Mexico

Chiapas is the southern-most state of Mexico and home to nine major ethnicities and nearly one million indigenous language speakers. Of the 4.3 million people in Chiapas, most are poor, rural farmers with limited access to health care and education. Grounds for Health began working with coffee farmers in Chiapas in 2007, first in partnership with the Campesinos Ecologicos de la Sierra Madre de Chiapas (CESMACH), then expanding in 2010 to include three additional coffee co-ops: Finca Triunfo Verde, Comon Yaj Noptic, and Ramal Santa Cruz. Together the four co-ops form the association La Union el Triunfo, which is named for the protected biosphere reserve, el Triunfo, located in the highlands of the Sierra Madre Mountains where most of the co-ops’ coffee is cultivated.

In 2011, the four co-ops had a total of 1,233 members in communities dispersed throughout the municipalities of Angel Albino Corzo, Monte Cristo, La Concordia, and Siltepec. The settings ranged from small urban areas with access to both primary and secondary health services to extremely rural regions with only rudimentary health posts. Indigenous groups reside in many of the co-ops’ most isolated communities where language and cultural norms present barriers to uptake of women’s health services.

While women in many communities served by the social welfare program, Oportunidades, were accustomed to getting the Pap test, few had accurate information about cervical cancer, and fears about the screening and treatment procedures prevailed. Among health workers, misinformation about cervical cancer and the appropriate methods for treatment of early disease was also rampant. Many providers incorrectly identified normal, healthy cervixes, as “ulcerated,” “tumorous” or “inflamed” and referred women to specialists for unnecessary procedures, sometimes leading to costly and invasive testing and even treatment. Virtually all providers taking Pap tests had been trained incorrectly on how to take a sample, and as a result, a very large portion of Pap samples were deemed “insufficient,” or the results were unreliable.

Grounds for Health led seven clinical trainings for local providers in Chiapas, including an initial training in Comitan in 2006 and six subsequent trainings in municipalities pertaining to the co-op partners. Clinical trainings were combined with campaigns in co-op communities in which local providers practiced new skills under the supervision of US medical volunteers. It was not until the third clinical training in December 2007 that Grounds for Health adopted the Single Visit Approach and began training local providers in Visual Inspection with Acetic Acid (VIA) and cryotherapy. With the introduction of VIA women were able to receive screening and treatment on the same day.

The co-ops recruited women for the campaigns, coordinated transportation for them to and from the campaign site, and provided overall logistical support for the program. Beginning in 2011, co-ops also assumed responsibility for community health promoter trainings and all community education activities. In the final year of the collaboration, outreach efforts focused on the most isolated communities where few women had had the opportunity to get screened, or were still reluctant to do so. Representatives from these communities, including men, indigenous leaders, as well as women served as community health promoters.

The local health authorities assumed responsibility for selecting local providers to be trained by Grounds for Health, giving them permission to participate in the trainings and campaigns, and ensuring access to appropriate follow-up services. The health authorities and the municipal government also jointly committed to making same day screen-and-treat services available in the municipal hospital, as well as in marginalized communities outside of urban Angel Albino Corzo.

Other activities include a Training of Trainers in March 2012; transition planning aimed at preparing co-op partners and local health care providers to assume responsibility for continuing the program; a proposal-writing workshop; and disbursement of three mini-grants to support co-ops in expanding community outreach and education programs and organizing screening and treatment services independently.

Between 2006 and 2011, 8,744 women were screened through Grounds for Health’s program. A total of 592 (6.7 %) women were identified with VIA positive lesions or high-grade Pap results, and 455 (77%) of these women were treated with cryotherapy. All women with positive screening tests who were not eligible for immediate treatment were either referred or advised to return for a control test, as appropriate. Annual numbers shown in the table below highlight the impact of two key programmatic changes: 1) the introduction of the Screen and Treat Approach in late 2007 (PY2008), which allowed women to receive treatment directly through the program, and 2) tracking performance of local providers beginning in 2011 which shows the exponential increase in women screened and treated as a result of clinical training and supportive supervision. However, this also coincides with a decline in the percent of women treated, as most providers were not able to offer treatment on the same day, and treatment for women referred was not always verified.

Program Year (PY): October – September

Conduct focused clinical trainings

While Grounds for Health subscribes to the concept and practice of integrated health care—which allows patients to access an array of services at a primary health clinic—our experience has demonstrated that the most effective way to train providers in new skills is through a focused clinical training. For a few years, Grounds for Health integrated cervical cancer screening with breast cancer screening and family planning consults during campaigns. However, this increased the amount of time providers spent with each patient and therefore limited the number of times providers were able to practice VIA and cryotherapy under supervision. For this reason, Grounds for Health decided to focus on VIA and cryotherapy during clinical training events, and encourage providers to integrate cervical cancer prevention with other services once they complete their training.

Provide vision tests and glasses to providers who need them

As the name implies, Visual Inspection with Acetic Acid requires providers to look at the cervix with the naked eye for the characteristics that denote cellular changes. After observing several capable providers struggling to see the necessary level of detail on the cervix, Grounds for Health discovered that many providers were farsighted. The problem was remedied with a simple vision test and by providing reading glasses of the appropriate strength to the providers who needed them. This has since become standard practice in all Grounds for Health trainings.

Use community health promoters to link women with providers

Grounds for Health’s experience reinforces the well-known value of using community health promoters. Among the providers trained by Grounds for Health in Chiapas, those who continued offering screening and treatment services in co-op communities were able to do so largely because of the effectiveness of the community health promoters involved in the program. “Son las estrellas de esta película” (“they are the stars of the show”) one provider explained; without community health promoters, women would not come for screening.

Anticipate leadership transitions

To address the common challenge of ensuring support from new leadership after election cycles, Grounds for Health and its collaborators deployed community health promoters to increase community participation and demand for screening and treatment services, and met with incoming co-op and municipal leaders to present the program and gain immediate buy-in. Seeing clear community support, evidenced by active community health promoters and women seeking screening services, the incoming leaders tended to commit to furthering the program.

Influence local norms for cervical cancer prevention and control

Despite having forged alliances with a number of health authorities in Chiapas, the Mexican national norms for cervical cancer prevention and control remain largely ineffective in rural settings. After adopting the Single Visit Approach, Grounds for Health’s training succeeded in “winning over” individual providers on the advantages of VIA and cryotherapy, but was unable to influence changes in the national screening and treatment norms. Deeper engagement with senior health authorities at the national and local levels is needed to promote adoption of new or modified norms in low resource areas.

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• Grounds for Health: Mexico Final Report (PDF)