title: Major challenges to scale up of visual inspection-based cervical cancer prevention programs: the experience of Guatemalan NGOs.
abstract: BACKGROUND
  Like many other low- and middle-income countries, Guatemala has adopted visual inspection with acetic acid (VIA) as a low-resource alternative to the Pap smear for cervical cancer screening. Nongovernmental organizations (NGOs) introduced VIA to Guatemala in 2004, and a growing number of NGOs, working both independently and in collaboration with the Guatemalan Ministry of Health, employ VIA in cervical cancer prevention programs today. While much research describes VIA efficacy and feasibility in Latin America, little is known about NGO involvement with VIA programming or experiences with VIA outside the context of clinical trials and pilot projects in the region.
  
  
  METHODS
  To explore challenges faced by NGOs implementing VIA programs in Guatemala, we conducted semi-structured interviews with 36 NGO staff members involved with 20 VIA programs as direct service providers, program administrators, and training course instructors. Additionally, we collected data through observation at 30 NGO-sponsored cervical cancer screening campaigns, 8 cervical cancer prevention conferences, and 1 week-long NGO-sponsored VIA training course.
  
  
  RESULTS
  Frequently highlighted challenges included staff turnover, concerns over training quality, a need for opportunities for continued supervision, and problems with cryotherapy referrals when immediate treatment for VIA-positive women was unavailable.
  
  
  CONCLUSIONS
  Reducing staff turnover, budgeting to train replacement providers, standardizing training curricula, and offering continued supervision are key strategies to improve VIA service quality and program sustainability. Alternative training methods, such as on-the-job mentoring and course prerequisites of online learning, could help increase training time available for clinical supervision. Efforts should be made to ensure that VIA testing is coupled with immediate cryotherapy, that providers trained in VIA are also trained in cryotherapy, and that cryotherapy supplies and equipment are maintained. Where this is not possible and only VIA screening is available, referral systems must be strengthened.
authors.affiliation: Washington University in St. Louis, School of Medicine and Department of Anthropology , St. Louis, MO. , USA.
authors.forename: Anita Nandkumar
authors.initials: AN
authors.lastname: Chary
authors.affiliation: Harvard Medical School, Brigham and Women's Hospital , Boston, MA. , USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Rohloff
mesh_terms: D019342:Acetic Acid; D000328:Adult; D003153:Community Health Services / Q000458:organization & administration*; D003695:Delivery of Health Care / Q000458:organization & administration; D055088:Early Detection of Cancer / Q000379:methods; D005260:Female; D006166:Guatemala; D006801:Humans; D008403:Mass Screening / Q000458:organization & administration*; D011230:Precancerous Conditions / Q000175:diagnosis; D011795:Surveys and Questionnaires; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000517:prevention & control*
chemical_list: D019342:Acetic Acid