and frequent political instability, and knowledge of cervical cancer and screening uptake in Haiti is universally low.^6,7 Additional barriers to screening include gendered family responsibilities, concerns about quality of care, time and financial constraints, worries about exam discomfort, and emotional deterrents such as despair at lack of treatment.⁸ Working-class Haitian women have been shown to have even less knowledge and access than the poorest Haitian women, perhaps due to long working hours and difficulty accessing existing health systems.^7,9 Working-class women earn only about US$5/day in Haiti, and often provide the sole income for households. The confluence of lack of resources, lack of knowledge, suspected high rates of HPV, and high levels of political insecurity combine to put working-class Haitian women at high risk of cervical cancer.

Low-and middle-income countries (LMICs) around the world are faced with a disproportionately high burden of disease from cervical cancer. Although it is highly preventable, cervical cancer remains the fourth highest cause of cancer-related mortality in women globally, with approximately 270 000 deaths and 530 000 cases annually.¹⁰ A variety of screening programs have been implemented in LMICs, including Pap cytology-based screening, visual inspection with acetic acid screenings (VIA), and HPV screening.¹¹ HPV screening been shown to be a low-cost way to prevent cervical cancer,¹² has been demonstrated to compare favorably to cytology in sensitivity and specificity, is easy to implement, and is acceptable for women in LMICs who may not be comfortable with pelvic exams.^13,14 Vaginal self-sampling has previously been shown to be accurate at detecting HPV and acceptable for use among Haitian women.^15,16 WHO currently recommends HPV testing as the central cervical cancer screening technique in places where Pap testing is not feasible, and further recommends that treatment be offered immediately after a positive screening test for cervical cancer due to risk of loss to follow-up¹⁷; this is especially important in contexts like Haiti with high rates of loss to follow-up. In low-resource, high-risk contexts, treating precancerous lesions after a positive HPV test alone has been shown to be a relatively safe alternative which balances the risk of progression to cancer with the risks associated with thermoablation.^18,19 Thermoablation has been shown to treat precancerous lesions, can be performed by trained nurses, and has proven relatively easy to implement in developing contexts.²⁰

2 |. MATERIALS AND METHODS

We present a retrospective chart review of data gathered through an intervention implemented from October 2017 through January 2019 to educate and screen for HPV and cervical cancer in factories located in an industrial park in in Port-au-Prince. This project was approved by the University of Florida institutional review board (IRB) and the national IRB of Haiti. As the study was retrospective, informed consent was not obtained. Basic descriptive statistical analysis was conducted in IBM SPSS Statistics version 29 (IBM, Armonk, NY, USA). Statistical significance was not calculated for these descriptive statistics.

The project was implemented by two partners: Innovating Health International (IHI), a Haitian non-profit medical service delivery organization and Share Hope, an organization which works with garment factories to promote ethical production. Garment factories in a single industrial park were invited to participate and recruited based on convenience sampling.

2.1 |. Training and education

Community health workers (CHWs) selected from Haitian communities were trained by a social worker on women’s health topics, with a focus on cancer detection and prevention. Factory-employed nurses and physicians were recruited and trained on women’s health topics, including appropriate screening for breast and cervical cancer, HPV, and VIA images. This training consisted of 1 day of classroom didactics, and at least 4 days of VIA and thermoablation practical training alongside experienced practitioners. Practitioners successfully completed two positive VIA exams prior to independent practice; prior to this milestone, they were overseen by skilled nurse midwives, who remained at the factory for the week of screening, to be consulted as needed.

In each factory, all employees were invited to attend an educational workshop during their lunch hour at which food was provided. Attendance for workers at these sessions was not mandatory and care was taken to assure that no punitive action would be taken if workers chose to abstain. CHWs delivered culturally sensitive courses on screening, symptoms, and diagnosis of breast and cervical cancer using previously developed materials for cancer education in the Haitian context.^7,9 Topics included the basic biology of cervical cancer, cervical cancer symptoms, HPV transmission and prevention, self-swab risks and benefits, and thermocoagulation risks and benefits. After education, all eligible women were invited to be screened during their lunch break over the next several days.

2.2 |. Screening and treatment

Eligible women included all women aged 30–50 who were not pregnant or postpartum, had not had a hysterectomy, and had not had a Pap smear in the previous 3 years.¹⁷ Women of all ages were given a clinical breast exam by a trained nurse midwife and were taught to perform self-breast exam. Those aged 30–50 years who elected to participate were instructed on the use of HPV vaginal self-swab. Women entered a private area in the factory infirmary and collected an HPV self-swab for analysis. The midwife assisted with sample collection if requested; a very small percentage of women made use of midwifery assistance in sampling. Samples were sent for processing using a Qiagen care HPV machine (Venlo, The Netherlands). Results were processed within 4 weeks and returned to women through trained nurses in factory infirmaries. This 4-week window was deemed appropriate because most women were consistently employed at the same factories for months to years, and thus could be easily located for treatment.

Women who tested positive for HPV returned to the factory infirmary to be screened using VIA. Women with a positive VIA screening with more than 75% of cervical involvement, or endocervical or vaginal involvement, were referred to IHI’s cancer center in Port-au-Prince for further evaluation and treatment by a gynecologist. All other HPV-positive women who had an intact cervix without signs of infection were treated in factory infirmaries using a mobile, battery-operated thermoablation device (Thermocoagulator; Liger Medical (Lehi, UT)). The decision to treat HPV-positive but VIA-negative women was made after the first 100 women were screened due to the anticipated high percentage of loss to follow-up in the Haitian context, and the low risk of procedure complication.

Women who had abnormal breast exams were asked to return for follow-up clinical breast exam by a doctor and then received a breast ultrasound using a portable ultrasound machine (Micromaxx; Sonosite (Bothell, WA)). Women whose findings on ultrasound were concerning with regard to malignancy were referred to IHI’s cancer center for a core needle biopsy.

3 |. RESULTS

Out of 20 factories located in the industrial park, 12 were invited to participate, and 11 accepted. The remaining eight factories had never expressed interest in health initiatives in the past. Included factories employed a total of 6983 women. The participation of eligible workers in the program is shown in Figure 1. A total of 6843 out of 6983 women (98%) attended optional CHW-led health education sessions. Of these women, 4924 were between the ages of 30 and 50 years, and 4153 were ultimately eligible for screening. Reasons for ineligibility (N = 771) included pregnancy (N = 368), postpartum (N = 198), recent Pap testing (177) or previous hysterectomy (N = 28). Of the 4153 eligible women, 4005 (97%) were screened for HPV using HPV self-swab. Women who declined HPV testing (N = 28) most often cited religious or moral beliefs as their reason. Out of 6983 educated women, 5176 (74%) received a clinical breast exam and were taught how to carry out a self-breast exam. Women most frequently declined the breast exam because they were ineligible for cervical cancer screening.

FIGURE 1.

Participants and outcomes. HPV, human papillomavirus; VIA, visual inspection with acetic acid.

In all, 1001 (25%) women screened for HPV tested positive (Table 1). Women with positive results were discreetly notified through the factory infirmary and asked to return for further testing and treatment. Of the 1001 women found to be HPV-positive, 905 (95%) received VIA testing administered by a trained nurse and 805/1001 (80%) were treated with thermoablation. The first 100 women who were HPV-positive but VIA-negative were not treated with thermoablation unless they had a positive VIA; however, concern over high rates of loss to follow-up prompted the decision to treat all HPV-positive women. Reasons for not receiving thermoablation included no longer working at the factory (N = 40), having become pregnant (N = 16), cervicitis (N = 15), requiring more advanced treatment and referral (N = 15), or declining treatment (N = 8). One case of cervical cancer was discovered after biopsy at IHI Cancer Center. Only 121 (13%) of the 905 HPV-positive women were also found to be VIA-positive. Only 20 out of 805 women (2.5%) who were treated reported any complications or side effects of this procedure, most commonly self-limited vaginal bleeding. No women experienced serious complications and no women missed any work due to this intervention. Results were kept confidential and there were no reports of stigma for those undergoing treatment or based on their results either to IHI, Share Hope, or infirmary staff.

TABLE 1.

Outcomes of screening.

Description	N (%)
Total factory workers	6983 (100%)
Total women educated	6843 (98%)
Total eligible for HPV testing	4153 (59%)
Screened for HPV	4005 (57%)
HPV-positive	1001 (25%)
VIA tested	905 (13%)
Received thermoablation	699 (10%)
Clinical breast exam	5176 (74%)
Midwife-identified clinically suspicious mass	368 (7%)
Breast ultrasound	168 (2%)
Referred outside of factory	18 (0.25%)
Biopsy	3 (0.04%)
Breast cancer	1 (0.01%)

Abbreviations: HPV, human papillomavirus; VIA, visual inspection with acetic acid.

Of the 5176 (74%) women who received a clinical breast exam, the midwife noted 368 (7%) to have a clinically suspicious breast mass requiring a further physician clinical exam. Following this exam, 168 (3%) out of 5176 screened ultimately underwent breast ultrasound in the workplace infirmary using a portable ultrasound device. Three women were referred to IHI’s clinic for breast biopsy and one was found to have breast cancer. Cancer patients discovered as a part of the project received surgical treatment and chemotherapy at IHI’s cancer center; radiation therapy remains unavailable in Haiti.

The total cost of the program was US$76 000, the majority of which ($43 000) was spent on the Qiagen care HPV machine and testing kits. This cost is inclusive of all costs, including provider-time costs, travel, and IHI costs; there was no cost to the patient. Lunches and other in-kind donations from factory owners, and IHI and Share Hope reduced costs. The per-woman cost for screening and treatment was approximately US$12–13.

4 |. DISCUSSION

The confluence of economic, political, and health system level factors at work in Haiti puts Haitian women at high risk of developing invasive cervical cancer. Novel approaches are needed, especially for difficult to reach populations, such as women who work 6 days a week. At the time of the intervention, there were 32 000 women working in large factories across Haiti; this program reached nearly 20% of these women.

Women screened had higher rates of HPV positivity (25%) than those in previous studies of urban Haitian populations.⁵ This may be due to high rates of HPV in the Haitian population generally, or to the especially vulnerable nature of women working in factories in urban Port-au-Prince. Vaccination for HPV is still largely unavailable in Haiti. Only 177 women (2.6%) reported a recent cervical exam, findings that underscore the paucity of health resources available to work-class women in Haiti.

Previous systematic reviews have shown that HPV self-swab testing is a feasible approach in LMICs.^13,14 These technologies allowed screening and treatment to be conducted in the workplace, with minimal disruption of normal workflow and high levels of buy-in from factory administration, who contributed towards costs. No women missed work as a result of this intervention, making it acceptable to women workers unable to miss work time to attend to preventative health needs. Most women were only off the factory floor for 30 min or less, which is of critical importance to these women who are paid on productivity. The innovative combination of public–private partnership, mobile health technology, and CHW-led activities permitted low-cost, rapid screening of a population that would otherwise have been unable to access the health system. Although there was a 4-week wait between ‘seeing’ and ‘treating’ in this program, the use of the workplace as a venue for screening provided a stable environment in which women were seen consistently over several weeks, resulting in low rate of loss to follow-up. In contrast to studies of HIV testing in workplaces,²⁰ there were no reports of any stigma against those who sought testing, tested positive, or were treated. This may indicate an absence of stigma in relation to HPV infection or cervical cancer, leading to opportunities for screening programs. Women declined breast cancer screening if they were not eligible for cervical cancer screening; this may indicate a need to enable all women eligible for breast cancer screening to receive this service, despite logistical reasons for combining screening programs.

Unfortunately, since the conclusion of this project, the political situation in Haiti has continued to deteriorate. The instability and unrest in Haiti underscore the necessity of efficient, timely screen- and-treat programs for cervical cancer which meet the needs of vulnerable women. While this program could not be expanded or repeated due to loss of funding amidst the tumultuous political situation, factories in Haiti remained open throughout significant unrest. Sustainability, a key metric of the success or failure of such programs, could not be addressed through this pilot project; however, aside from loss of funding support due to political turmoil, no barriers to continuation or expansion of the program were identified, despite the difficult social and economic landscape. We suggest that the bundle of education, screening, and treatment for cervical cancer and pre-cancer centered in the relatively stable work environment could serve as a model for future interventions in Haiti, or in similar contexts globally.

4.1 |. Limitations

This study was a retrospective examination of data gathered as a part of an intervention. Each factory in which the intervention was conducted had different hours and different production demands, making it difficult to standardize education and screening. This required that the intervention be tailored to each site. Demographic data that were not relevant to the intervention were not collected, reducing our ability to fully describe the population targeted. The treatment plan also evolved during the project. As some women (1%) were fired or laid off after seasonal work was completed and were lost to follow-up.

5 |. CONCLUSION

In Haiti, access to adequate screening and treatment for cervical cancer is limited. We present the results of a relatively low-cost ($12–13 per woman) intervention targeting a difficult-to-reach population successfully implemented in Port-au-Prince, Haiti. These results reveal high rates of HPV infection and low baseline access to cervical cancer screening. They suggest that factory-based cervical cancer screening using HPV self-swab followed by thermoablation is feasible, acceptable, and relatively low cost in Haiti, and may reduce loss to follow-up even amidst economic and social insecurity. As loss to follow-up is a major consequence of programs that do not adopt a ‘screen and treat’ approach, the bundling of services and use of the workplace environment as occurred in this program may serve as a model for future interventions. The workplace setting allows increased access to screening services for a population of women shown to be less likely to seek healthcare resources due to the demands of their employment. Future projects could target other captive audiences of women, such as women who work in agricultural collectives that grow crops to sell to distributors, mothers of school-aged children screening at schools, or religious groups screening at churches. Community collectives and women’s groups at the local level can also be approached in future efforts to develop and implement cervical cancer screening services tailored for women residing in smaller cities and in rural provinces of Haiti. In addition, other screening services could be implemented using this model, including for hypertension and diabetes, while also offering family planning services.

DATA AVAILABILITY STATEMENT

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.