Cervical cancer screening and management of cervical pre-cancers
VIA, HPV detection test and cryotherapy
Training of health staff in
Facilitators’ guide
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Cervical cancer screening and management of cervical pre-cancers Package contents • Training of health staff in VIA, HPV detection test and cryotherapy Trainees’ handbook Facilitators’ guide
• Training of health staff in colposcopy, LEEP and CKC Trainees’ handbook Facilitators’ guide
• Trainees’ handbook and facilitators’ guide Programme managers' manual • Trainees’ manual for community health workers • Counselling cards • Flip chart • Teaching aids
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Contents Foreword v Acknowledgements vi Abbreviations vii Section 1: General guidelines for training 1.1 Introduction 1.2 Training objectives 1.3 Trainees’ profile 1.4 Facilitators’ profile 1.5 Batch size of trainees and number of facilitators 1.6 Training materials 1.7 Checklist of equipment and supplies required for training 1.8 Training site 1.9 Duration of training 1.10 Record keeping 1.11 Dos and don’ts for facilitators Section 2: Session plan Section 3: Training methodologies 3.1 Introduction 3.2 Guidelines for conducting classroom training 3.3 Guidelines for conducting clinic-based training Section 4: Assessment of trainees 4.1 Introduction 4.2 Guidelines for conducting knowledge assessment 4.3 Guidelines for conducting skills assessment in clinics Section 5: Conducting the training 5.1 Introduction 5.2 Distribution of sessions and flow of events 5.3 Feedback session 5.4 Certification and closing Section 6: Annex 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 Trainees’ feedback form Sample questionnaire for knowledge assessment Sample informed consent form for VIA test Sample informed consent form for VIA test and cryotherapy Checklists for counselling Checklist for VIA Checklist for cervical sample collection technique for HPV test Checklist for cryotherapy Checklist for cold coagulation 1 2 2 3 4 6 6 6 8 10 10 11 13 27 28 28 40 47 48 48 50 53 54 55 80 81 83 84 86 90 92 94 100 103 106 109
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Foreword Cervical cancer is the second most common cancer among women worldwide and causes a significant number of deaths in the South-East Asia Region. Nearly 200 000 new cases of cervical cancer occurred in SEA Region Member States in 2008, giving an incidence of almost 25 per 100 000 and a mortality rate of almost 14 per 100 000. Cervical cancer can be prevented by early screening and vaccination. However, due to poor access to screening and treatment services, the vast majority of these deaths occur in women from nine Member States of the South-East Asia Region which account for more than one third of the global burden of cervical cancer. In 2015, the WHO Regional Office for South-East Asia, in consultation with Member States, launched a Strategic Framework for the Comprehensive Control of Cervical Cancer in the South-East Asia Region. To strengthen the capacity of health-care providers, a training package has been developed based on the emerging scientific evidence related to new technologies and novel paradigms in cervical cancer screening and to the safety and efficacy of the vaccines. A paradigm shift has taken place over the recent years in the understanding of the natural history of the disease, the preventive strategies, and the technologies associated with its early detection and treatment. The availability of effective and safe human papillomavirus (HPV) vaccine has introduced an entire new dimension to the prevention of the disease. The South-East Asia Region is the first region of WHO to publish a training package on a comprehensive approach to cervical cancer screening and management of cervical pre-cancers. The training package provides strategies for a screen-and-treat programme building upon the existing evidence-based WHO global guidelines. The training package is intended for programme managers, health-care providers and other professionals who have a responsibility for cervical cancer prevention, detection and treatment at the national and sub-national levels. There are eight separate modules for different target audiences including the facilitator’s guides. I am convinced that the success of the Sustainable Development Goals and implementation of the Global Strategy on Women’s, Children’s and Adolescents’ Health will depend on strong commitment towards the ‘Survive, Thrive and Transform’ objectives for building healthy societies. This is our vision as we work together for stronger health systems, universal health coverage and scaling-up of life-saving interventions for comprehensive cervical cancer prevention and control. I would urge Member States to strengthen the capacity of health-care providers in the prevention and control of cervical cancer. Dr. Poonam Khetrapal Singh Regional Director WHO South-East Asia Region
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Acknowledgements The World Health Organization (WHO) would like to thank all experts, partners and reviewers involved in developing this training package on cervical cancer screening and management of pre-cancers. The enormous task of preparing the comprehensive package to train the complete spectrum of providers in a cervical cancer screening program could be completed successfully due to the contributions of several experts from Member States of the WHO South-East Asia Region. The development of the training package was coordinated by the WHO Collaborating Centre for Human Reproduction at the Department of Obstetrics and Gynaecology, Post-Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India, under the leadership of Professor Lakhbir Dhaliwal and Professor Vanita Suri, along with team members Professor Reshmi Bagga, Dr Rakhi and Dr Parul. Inputs from consultants who worked on the project, Dr Partha Basu, Screening Group, International Agency for Research on Cancer (WHO), France, and Dr Srabani Mittal, Child in Need Institute, India, were critical. WHO would like to thank the following experts who contributed and provided technical support to the development and finalization of this publication – Dr Ashrafun Nessa, Bangladesh; Dr Ugyen Tshomo, Bhutan; Dr Suchitra Pandit, Dr Neerja Bhatla, Dr Jerard Maria Selvam, Dr Shuchi Jain, India; Dr Prof Mya Thida, Dr Theingi Myint, Myanmar; Dr Kiran Regmi, Dr Sarita Ghimere, Nepal; Dr Nethanjali Mapitigama, Sri Lanka; Dr Prof. Somchai Niruthisard, Thailand; Dr Abhijeet Pathak, IPPF, India; Dr Rashmi Asif and Dr Geeta Chibber, Jhpiego (an affiliate of Johns Hopkins University), India; Dr Sharad Singh, Population Services International, India; Dr Anchita Patil, UNFPA, India. Technical support in finalization of this package was provided by Dr Arvind Mathur, Dr Neena Raina, Dr Anoma Jayathilaka, Dr Priya Karna, WHO Regional Office for South-East Asia, New Delhi, India. The pictures have been taken from IARC and reproduced with permission from IARC.
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Abbreviations CIN CKC cervical intraepithelial neoplasia cold knife conization
C4GEP Comprehensive Cervical Cancer Control: A Guide to Essential Practice HPV human papillomavirus
IUCD intrauterine contraceptive device LEEP LMP SCJ TZ VIA loop electrosurgical excision procedure last menstrual period squamocolumnar junction transformation zone visual inspection with acetic acid
WHO World Health Organization
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Section 1: General guidelines for training
1.1 Introduction
This manual is an instruction guide for facilitators to provide competence based training to providers for screening (with VIA or HPV test) and ablative treatment services in a cervical cancer screening programme. The training is intended to assist midwives, paramedical workers, nurses and clinicians to learn and improve upon their skills to perform counselling, screening tests and treatment. Facilitators are required to consult both the Facilitators’ guide and the Trainees’ handbook while training through interactive presentations, group discussions, role plays, simulated learning sessions, and clinical practice sessions. The Facilitators’ guide contains detailed training methodologies, structure of the individual training sessions, simulated learning sessions and guidelines for assessment of trainees. The Trainees’ handbook contains different modules to assist trainees with step-by-step learning of screening and treatment procedures. Training resources are based on the WHO Comprehensive cervical cancer control: A guide to essential practice (C4GEP), 2nd edition, which will be the primary reference book for trainees. Henceforth, the book will be referred to as WHO Guidance book in this document. The WHO Guidance book is available online at http://apps.who.int/iris/bitstream/10665/144785/1/9789241548953_eng. pdf. Facilitators should be conversant with the contents of the WHO Guidance book since all the modules in the Trainees’ handbook are linked to the corresponding chapters and the practice sheets in the practice guidelines.
1.2 Training objectives
The training on Cervical Cancer Screening and Management of Cervical Precancers aims to enhance the knowledge and skills of paramedical workers, midwives, nurses and clinicians involved in various activities related to cervical cancer screening, early detection and treatment at different tiers of the health system. After completion of the training, trainees will be able to: • counsel women before and after cervical cancer screening; • screen women using VIA and HPV detection tests; • make decisions related to treatment and/or referral of women with cervical precancers; • treat cervical precancers by ablative methods. The objectives include both knowledge enhancement and skill development. Knowledge based objectives By the end of the training, trainees will be able to: • describe the concept of screening for cervical cancer – necessity, basic principles and different components of the programme; • describe the anatomy and physiology of female genital organs in relation to cervical cancer screening; • explain the natural history of cervical neoplasia and the causal role of HPV infection;
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• describe VIA – principles, techniques, interpretation of test results; • explain the management algorithms of VIA positive women; • describe HPV test – sample collection and interpretation of results; • explain the management algorithms for women with a positive HPV test; • explain principles and techniques of cryotherapy and cold coagulation; • describe infection prevention practices; • describe how to ensure quality parameters at each level of service; • discuss how to maintain a referral system; • describe record keeping and data management. Skill-based objectives By the end of the training, trainees will be able to: • demonstrate counselling of women for VIA/HPV test; • perform VIA step-by-step; • collect cervical samples for HPV testing; • perform cryotherapy or cold coagulation as appropriate; • manage women with procedure-related complications; • conduct follow-up of women after treatment; • follow appropriate infection prevention practices; • provide quality services as per the standard operating procedures.
1.3 Trainees’ profile
Paramedical workers, midwives, nurses and clinicians designated by health authorities at the national or sub-national levels to provide cervical cancer screening services need to be trained. It is preferable that trainees should have basic knowledge and skills for performing female pelvic examinations. Each trainee has to fill in the experience record (Box 1.1) prior to initiation of training to help facilitators understand their background and job experience.
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Box 1.1: Experience record of trainees Fill in details wherever specified or circle the appropriate response 1. Name: ____________________________________________________________ 2. Designation: _______________________________________________________ 3. Age: ______________________________________________________________ 4. Sex: ______________________________________________________________ 5. Contact no.: ________________________________________________________ 5. Place of posting: _____________________________________________________ Govt./Non-govt./Private_______________________________________________ 6. Highest educational qualification: _____________ Year of passing: _______________ 7. Duration of work experience: 8. Have you ever been trained to do screening for cervical cancer? Yes No VIA/ Taking Pap Smear/ Taking sample for HPV test/ Other –specify______________ 9. If yes, on which of the following procedures have you been trained? 10. Have you been trained to do cryotherapy or cold coagulation? Yes No 11. Current job responsibilities: Clinical/Training/Supervision/Others 12. Do you practise the following in your work? a) Vaginal delivery: Yes b) IUCD insertion: Yes c) Medical termination of pregnancy: Yes d) Other procedures requiring female pelvic examination: Yes e) If yes, please specify ………………………………………………… No No No No
1.4 Facilitator’s profile
Facilitators should have adequate knowledge and skills in the concerned subjects. They should undergo training of trainers to be conversant with training objectives, methodologies, session plans and training materials. It is preferable that facilitators be trained in training technology. Facilitators should be conversant with the cervical cancer control guidelines of their respective countries/region (if available).
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1.4.1 Course coordinator One facilitator will be designated as the course coordinator whose responsibilities will be as follows: For classroom training • Check the audio-visual system for proper functioning • Check availability of all training aids • Ensure that sessions are conducted as per schedule • Introduce the course • Oversee administrative aspects including record maintenance • Check for general facilities like running water, washrooms, power back-up, refreshments etc For clinic-based training • Check for availability of adequate number of cases for demonstration, prepare a list of cases and get informed consent signed • Engage nursing and other staff at the clinical facility for the training • Check the functioning of all equipment • Check availability of adequate number of instruments and adequate amount of consumables, including those required for simulation sessions • Plan the allocation of cases and trainees to different practice stations
1.4.2 Facilitator’s skills checklist At the beginning of the training, all selected facilitators need to fill in the facilitators’ skills checklist and submit it to the course coordinator. The checklist serves as a self-evaluation tool and is an important document for assessment of quality of training. Box 1.2: Facilitator’s skills checklist Facilitator’s skills checklist (please circle the statements that are appropriate for you) • You have undergone a course on VIA, HPV test and cryotherapy or its equivalent at a recognized training centre/medical college • You have undergone training of trainers • You have been trained in training technology • You have been practising VIA and/or HPV test and treatment of precancers regularly for at least two years • You have previously been a facilitator for a similar course (If yes, number of times _______) • You know your subject matter and are fully prepared to conduct the training sessions • You are flexible and empathetic and can adapt your plans to meet trainees’ needs • You encourage co-facilitators and trainees to give feedback and constructive criticism • You give timely constructive feedback to co-facilitators and trainees Facilitator’s name: Designation: 5
1.5 Batch size of trainees and number of facilitators
The total number of trainees should be six to 10 per batch. The batch should have a combination of clinician and non-clinician trainees. There should be at least three facilitators per batch.
1.6 Training materials The following training materials will be provided • Training of health staff in VIA, HPV test and cryotherapy:Facilitators’ guide • Training of health staff in VIA, HPV test and cryotherapy:Trainees’ handbook • CD-ROMs/flash drives containing the PowerPoint presentations, digital images, videos of various procedures and electronic copies of Comprehensive cervical cancer control: A guide to essential practice, 2nd edition, WHO, 2014 and Strategic framework for the comprehensive control of cancer cervix in South-East Asia region, WHO SEARO, 2015 • Demonstration models • Flashcards • Counselling cards and flip chart
1.7 Checklist of equipment and supplies required for training Item Remarks For classroom teaching 1. Folders for trainees containing: i. Trainees’ handbook containing the modules for different training sessions
ii. Trainees log sheets iii. CD-ROMs/Flash drives containing PowerPoint presentations, videos of the procedures, WHO C4GEP manual, trategic framework for the comprehensive control of cancer cervix in South-East Asia region, WHO SEARO, 2015 iv. Flip charts, counselling cards v. Pen, pencil, eraser, sharpener
vi. Writing pad
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2. 3. 3. 4. 5. 6. 7. 8. 9.
Name tags of trainees and facilitators Attendance sheet for trainees and facilitators Pens, pencils, A4 size paper, note pads, staplers, punching machine, cello tape Laptop, LCD projector, pointer, extension cords, TV monitor or projection screen Microphone, podium, tables for models and training material Flip charts and stand, marking pens – various colours, large clips to hold flip chart paper on stand White board, pin board,duster, chart papers, tapes for posting papers on boards, pins PowerPoint presentations, images and videos for demonstration, flash cards Print outs of pre- and post-training knowledge assessment questionnaires, checklists, log sheets, case record forms, consent forms
10. ZOE model, other anatomical models of female pelvic organs 11. Specula for practise on models 12. Certificates for trainees 13. Cryotherapy unit, cold coagulator (optional) for equipment demonstration 14. Animal tissues/apples for simulated learning 15. Nitrous oxide or carbon dioxide cylinders For clinical sessions 16. Supplies for preparation of dilute acetic acid, chlorine solution (as mentioned in the module) 17. Normal saline 18. Ethyl alcohol, glutaraldehyde solution 19. Examination gloves (Sizes 6.5,7,7.5), cotton swabs, cotton swab sticks, lubricant jelly 20. Focusing lamp, examination table, watch 21. HPV test kits, marking pens, ice box 22. Self-retaining bi-valve speculum, sponge holding forceps,instrument tray 23. Kidney trays, galipots 24. Cryotherapy unit, cold coagulator (optional) 25. Sterilizer 26. Consent forms, case record forms, log sheets, client record card 27. Writing desk, stools, chairs, curtains for clinic doors and windows, screen/ cover sheets for women to be examined 7
1.8 Training site
The training should be held in a hospital or other health facility with existing screening and ablative treatment services. The readiness of a proposed training site should be assessed by a competent person using the checklist provided below. Box 1.1: Training site readiness checklist Facility/item A. Provision of the following clinical services 1. 2. 3. 4. Screening of women by VIA Sample collection facilities for HPV test Treatment by cryotherapy Treatment by cold coagulation (optional) Number where Functional applicable yes/no/NA Remarks
B. Infrastructure for classroom teaching 5. 6. 7. 8. 9. Classroom with minimum seating capacity of 15 (to accommodate 6–10 trainees, 2–3 facilitators and 1–2 observers) seating arrangement – preferably U-shaped Classroom should be well-lit and ventilated Lights and fans or air-conditioner in working condition Audio-visual facilities in classroom Electricity (sockets and extension cords)
10. Toilet facilities 11. Drinking water supply 12. Electrical power backup C. Training aids Audio-visual aids with accessories
13. LCD Projector 14. TV Monitor or projection screen 15. Microphone Other teaching aids
16. ZOE model with accessories 17. Flip chart with stand 18. Large clips to hold chart paper 8
19. Flash cards 20. White board with marker pens 22. Highlighters, marker pens and duster 23. Staplers, stapler pins, punching machine, scissors 24. A4 size plain papers 25. Coloured sticky labels, cello tapes Computer facilities 26. Computers accessible to trainees 27. Internet facility accessible to trainees 28. Printer 29. Photocopier D. Library facility for trainees E. Attitude of facility staff for training 30. Willingness of facility manager/in-charge to make the facility a training site for cervical cancer screening and treatment 31. Potential facilitators among service providers willing to train 32. Other service providers willing to support the activities E. Availability of infrastructure, equipment and supplies for VIA and ablative treatment 33. VIA clinic 34. Clinic and counselling areas well-lit and ventilated 35. Curtains/screens on windows and doors for privacy 36. Space and stools/chairs for counselling 37. Examination tables with mattresses, sheets and pillows 38. Focusing light 39. Instruments and supplies for VIA 40. Instruments and supplies for HPV sample collection 9
41. Equipment and supplies for cryotherapy 42. Equipment and supplies for cold coagulation (optional) 43. Infection prevention facilities 44. Forms, referral cards and registers Final assessment: Site ready Needs additional facilities as listed in remarks column
Signature of person assessing readiness of site:
1.9 Duration of training
The total duration of training will be 10 days. Details of the training schedule and the session plans are given in later sections.
1.10 Record keeping
Training records provide evidence pertaining to the conduct of a training and can be useful in identifying training gaps. Keeping paper records during the training is a simple and convenient method. However, maintaining computerized training records is useful for ease of data retrieval and sharing with programme managers. Facilitators are required to maintain the following records. • Attendance sheet/register of trainees • Trainees experience record • Facilitators’ skills checklist • Log sheets submitted by trainees • Completed assessment questionnaires from trainees • Knowledge assessment matrix filled in by facilitators • Filled in image recognition forms of trainees • Image recognition skills assessment matrix completed by facilitators • Summary performance sheet of trainees
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1.11 Dos and don’ts for facilitators Do • Be conversant with the session plan and training materials prior to start of training • Ensure the training site is ready prior to onset of training • Maintain a friendly and supportive environment • Call trainees by their name as much as possible • Speak clearly and loudly • Spend enough time with trainees so that all their queries can be answered • Give simple and clear instructions to trainees • Ensure clear visualization of the presentations/demonstrations by all trainees • Encourage trainees to interact and be involved in all the sessions • Strictly adhere to the session plan and session contents Don’t • Make adverse/negative about any trainee • Be shy, nervous or worried • Use one-way teaching without any interaction • Ignore trainees’ queries • Make presentations without facing the trainees or avoiding eye contact with them • Use teaching aids or materials other than the prescribed ones • Rush through any of the sessions comments
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Section 2: Session plan
Session plan Day Session Time Contents Registration of name and contact details and Filling up of experience records of trainees Signature of trainee on attendance sheet Handing over of the training folder Introduction of facilitators and trainees Assessment of trainees’ expectations and concerns Presentation of training objectives Ground rules and other logistics of training Agenda of training Pre-training knowledge assessment Day 1 Registration 8:30 a.m.–9:00 a.m. Opening session
9:00 a.m.–10:00 a.m. Welcome of participants
Session 1: Introduction to cervical cancer screening
10:00 a.m.–11:00 a.m. Need for cervical cancer screening
Interactive presentation
Magnitude of problem of cervical cancer Principles of cervical cancer screening Concept of organized screening programme Concept of opportunistic screening programme Protocol for cervical cancer screening Screening tests for cervical cancer Target population for cervical cancer screening Frequency of cervical cancer screening Informed consent for cervical cancer screening National cervical cancer screening protocol
Session 2: Anatomy 11:00 a.m.–12:00 p.m. and physiology of female genital tract
2 a: Interactive presentation
Gross anatomy of female external and internal genitalia Microscopic features of cervical epithelium and concept of squamocolumnar junction (SCJ)
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Day
Session
Time
Contents Metaplasia and concept of transformation zone (TZ) Features of normal TZ Changes in TZ during pregnancy and menopause Recognition of parts of uterus and cervix on models Recognition of the microscopic anatomy on digital images Speculum examination on ZOE model
2 b: Facilitated group learning activity Session 3: Pathogenesis of cervical cancer with special reference to HPV infection
12:00 p.m.–1:00 p.m. Risk factors of cervical cancer
Interactive presentation Lunch break 1:00 p.m.–2:00 p.m. 2:00 p.m.–4:00 p.m. Session 4: Counselling
Epidemiology of HPV infection Mechanism of carcinogenesis by HPV infection Natural history of cervical intra-epithelial neoplasia
4 a: Interactive presentation 4 b: Facilitated group learning activity Summary of the day’s activities Discussion of the next day’s agenda
Necessity of counselling Being a good counsellor Steps for counselling Using checklists, flip chart and counselling cards Counselling messages Role play
4:00 p.m.–4:30 p.m. 4:30 p.m.–5:00 p.m.
Key points to be presented by trainees Discussion to be led by the facilitator
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Day
Session
Time
Contents Presentation of key-points by trainees. Discussion to be led by facilitators for doubt clearance
Day 2 9:00 a.m.–9:30 a.m. Review of the previous day’s activities and doubt clearance Session 5: Screening by visual inspection using acetic acid (VIA) 9:30 a.m.–11:00 a.m.
5 a: Interactive presentation 5 b: Facilitated group learning activity Session 6: HPV 11:00 a.m.–12:00 p.m. detection test and cervical sample collection technique for HPV test
Principles of VIA Equipment/instruments required Consumables required Steps of VIA VIA test outcome categories Documentation of VIA findings Common benign conditions of cervix detected at VIA Common lower genital tract infections detected before VIA Post-VIA tasks and follow-up Image recognition skill (Flash cards/digital images)
6 a: Interactive presentation
Types of HPV detection tests Equipment/instruments required Consumables required Steps of cervical sample collection Sample transportation and storage Interpretation of test results Practise on ZOE model
6 b: Facilitated group learning activity
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Day
Session Session 7: Management of women with positive VIA or HPV test
Time 12:00 p.m.–1:00 p.m.
Contents
7 a: Interactive presentation
Management of VIA positive women Management of HPV positive women Importance of reducing the number of visits for screening Treatment options for cervical precancers Follow-up of women after treatment Case studies
7 b: Facilitated group learning activity Lunch break
1:00 p.m.–2:00 p.m.
Session 8: 2:00 p.m.–3:00 p.m. Treatment of cervical precancers by cryotherapy and follow-up Principles of cryotherapy Instruments and consumables required Eligibility criteria for cryotherapy Steps of cryotherapy Post treatment advice Advantages and limitations Management of treatment complications Troubleshooting Sterilization of equipment Role play
8 a: Interactive presentation
8 b: Facilitated group learning activity
Session 9: 3:00 p.m.–3:45 p.m. Treatment of cervical precancers by cold coagulation and follow-up
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Day
Session
Time
Contents Principles of cold coagulation Instruments and consumables required Eligibility criteria for cold coagulation Steps of cold coagulation Post treatment advice Advantages and disadvantages Management of treatment complications Troubleshooting Sterilization of equipment Role play
9 a: Interactive presentation
9 b: Facilitated group learning activity
3:45 p.m.–4:15 p.m. Importance of infection prevention Session 10: Infection practices prevention Standard precautions practices 10 a: Interactive presentation 10 b: Facilitated group learning activity Day 3 Summary of the day’s activities Discussion of the next day’s agenda Prevention of spread of infection, hand washing Processing of instruments Waste disposal Role play
4:15 p.m.–4:45 p.m. Key points to be presented by trainees 4:45 p.m.–5:00 p.m. Discussion to be led by the facilitator Presentation of key-points by trainees Discussion to be led by facilitator for doubt clearance Ensuring quality of services by healthcare providers Programme monitoring and its necessity Indicators to monitor cervical cancer screening programme
Review of the 9:00 a.m.–9:30 p.m. previous day’s activities and doubt clearance Session 11: 9:30 a.m.–10:30 a.m. Ensuring quality of services and programme monitoring in cervical cancer screening
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Day
Session
Time
Contents Quality assurance and quality control Framework for effective quality assurance Supportive supervision Supportive supervision guidelines and tool Evaluation of programme performance Using evaluation results for quality improvement
Organization of groups for clinical sessions Clinic based training Demonstration session 10:30 a.m.–11:00 a.m.
11:00 a.m.–4:00 p.m. 11:00 a.m.–11:30 a.m. Introduction to ingredients and consumables Method of preparation Storage and use Precautions
i) Preparation of dilute acetic acid ii) Preparation of Lugol’s iodine iii) Preparation of 0.5% chlorine solution
iv) Arrangement of instrument tray for HPV sample collection v) Arrangement of instrument tray for VIA Clinical skills training 11:30 a.m.–1:00 p.m.
Introduction to instruments and consumables Working with the instruments Decontamination and sterilization of instruments
i) Counselling
Individual counselling / group counselling/couple counselling using skills checklist, counselling cards and flip charts
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Day
Session
Time
Contents Observation of procedure on client Procedure to be performed under supervision technique for procedure to be performed client independently on HPV testing Observation of procedure on client Procedure to be performed under supervision Procedure to be performed independently on client
ii) Sample collection technique for HPV testing iii) VIA
Lunch break 1:00 p.m.–2:00 p.m. 2:00 p.m.–2:30 p.m. Demonstration session
i) Getting to know cryotherapy/ cold coagulator equipment ii) Arrangement of instrument tray for cryotherapy/ cold coagulation Clinical skills training 2:30 p.m.–4:00 p.m.
Introduction to different parts of cryotherapy/ cold coagulator unit Functions of each part of the unit Connections and adjustments Equipment maintenance Troubleshooting Introduction to instruments and consumables Working with the instruments Decontamination and sterilization of instruments
i) Treatment with cryotherapy/ cold coagulation Summary of the day’s activities Discussion of the next day’s agenda
Procedure to be performed on client Simulated learning Procedure to be performed under supervision
4:00 p.m.–4:30 p.m. Key points to be presented by trainees 4:30 p.m.–5:00 p.m. Discussion to be led by the facilitator Presentation of key-points by trainees Discussion to be led by facilitator for doubt clearance
9:00 p.m.–9:30 p.m. Day 4– Review of the previous day’s Day 5 activities and doubt clearance
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Day
Session
Time
Contents
Classroom training Image recognition 9:30 a.m.–10:30 a.m. Presentation: Videos of procedures being session (digital or performed flash cards) / video presentation Clinic based training 10:30 a.m.–4:00 p.m.
Practice session on 10:30 a.m.–11: 00 a.m. preparation of dilute acetic acid, Lugol’s iodine, 0.5% chlorine solution Clinical skills training 11:00 a.m.–1:00 p.m. Individual counselling / group counselling/couple counselling using skill checklists, counselling cards and flip charts Observation of procedure on client Procedure to be performed under supervision Procedure to be performed independently on client Observation of procedure on client Procedure to be performed under supervision Procedure to be performed independently on client Observation of procedure on client Simulated learning Procedure to be performed under supervision Procedure to be performed independently on client
i) Counselling ii) Sample collection technique for HPV testing iii) VIA
iv) Treatment with cryotherapy/ cold coagulation Lunch break 1:00 p.m.–2:00 p.m. 2:00 p.m.–4:00 p.m.
Clinical skills training
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Day
Session
Time
Contents Individual counselling / group counselling/couple counselling using skill checklists, counselling cards and flip charts Observation of procedure on client Procedure to be performed under supervision Procedure to be performed independently on client Observation of procedure on client Procedure to be performed under supervision Procedure to be performed independently on client Observation of procedure on client Simulated learning Procedure to be performed under supervision Procedure to be performed independently on client
i) Counselling ii) Sample collection technique for HPV testing iii) VIA
iv) Treatment with cryotherapy/ cold coagulation
Summary of the day’s activities Discussion of the next day’s agenda
4:00 p.m.–4:15 p.m. Key points to be presented by trainees 4:15 p.m.–4:30 p.m. Discussion to be led by the facilitator Orientation to mid-course assessment, explanation of assessment process (knowledge assessment and skills assessment) Presentation of key-points by trainees Discussion to be led by facilitator for doubt clearance
4:30 p.m.–5:00 p.m. Preparation for mid-course assessment Day 6 9:00 a.m.–9:30 a.m. Review of the previous day’s activities and doubt clearance Mid-course assessment 9:30 a.m.–3:30 p.m. 9:30 a.m.–11:00 a.m.
Knowledge assessment Preparation
9:30 a.m.–10:00 a.m. Aims and objectives Assessment process (knowledge assessment and clinical skills assessment)
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Day
Session
Time
Contents
10:00 a.m.–11:00 a.m. Administration of knowledge assessment Conducting knowledge questionnaire and image recognition skill assessment assessment form 11:00 a.m.–3:30 p.m. Counselling Clinical skills assessment Sample collection technique for HPV testing VIA Lunch break 1:00 p.m.–2:00 p.m. Counselling Sample collection technique for HPV testing VIA Treatment with cryotherapy/cold coagulation Treatment with cryotherapy/cold coagulation
2.00 p.m.–3.30 p.m. Clinical skills assessment (contd.) Review of filled 3:30 p.m.– 4:00 p.m. in mid-course knowledge assessment questionnaires, image recognition forms and assessment matrix sheets Discussion of clinical skills assessment Discussion of the next day’s agenda
4:00 p.m.– 4:30 p.m. Key points to be presented by trainees
4:30 p.m.–5:00 p.m.
Discussion to be led by the facilitator Presentation of key points by trainees Discussion to be led by facilitator for doubt clearance
9:00 a.m.–9:30 a.m. Day 7– Review of the previous day’s Day 8 activities and doubt clearance Classroom training
Image recognition 9:30 a.m.–10:30 a.m. Presentation: Videos of procedures being session (digital performed or flash cards) / video presentation Clinic based training 10:30 a.m.–4:00 p.m.
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Day
Session
Time 10:30 a.m.–11:00 a.m.
Contents
Practice session on preparation of dilute acetic acid, Lugol’s iodine, 0.5% chlorine solution Clinical skills training
11:00 a.m.–1:00 p.m. Individual counselling / group counselling/couple counselling using skill checklists, counselling cards and flip charts Observation of procedure on client Procedure to be performed under supervision
i) Counselling ii) Sample collection technique for HPV testing
Procedure to be performed independently on client iii) VIA Observation of procedure on client Procedure to be performed under supervision Procedure to be performed independently on client
iv) Treatment with Observation of procedure on client cryotherapy/ Procedure to be performed under cold supervision coagulation Procedure to be performed independently on client Lunch break Clinical skills training 1:00 p.m.–2:00 p.m. 2:00 p.m.– 4:00 p.m. Individual counselling / group counselling/couple counselling using skill checklists, counselling cards and flip charts Observation of procedure on client Procedure performed under supervision Procedure performed independently on client Observation of procedure on client Procedure to be performed under supervision Procedure to be performed independently on client
i) Counselling ii) Sample collection technique for HPV testing iii) VIA
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Day
Session
Time
Contents Observation of procedure on client Procedure to be performed under supervision Procedure to be performed independently on client
iv) Treatment with cryotherapy/ cold coagulation Summary of the day’s activities Discussion of the next day’s agenda
4:00 p.m.– 4:15 p.m. Key points to be presented by trainees 4:15 p.m.– 4:30 p.m. Discussion to be led by the facilitator Orientation to final assessment, explanation of final assessment process (knowledge assessment and skills assessment) Presentation of key points by trainees Discussion to be led by facilitator for doubt clearance
4:30 p.m.–5:00 p.m. Preparation for final assessment (Day 8) Day 9 of the 9:00 a.m.–9:30 a.m. Review previous day’s activities and doubt clearance Final assessment Knowledge assessment Preparation 9:30 a.m.– 4:00 p.m. 9:30 a.m.–11:00 a.m.
9:30 a.m.–10:00 a.m. Aims and objectives
10:00 a.m.–11:00 a.m. Administration of knowledge assessment Conducting knowledge questionnaire and image recognition skill assessment assessment form 11:00 a.m.–4:00 p.m. Counselling, sample collection technique for Clinical skills assessment HPV testing VIA, treatment with cryotherapy/cold coagulation
Lunch break
1:00 a.m.–2:00 p.m. 4:00 p.m.– 4:30 p.m.
Review of filled in knowledge assessment questionnaire and image recognition forms and assessment matrix sheets
Discussion of next 4:30 p.m.–5:00 p.m. step forward and action plan Discussion of next 4:30 p.m.–5:00 p.m. day’s agenda
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Day
Session
Time
Contents Counselling, sample collection technique for HPV testing VIA, treatment with cryotherapy/cold coagulation
Day 10 9:30 am–12:30 pm Clinical skills assessment Filling in of feedback forms Lunch break 12:30 p.m.–1:00 p.m. 1:00 p.m.–2:00 p.m.
2:00 p.m.–3:00 p.m. Discussion of clinical skills assessment Certificate distribution and comments from trainees Closing 3:00 p.m.–4:00 p.m.
Discussion of summary performance sheets Feedback forms
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Section 3: Training methodologies
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3.1 Introduction The training on VIA, HPV test and cryotherapy involves knowledge development through interactive presentations and skill enhancement through group learning activities and clinical sessions. Training sessions should be conducted according to a pre-decided schedule and adherence to this schedule is important for timely and efficient conduct of sessions. Facilitators should meet daily after all the sessions are over to review the day’s activities and plan for the next day’s training and to ensure availability of all training materials and teaching aids. All facilitators should be in agreement about each others’ roles and responsibilities prior to the start of training. The training has two primary components: • classroom training; • clinic-based training. Both components include the group learning activities for which the breakout groups should be formed as instructed in Box 3.1. Box 3.1: Formation of breakout groups • Organize trainees into small groups during the opening session • Each group should not have more than four trainees • Designate one facilitator to each group • Print a list showing the groups to which trainees and facilitators have been assigned • Display the list in the classroom and in the clinical stations for all trainees to see • Instruct trainees not to change groups
3.2 Guidelines for conducting classroom training
• Conduct all the interactive presentations, video presentations and some of the breakout group learning activities (as indicated in the modules) in the classroom. • Start each day’s session in the classroom by reviewing the previous day’s activities and discuss the relevant queries of the trainees. Let trainees respond to each others’ queries. The facilitator may provide the correct explanation if trainees are not able to do so correctly. • Review the day’s timetable along with the trainees. • For each session: Follow the instructions for conducting training as per the corresponding modules given in Section 5 of the Facilitators’ guide. Present the learning objectives at the beginning of each session. Use the PowerPoint and video presentations included in the teaching aids for each module.
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Refer to the facilitated group learning activities listed at the end of each module. Facilitated group learning activities in the classroom include: – role plays; – image recognition (digital images/flash cards); – case studies; – practise on ZOE models or other models; – demonstration of different equipment. • At the end of each day, ask trainees to summarize the day’s activities and the key points. • Brief trainees on the next day’s agenda.
3.2.1 Guidelines for delivering PowerPoint presentations Purpose: PowerPoint presentations serve as excellent teaching tools that help in transfer of knowledge with focused content, clear messages and effective visuals. They enhance the learning process by allowing trainees to analyse, interpret and interact on topics covered. Preparation a. Know the subject well by reading individual modules and the corresponding information in the WHO Guidance book relevant to the PowerPoint presentation. b. Familiarize yourself with the contents and sequence of the presentation. c. Refer to the key points for discussion for the corresponding module provided in this manual. d. You may add your own notes to emphasize issues of local importance. e. Rehearse the presentation so that you cover all important points within the given time limit. Delivering the presentation • Check the seating arrangement to make sure that the slides are clearly visible to trainees. • Introduce yourself, if not done earlier. • Speak clearly and ensure that all trainees can hear you. • Inform trainees that they are free to ask questions anytime during the presentation and can do so one at a time by raising their hands. • Introduce the topic and give an overview of the content of the presentation. • Face the trainees and not the slides while making presentations. • You may use a pointer, stick or pencil to indicate a specific part of the presentation. • Explain each slide slowly, highlighting the key points. • Never read from slides or from the notes.
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• Make sure you cover all the information provided in the notes accompanying each slide. • Maintain the logical order of ideas in the presentation. • Do not give extra information except about updated information or relevant national/regional guidelines. • Make the presentation interactive by asking trainees questions in between slides. This will also allow you to assess their understanding. • Keep the interactive discussion focused on the topic of the presentation. • Strictly adhere to the time limit of the presentation. • Summarize key points at the end of the session. • Allow time for questions from trainees. Provide complete answers. • Thank trainees after the presentation.
3.2.2 Guidelines for video presentations Purpose: Video presentations a clinical procedures allow trainees to become familiar with the procedure while remaining in a classroom setting. It is an excellent tool to learn the steps of a procedure before doing it in clinical practice. Preparation • Check the video well in advance by using the projection system and computer used for classroom teaching. • Familiarize yourself with the contents of the video and make your own notes for the session. • Check seating arrangements so that all trainees are able to see the videos clearly. Presenting a video • Inform trainees about the objective of showing the video and the procedure that it will show. • Ask trainees to carefully watch all the steps of the procedure shown. • Ask them to list their queries, if any, for discussion at the end of the video presentation. • Discuss the queries systematically. If required, repeat relevant segments of the video for improved understanding. • Summarize key points at the end of the session.
3.2.3 Guidelines for managing a role play Purpose: Role plays are conducted to give trainees an opportunity to practise and perfect their knowledge and skills in a non-threatening and simulated environment before performing procedures on clients. Role plays help in changing attitudes of trainees towards concerned problems.
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Organizing a role play • Check the list of suggested role plays provided at the end of the corresponding module and select one of them. • Identify the group that will be performing the role play. • Identify or ask trainees to volunteer to enact the specified roles. • Brief trainees about the background situation and focus of the role plays described in the module. • Clearly describe each role to the trainees. • Encourage adherence to the counselling steps given in the checklists while enacting role plays for counselling. • Allow trainees adequate time (10 min) to develop the script for the given situation. • Ensure that the focus of the script remains on the theme related to the given topic. • Assign the role of observers to the remaining trainees. Observer trainees should use the skills checklist to observe trainees playing the role of providers and give feedback at the end. • Set a time limit for the role play (approximately 7–10 min). • Ask trainees to speak loudly and clearly. • Ensure the role play remains focused to the given situation. • Thank the group after the role play is over. • Ask trainees (actors) how they felt while performing the role. • After completion of the act, facilitate debriefing by asking observer trainees to provide constructive feedback. Discuss what else could have been addressed during the role play. • Provide constructive feedback and necessary improvements for the benefit of the whole group. • Encourage all trainees of the group to ask questions. Always ensure complete answers are given. • Check Box 3.2 for a model role play. While conducting role play or case studies, the facilitator may change the subjects’ names, locations or the circumstances of the situation as described in the module to make them locally and culturally appropriate.
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Things to be observed during a role plays • How did the trainee enacting the role of provider approach the trainee enacting the role of client? • Did the provider use language easily understood by the client? • Did the provider encourage the client to talk, to make the communication two-way and share her concerns? • Did the provider give the client enough information relevant to the given situation? • Was the provider non-judgmental and using positive verbal and non-verbal communication? • Did the provider use any educational tools or audio-visual aids to clarify the messages effectively? • Did the provider encourage the client to ask questions? • Did the provider adequately address the client’s questions and concerns? • What could the provider do to improve the interaction with the client? Box 3.2: Model role play Counselling a woman for VIA test • Roles and background situation for the role play Select trainees or ask trainees from the group to volunteer to perform the following roles: – Marium, a 30-year-old woman, having two children, who is seeking VIA at a primary health centre. She has been advised by the community health worker to take a VIA test. – Seetha, a nurse who performs VIA at the primary health centre. The entire group, including the role players, should know the following background situation: Marium has been advised by a community health worker to take a VIA test. Marium has been told that this test can detect cancer. She has never had this test before and is very nervous and anxious that the test may be painful.
• Focus of the role play The focus of the role play is the interaction between a woman seeking VIA test for the first time in her life and a nurse provider. Seetha assesses Marium’s knowledge about cervical cancer and its early detection through screening and finds out that the community health worker has not explained anything to her. Seetha explains the necessity of VIA and how the procedure will be done. She explains that the test is primarily to identify women who have the risk of developing cervical cancer in future, though cancer can also be detected by the test. She reassures Marium that the test is not at all painful but some women may experience discomfort. Seetha describes in brief how treatment would be done, if possible at the same visit, in case any abnormalities are detected after the test. As Marium agrees to have the test, Seetha gets the consent form signed by Marium.
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• Time allotted for the role play: 10 minutes
3.2.4 Guidelines for conducting case studies Purpose: Case studies allow trainees to thoroughly analyse a situation or a case that will reveal interesting and useful information and their attitudes towards the issue of the case study. Case studies are preferably done in small groups to allow everyone to participate, including those who might not speak in a larger group. Preparation • Check the list of suggested case studies provided at the end of the corresponding module and select one. • Familiarize yourself with the case study and the issue to be discussed. • Prepare a slide of the case study for projection during the session or have print outs of it/them for distribution to the groups. How to conduct case studies • Identify groups for discussion of case studies and let each group select their group rapporteur. • Project the slide of the selected case study describing a familiar problem/situation or distribute hand-outs of the case study to the group. • Include images where appropriate and show the images along with the case study. • Allow trainees to go through the problem/situation and discuss. Assign time for group work (approximately 10 minutes). • Ask group rapporteurs to present their group’s point of view regarding the case along with their rationale and further course of action, if appropriate. • Ask the members of other groups to comment and provide their inputs, if any, on the case. • Facilitate the necessary corrections with explanations and ask one member of the group to record the key points on a flip chart. • Ask a trainee to make a final brief summary of the case and the course of management. • Encourage all trainees to ask questions and give feedback. • A model case study is given in Box 3.3.
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Box 3.3: Model case study Case study: Woman with a positive VIA test Jeena, a 32-year-old woman, has attended the primary health centre for VIA. She has been examined by Fileeshia the nurse at the health centre. Appearance of the cervix before and after acetic acid application is given below: VIA Cryo pictures shown Questions for discussion
What is the VIA diagnosis (explain with reasons)? – negative/positive/suspected cancer.
Before acetic acid application
What advice (treatment and follow-up) will you give to her? After acetic acid application Time allotted for case study: 10 minutes *Reproduced with permission from Atlas of Colposcopy and Management of Cervical Precancers. IARC, Lyon (forthcoming)
3.2.5 Guidelines for conducting an image recognition session
Purpose: Image recognition helps teach trainees how to identify normal and abnormal features of a cervix based on digital images. They can also be taught to plan management of women based on clinical information and the images. i) Conducting an image recognition session using digital images Preparation • Check the corresponding module to find out if the image recognition session is included in the group learning activities for that module. • Ensure that images for the session are included in the PowerPoint presentation of the corresponding module. • Familiarize yourself with the images and their descriptions. How to conduct the session • Identify groups for the image recognition session. • Explain that images of the cervix will be projected in sets. Each set of images will have a picture of the cervix in the following sequence – before application of acetic acid and 1 minute after application of acetic acid. • Inform trainees that they will have to fill out the image recognition form (Box 3.4) for each set of images.
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• Project each set of images for 1 minute. Ask trainees to identify the SCJ, detect if there is any abnormality, give the VIA diagnosis and comment on the appropriate management for each set of images. • Collect all the forms from trainees and later review them and fill in the image recognition skills assessment matrix (Box 3.5). • Discuss the correct answers and clarify doubts. Box 3.4: Image recognition form Image set 1. Description of features Management
a) Visualization of SCJ – completely visible, • Screen after 5 years partially visible, not visible • Cryotherapy b) Acetowhite area – absent/ present • Refer for colposcopy c) VIA diagnosis – Negative/positive/suspected cancer • Refer for treatment of cancer a) Visualization of SCJ – completely visible, partially • Screen after 5 years visible, not visible • Cryotherapy b) Acetowhite area – absent/present • Refer for colposcopy c) VIA diagnosis – Negative/positive/suspected cancer • Refer for treatment of cancer a) Visualization of SCJ – completely visible, partially • Screen after 5 years visible, not visible • Cryotherapy b) Acetowhite area – absent/ present • Refer for colposcopy c) VIA diagnosis – Negative/positive/suspected cancer • Refer for treatment of cancer
2.
3.
Box 3.5: Image recognition skills assessment matrix Note: Put a in the row of each trainee for questions that have a correct response. Trainee number Correct responses to image question sets Set 1 a b c 1 Set 2 a b c ... Set 5 VIA Management a b c VIA Management VIA Management
2 3 4 5 6 7 8 9 10 35
ii) Conducting an image recognition session using flash cards There are 115 flash cards in the set. Cards are numbered serially from 1–115 to help track cards that are viewed during group activity. (20 Colposcopy sets & 20 VIA sets). The front of the flash card displays a coloured image of the cervix and the flash card number. The back of the flash card shows the same image in black and white with lines pointing to the SCJ and any lesion/s. It also contains 5 questions, uniform for all cards, about the cervical image and potential management options, followed by answers related to VIA clinical training based on each question. The upper right hand corner of the back of the card has a quick reference box that identifies each image as negative (blank box), positive (box with diagonal lines) or suspicious for cancer (dark box). These boxes help in choosing a specific number of positive, negative and/or cancerous images for trainees to review. Questions are listed on a separate question card that has all the possible questions for a cervical image. A set of 10 blank answer sheets are provided for the trainee to record answers for each set of 10 cards reviewed. Each sheet contains a place to record the card number and the trainees’ answers in sequence. The cards are laminated, allowing answers to be written in dry-erase marker that can be wiped clean for reuse. Facilitators and trainees should use copies of the blank sheets when using other writing pens or pencils and when reviewing more than 10 cards at a time. At the end of each set is an index card that lists the cards by number and by finding – negative, positive or suspicious for cancer. Preparation • Read the cards on significance of acetowhite lesions and eligibility for cryotherapy. • Make yourself familiar with the instructions for uses, questions, answer sheet and layout of the flash card images. • Select the cards you plan to use during the session. (It is recommended to use small groups of cards rather than all the cards in one sitting, to avoid the exercise from becoming too overwhelming and time consuming). • Make sure enough blank answer sheets or pieces of paper are available to record answers. If using the laminated sheets from the set, use only erasable markers to record answers. How to conduct the session (when working with a single group) • Check if the image recognition session is included in the group learning activities in the corresponding module. • Identify the group for the image recognition session using flash cards. • Start the session by holding selected cards one-by-one in such a manner that the coloured image side (front of the card) faces the trainee and the back of the card faces you. • Ask the trainee to look at the image carefully and then ask questions one-by-one from the back of the card. • Identify the knowledge gaps and discuss the correct answers after review of each card. • Repeat the exercise with all selected cards for the session. 36
How to conduct the session (when working with more than one group) • Check if the image recognition session is included in the group learning activities of the corresponding module. • Identify groups for the image recognition session using flash cards. • Distribute at least 10 selected flash cards to each group (either the same flash cards from two flash card sets, or different but similar flash cards for lesion, diagnosis and type of management). • Take a flip chart and draw columns on the chart equal to the number of groups and write individual group names or numbers at the top of each column. • Ask one group to pull out a specific card from the given set, e.g., VIA negative card. • Check the card and ask the other group whether or not they agree. Discuss doubts if any. • The group that pulls out the correct card gets one mark displayed on the flip chart. • Repeat the exercise with other specific characteristics, e.g., VIA positive, suspicious for invasion. Keep adding the tally marks on the flip chart. • Score the marks obtained by each group at the end of the exercise. • Praise the group that obtains the highest marks. • Thank the groups at the end of the session.
3.2.6 Guidelines for practising on a ZOE model Purpose: The ZOE model is a simulator of the female pelvis and lower abdomen that can be used by facilitators to demonstrate, and trainees to learn, how to perform speculum examination, exposure of the cervix and application of cryotherapy probes on the cervix. Using the ZOE model for demonstration/practise of various techniques Preparation • Assemble the ZOE model with all the different anatomical parts of the female pelvis according to the instruction manual. • Put the model at the edge of an examination table with a focus lamp adjusted to view the inside of the vagina. Demonstrating various procedures a) Speculum examination and exposure of cervix Wash hands and wear disposable or high-level disinfected gloves on both hands. Select an HLD/sterile appropriate sized bi-valve speculum. Dip it into HLD water (boiled and cooled) or available lubricant (not on ZOE). Inform trainees that before inserting the speculum, they should explain what they are going to do and assure the woman that it will not be painful. However, she may feel some discomfort. Retract the labia minora with one hand.
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Insert the speculum keeping the blades closed and angled posteriorly. Once completely in the vagina, open the blades until the cervix is fully visualized. Fix the blades of the speculum by tightening the screws. See the cervix with the oval shaped external os at the centre. Perform the necessary procedures (collect a cervical sample for the HPV test or apply cryotherapy probe on the cervix). Loosen the screws and close the blades of the speculum. Remove the speculum gently and decontaminate it and other instruments used in 0.5% chlorine solution. Dip gloved hands in 0.5% chlorine solution and remove them, wash hands and air dry. b) Application of cryotherapy probe Follow the same steps as above to expose the cervix. Select a cryotherapy probe of appropriate size to cover the cervix. Connect the probe to the cryotherapy machine and apply it on the cervix. Make sure that the probe is free from the vaginal wall. Withdraw the probe without touching the vagina. Remove speculum as before. Dip gloved hands in 0.5% chlorine solution and remove them, wash hands and air dry. c) Collection of cervical sample for HPV detection test Expose the cervix following the above mentioned steps. Insert the sample collection brush/broom into the external os until the outer bristles touch the ectocervix. (Do not insert the brush/broom completely into the endocervical canal). Gently rotate the brush/broom in a clock-wise direction 3–5 times. Remove the brush/broom from the canal. Remove speculum as before. Dip gloved hands in 0.5% chlorine solution and remove gloves, wash hands and air dry.
3.2.7. Guidelines for conducting demonstration sessions on equipment Purpose: Demonstration sessions are fundamental for acquisition of new clinical skills and to allow small group interactions facilitating the learning process. In this session, trainees will learn about the different parts of the equipment, their accessories and usage. 38
Preparation • Identify and prepare the place where you will conduct demonstration sessions. • Ensure adequacy of space to avoid crowding. • Ensure all trainees in the group can clearly see the demonstration performed by you. • Make sure all materials required by you for the proposed session are available well in advance. The list for instruments/equipment required for demonstrations is given in Table 3.1. • You may require someone to help you while giving the demonstrations. Identify your assistant (e.g., a trainee or a nurse) beforehand and brief her/him on the activity and her/his role. • You may arrange a practice demonstration session with your assistant, if possible, a day or two earlier than the proposed day of the session. How to conduct demonstration sessions • Ensure all trainees in the group can clearly see the demonstration being performed by you. • Give demonstrations slowly and step-by-step. Follow the discussion points given in the boxes below. • After you have finished demonstrating, encourage trainees to ask questions. Answer all queries. Table 3.1: List of demonstration sessions in the classroom and the items required Module Module name no. 8 Treatment of cervical precancers by cryotherapy and follow-up Demonstration session Getting to know the cryotherapy machine and its accessories Items required • Cryosurgical unit: Cryoprobes Cryogun Gas conveying tube Pressure gauge Gas cylinder connector • Gas cylinders • Skills checklist 9 Treatment of cervical precancers by cold coagulation and follow-up Getting to know the cold coagulator machine and its accessories • Cold coagulator • Metallic probe • Wire for electrical connection • Skills checklist
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Box 3.6: Discussion points for demonstration of the cryotherapy unit • Introduction to the cryotherapy unit • Parts of the cryotherapy unit and functions of each part • How to get the cryotherapy unit ready for use • Equipment maintenance • Troubleshooting Box 3.7: Discussion points for demonstration of the cold coagulator unit • Introduction to the cold coagulator • Parts of the cold coagulator and functions of each part • How to get the cold coagulator unit ready for use • Equipment maintenance • Troubleshooting
3.3 Guidelines for conducting clinic-based training
The clinic-based training comprises both facilitated group learning activities and clinical skills training to learn VIA, sample collection techniques for HPV testing, treatment by cryotherapy and cold coagulation. Facilitated group learning activities at the clinic • Demonstration of preparation of different consumables • Simulated learning procedures Phases of clinical skills training • Letting trainees observe the procedures • Letting trainees perform procedures under supervision with assistance • Letting trainees perform procedures independently Clinical skills training • Maintain the same groups of trainees as done for classroom teaching. • Reorganization of the groups may be necessary if the number of clinical practice stations is different from the original number of groups. • Ask trainees to consult the checklists in the corresponding module of the Trainees’ handbook for step-by-step learning of the procedures for simulated learning and clinical skills training. • During initial clinical practice sessions, perform clinical procedures (VIA, cryotherapy, etc.) yourself and allow trainees to observe, using the relevant skills checklist. • Ask trainees to carry out the procedures under your supervision after they have observed the recommended number of cases. 40
3.3.1 Guidelines for conducting demonstration sessions on preparation of consumables Purpose: Demonstration sessions are fundamental for acquisition of new clinical skills and to allow small group interactions facilitating the learning process. In this session trainees, will learn and practise the steps for preparing different consumables required for cervical cancer screening. Preparation • Identify and prepare the place where you will conduct demonstration sessions. • Ensure adequacy of space to avoid crowding. • Ensure all trainees in the group can clearly see the demonstration performed by you. • Ensure all materials required for the proposed session are available well in advance. The list of consumables required for demonstrations in clinics is given in Table 3.2. • You may require someone to help you while giving some of the demonstrations. Identify your assistant (e.g., a trainee or a nurse) beforehand and brief her/him on the activity. • You may arrange a practice demonstration session with your assistant, if possible, a day or two earlier than the proposed day of the session. • Familiarize yourself with the steps of the skill to be demonstrated. How to conduct demonstration sessions • Ensure all trainees in the group can clearly see the demonstration performed by you. • Give demonstrations slowly and step-by-step. • Allow at least one trainee to do the procedure. • After you have finished demonstrating, give trainees time to ask questions. Answer all queries completely. Table 3.2: List of demonstration sessions in the clinic and items required Module no. 5. Module name Principles and technique of VIA Demonstration session Preparation of dilute acetic acid Items required • Glacial acetic acid • Distilled water • Glass container • Graduated measuring cylinder • 10 ml syringe • Gloves • Labels • Lab apron
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10.
Infection prevention practices
Preparation of 0.5% chlorine solution
• Bleaching powder kept in air tight container • Plastic bucket (medium size) with lid and mug • Wooden stirrer • Plastic tea spoon • Water • Utility gloves • Labels • Lab apron
3.3.2 Guidelines for conducting simulated learning sessions Purpose: Simulated learning sessions are designed with specific learning objectives for each technique/procedure. They offer ample opportunity to trainees for hands-on learning in a structured manner. Debriefing is also conducted in a non-threatening environment for competence building. Simulated learning helps in integrating theoretical knowledge with practical skills necessary for service delivery. Preparation • Identify and prepare the place where you will conduct simulation sessions. • Ensure adequacy of space to avoid crowding. • Ensure all trainees in the group can clearly see the procedure performed by you. • Ensure that all materials required for the proposed simulation session are available well in advance. The list for equipment/instruments and consumables required for simulation sessions is given in Table 3.3. • Familiarize yourself with the steps of the procedure to be demonstrated. How to conduct simulated learning sessions • Explain the learning objectives of the particular simulated learning session and orient trainees to the procedure. • Familiarize trainees with the necessary equipment/instruments and consumables prior to the start of the simulation session. • Explain the sequence of steps of the simulation procedure you are going to perform. • Ask trainees to consult the checklist for the particular procedure that is provided in the corresponding module. • Carry out the simulation procedure slowly and step-by-step. • Debrief after the simulation procedure and encourage trainees to ask questions. • Ask each trainee to carry out the simulation by turn and provide necessary guidance. 42
• Have individual discussions with trainees about the procedure steps you think the trainee should practise and improve before performing on clients. If required, repeat the simulation procedure yourself, stressing on identified problem areas. • Inform trainees about supporting texts given in the corresponding module and advise them to read these before attending the relevant clinical skills training sessions. Table 3.3: List of simulated learning sessions and the items required Module no. 8. Module name Treatment of cervical precancers by cryotherapy and follow-up Demonstration session Cryotherapy procedure Items required • Cryosurgical unit • Gas tanks containing compressed refrigerants • Gloves • Apple, animal tissue • Marker pen or whitener • Skills checklist 9. Treatment of cervical precancers by cold coagulation and follow-up Cold coagulation procedure • Cold coagulator • Extension board for electrical connection • Gloves • Apple, animal tissue • Marker pen or whitener • Skills checklist How to use the LEEP trainer model for a simulated cryotherapy procedure Fig. 3.1 shows the steps of assembling the LEEP trainer model. The model consists of a base plate, a circular rim attached to the plate and a detachable cylindrical pipe (Fig. 3.1a). The cylinder is positioned on the base plate by sliding it through the circular rim so that one end rests on the base plate and the other end remains open (Fig. 3.1b). The cylinder serves as a realistic representation of the vaginal sidewalls. The final assembled model is shown in (Fig. 3.1c). Fig. 3.2 shows the steps for performing a simulated cryotherapy procedure using the LEEP trainer model: • Take an apple or animal tissue (e.g., sausage) and cut a small piece to resemble the cervix (Fig. 3.2a). • Use a white ink/whitener/white nail polish, etc. to draw an acetowhite lesion on the piece. • Place the cut apple or animal tissue inside the lumen of the inner cylinder in such a way that it rests on the base of the facilitator model. Make sure the piece fits snugly into the lumen of the inner cylinder so that it remains stable and does not slip. • Select a suitable cryoprobe (Fig. 3.2b) so as to cover the acetowhite area drawn on the “cervix”. • Take care not to touch the sides of the cylinder (Fig. 3.2c) representing vaginal sidewalls. 43
• Perform the cryotherapy procedure step-by-step (Fig. 3.2d) according to the checklist provided in the module. • Remove the cut and frozen portion of the apple or animal tissue. • Reuse the remaining portion of apple or animal tissue to recreate the necessary numbers of "cervix" for further simulated learning. • Remove the left over apple or animal tissue/other debris and clean the LEEP model thoroughly. Fig. 3.1: Assembling the LEEP trainer model Circular rim
Cylindrical pipe Base plate Fig. 3.1(a): Model consisting of base plate, circular rim attached to the plate and detachable cylindrical pipe
Fig. 3.1(b): Positioning of the cylinder by sliding it through the circular rim
Fig. 3.1(c): Final assembled LEEP trainer model
Fig. 3.2: Simulation of cryotherapy procedure using the LEEP trainer model
Fig. 3.2 (a) Apple/animal tissue cut to resemble a cervix and placed inside the lumen of the cylinder
Fig. 3.2 (b) Selection of an appropriate cryoprobe
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Fig. 3.2 (c) Applying the cryoprobe without touching the sides of the cylinder
Fig. 3.2 (d)Pressing the trigger to start freezing
3.3.3 Guidelines for conducting clinical skills training Purpose: Clinical skills training provides comprehensive learning opportunities to trainees for the development of core competencies in communication and procedural skills. The training is guided by a set of checklists that detail the steps or the tasks to be performed on a client. The checklists serve as a guide for the activities to be performed in a recommended sequence of standard practice. How to use the skills checklists in the Trainees’ handbook Checklists for counselling, VIA, sample collection for HPV test, cryotherapy and cold coagulation are included in the respective modules of the Trainees’ handbook. The checklists are designed to be used for both teaching as well as supervision of skill acquisition during clinical practice sessions by facilitators. The checklists will also be used during assessment of skills. Trainees will be rated as per performance indicated on the checklists. It is mandatory for trainees to learn and perform the critical steps highlighted in the checklists to be certified for skill acquisition. Preparation • Make sure that all equipment/instruments and consumables required for the planned clinical skills training session are available well in advance. The lists are included in the corresponding module of the Trainees’ handbook. How to conduct clinical skills training • Maintain the same group of trainees as done for classroom teaching. • Reorganization of the groups may be necessary if the number of clinical practice stations is different from the original number of groups. • Assign each group to their clinical practice stations. • Ensure adequacy of space to avoid crowding. • Ensure privacy in the clinical practice stations to avoid uneasiness to the client. • Designate at least one clinical facilitator for each group. • Ask trainees to consult the checklists in the corresponding module of the Trainees’ handbook for step-by-step learning of the clinical skills for the procedures. • Distribute print-outs of the necessary checklists appropriate for that particular clinical skills training session. Explain that the checklists have columns to be filled in while observing/ performing on clients. While observing or conducting supervised practice, trainees must complete one column for each client and get it signed by the facilitator at the end of each day’s clinical session. Completed and signed checklists serve as the log sheet, a record of client practice. • The recommended minimum client practice required by each trainee is given in Table 3.4. • Briefly discuss the procedures that trainees will observe or do under supervision. • Demonstrate procedures slowly and step-by-step.
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• Allow trainees to perform the procedure on clients individually only after they have completed observation of the necessary number of procedures. • Ask trainees to perform the procedures adhering to the steps given in the corresponding checklists. • Ask trainees to fill in their respective log sheets after completion of the observed or supervised procedures. • Review the performance of each trainee and discuss any particular step/technique that you feel a trainee requires to practise more. • Summarize the session and certify the log sheet at the end of the day’s training session. Table 3.4: Recommended client practice by trainees S. no. Activity 1. Counselling 2. VIA 3. 5. Sample collection for HPV test Cold coagulation (optional) 4. Cryotherapy Number to be observed 3 10 2 2 2 Number to be performed under supervision 5 10 3 2 2
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Section 4: Assessment of trainees
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4.1 Introduction
Assessment of trainees is an essential component of training that helps in assessing whether trainees have achieved the desired level of competence. The purpose of assessment is to analyse gaps in the existing level of knowledge and skills. It is recommended that the assessment of trainees be carried out in two phases – a) mid-course assessment and b) final assessment. The purpose of the mid-course assessment is to understand focused training needs of trainees and determine the areas that require improvement. It helps to monitor progress towards achieving training objectives more effectively and efficiently. Final assessment helps to assess how effective training efforts have been in enhancing the knowledge and related skills of trainees and to what extent the objectives of the training have been achieved. It also helps to determine how competently trainees would be able to provide screening and treatment services when they return to their own place of work. The process of assessment includes: i) Knowledge assessment (to be conducted in the classroom) using: • Assessment questionnaires having multiple-choice questions • Image recognition skills assessment ii) Skills assessment (to be conducted in the clinic) for various interventions
4.2 Guidelines for conducting knowledge assessment Preparation • Keep the following ready for knowledge assessment in the classroom: Copies of the assessment questionnaires – you may use the sample questionnaire given in this manual or develop your own set of MCQs based on the sample MCQs given at the end of each module. Printouts of image recognition skills assessment matrix (Box 3.5). Printouts of knowledge assessment matrix (Box 4.1). Digital images – five sets, queued in a PowerPoint presentation in the order in which images would be projected. Flip charts with stand and marker pens Conducting the knowledge assessment • Inform trainees about the purpose of the assessment (mid-course or final, as appropriate). • Brief them on the components of the knowledge assessment process and the order in which each component would be reviewed. (Trainees may be informed about the purpose of the assessment and the process to be followed a day prior so as to allow them to be prepared). • Check seating arrangements to ensure the projected digital images and case studies for assessment are clearly visible to trainees. • Distribute the assessment questionnaire, comprising 20 questions, to all trainees and explain how to tick the correct responses. • One mark should be allotted to each correct response and there should be no negative marking.
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• Allow 30 minutes to answer the questions. Collect all the completed questionnaires after the specified time. • Allow a 5 minute break before starting the image recognition skills assessment session. • Distribute the image recognition skills assessment forms to all trainees. • Project each set of images for 1 minute and allow trainees 4 minutes to write their responses. • Ask trainees to respond to all questions by putting a tick √ against the correct response on the assessment form. • Collect all the completed forms. • Evaluation of the responses in the submitted assessment questionnaires and image recognition skills assessment forms can be done immediately after the assessment or may be done later at a more convenient time. Trainees can evaluate each others’ responses. • Identify knowledge gaps from the assessment matrix sheets and write them down on the flip chart. • Discuss the knowledge gaps with the trainees, ensuring each issue is addressed. You may project the images again, explain the findings and describe the diagnosis so that trainees can rectify their mistakes. • Thank trainees after the knowledge assessment. Box 4.1: Knowledge assessment matrix Note: Mark a in the row of each trainee for questions that have a correct response. Correct response to question no. Trainee number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Total
1 2 3 4 5 6 7 8 9 10
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4.3 Guidelines for conducting skills assessment in clinics Table 4.1: Recommended client practice for assessment S. no. Activity Number of clients to be examined Mid-course 1. Counselling 2. Sample collection for HPV test 3. VIA 4. Cryotherapy 5. Cold coagulation (optional) 2 1 5 1 1 Final 2 2 5 1 1
Preparation • Keep the following ready for clinical skills assessments: Printouts of checklists for skills development included in the Trainees’ handbook List of clients for examination and procedures Arrangements for screening and treatment at the clinic How to conduct skills assessments • Distribute the checklists and informed consent forms to all the trainees (each facilitator should also have a copy of the checklists). • Designate each trainee to a particular clinical examination station. • Refer to the recommended client practice for assessment given in Table 4.1 and inform each trainee about the requisite number of procedures (counselling, sample collection for HPV test, VIA, cryotherapy, cold coagulation) they would have to perform. • If adequate number of cases are not available, then do the assessment by making trainees simulate the procedures. • Assign individual clients to each trainee and give them client IDs and names. • Ask trainees to perform the necessary procedures adhering to the corresponding checklist for skills development. • Make sure that one facilitator is present at each clinical examination station all through the assessment procedure. • The facilitator has to judge the trainees’ performance by using the corresponding checklist for skill development. • For each trainee, rate the performance of each step using the following rating scale: 1 – Step or sequence not performed correctly (needs improvement)
2 – Step or sequence partly performed 3 – Step or task efficiently and precisely performed in the proper sequence 50
• To be considered competent for a particular procedure, a trainee must perform the critical steps efficiently and precisely (Rating – 3) and obtain Rating 2 and above in at least 80% of all the steps (including the critical ones). • Discuss the scores individually with each trainee and guide them to rectify/improve the steps where necessary. • You may display the assessment scores in the summary performance table (Table 4.2) for comparative assessment. Table 4.2: Summary performance of trainees Mid-course assessment (score%) Final assessment (score%) Trainee number Knowledge Image Skills Total Knowledge Image Skills Total assessment recognition assessment assessment recognition assessment 1
2 3
To be eligible for certification, a trainee needs to have an overall final assessment score of 80% or above with all critical steps performed as per standards. Those securing less than this would be required to undergo re-orientation before final certification. The duration and focus of the re-orientation training will depend on the trainees’ weaknesses as perceived by facilitators. Such re-orientation training should be completed within 2 days.
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Section 5: Conducting the training
5.1 Introduction
The training comprises sessions of which some are classroom trainings and the rest are clinic -based trainings. A standard session plan has been included in the document. The timing of the classroom sessions and the clinic-based sessions may be re-arranged at times convenient for the health facility where the training is organized. For example, on days where there is a combination of both classroom and clinical sessions, the latter may be held in the morning (OPD hours) and classroom sessions in the afternoon, depending on the availability of clients and the local needs.
5.1.1 Classroom training Classroom training has been structured in the form of 11 modules. Each module starts with an overview that refers to the chapter and the sections of the WHO Guidance book on which that particular module is based. The module contains discussions on the key points and the list of relevant group learning activities. Checklists for clinical skills trainings are also included in the module where appropriate. The topics in each module are arranged in a logical sequence and it is recommended that facilitators follow the given sequence during teaching. All interactive presentations should be completed during the first two days.
5.1.2 Clinic-based training Clinic-based training is structured to include demonstration sessions, simulated learning sessions and clinical skills training sessions. All clinic-based trainings are to be completed within 5 days. There are a total of two demonstration sessions and two simulated learning session. Clinical skills training has been structured in the form of five sessions. Overlapping of activities in these sessions is expected as the flow of events is common to individual client assessment, examination and management. Checklists for all the clinical skills trainings are provided in the relevant modules.
5.1.3 Training assessment The mid-course training assessment is to be conducted on Day 6 and final assessment on Days 9 and 10. The process comprises assessment of both knowledge and clinical skills components. Each day, after completion of clinic-based training/assessment sessions trainees should go back to the classroom to summarize the day’s activities and discuss the next day’s agenda.
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5.2 Distribution of sessions and flow of events Day 1 5.2.1 Opening session Session length: 1 hour 30 minutes Ensure the following materials are ready before conducting the session • Flip charts with stand and marker pens • White board, marker pens, duster • Laptop, LCD projector, pointer, power source • PowerPoint presentation (Introduction to training on VIA, HPV detection test and cryotherapy) • A folder similar to the one distributed to trainees • Pre-training knowledge assessment questionnaire • Pre-training knowledge assessment matrix • Welcome the trainees. • Display a slide showing the overall objectives of the training. Explain the objectives. • Self introduction of facilitators and trainees. • Tell trainees that a few minutes will be spent on introduction of facilitators and trainees. • For the introduction of facilitators and trainees, write the following on a flip chart: Your name Place where you currently work A few words about the organization you work for Nature of your work • You and your co-facilitators should introduce yourselves first, based on the points listed on the flip chart. • Ask each trainee to introduce himself or herself briefly, covering the same points. • Do the following administrative tasks: – Inform trainees about the ground rules (show as a slide and explain). – Inform trainees about the available facilities (lunch room, toilets, computers, Internet facility, etc). 55
Ground rules for trainees: • Adhere to the training schedule according to session plans • Maintain attendance record for certification by the facilitator • Go through the subjects discussed during various sessions in the WHO Guidance book at the end of the day for better understanding and discussion with the facilitator • Attend all clinical sessions as per schedule • Participate in group activities according to the session plan • Complete the specified number of worksheets during each clinical session and get them certified by the facilitator • Ensure and respect privacy and rights of clients in the examination rooms – Inform them about reimbursement of expenses and names of the support staff providing secretarial assistance. – Display slide showing the contents of the folder given to trainees and ask them to verify the contents. Explain the parts of the training package. – Instruct trainees to fill in the experience record of trainees (show as a slide) and collect the filled in forms. – Divide trainees into smaller groups as per the instructions given in Box 1 for group learning activities. Discuss the overall session plan: – Show the following agenda of the training in a slide (modify session time according to local needs) and briefly highlight the modules to be covered and the clinical sessions. Day 1 Morning session Opening session Introduction to cervical cancer screening Anatomy and physiology of female genital tract Pathogenesis of cervical cancer with special reference to HPV infection 2 Principle and technique of VIA HPV detection test and cervical sample collection for HPV test Management of VIA and HPV positive women • Treatment of cervical precancers by cryotherapy and follow-up • Treatment of cervical precancers by cold coagulation and follow-up • Infection prevention practices Afternoon session • Counselling
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3
Ensuring quality of services and programme monitoring in cervical cancer screening
• Clinical practice session on cryotherapy and cold coagulation • Counselling practice sessions
4–5
Image and video demonstration Clinical practice session on VIA/ HPV sample collection
• Clinical practice session on cryotherapy and cold coagulation • Counselling practice sessions • Preparation for mid-course assessment (Day 5)
6 7–8
Mid-course assessment Image and video demonstration Clinical practice session on VIA • Clinical practice session on HPV sample collection • Clinical practice session on cryotherapy and cold coagulation • Preparation for final assessment (Day 8)
9–10
Final assessment
• Feedback and closing activities
Discuss how to use the Trainees’ handbook: – Ask trainees to take out the Trainees’ handbook from the folder. – Ask them to open the page for Module 4 and show them the structure of a sample module. – Display the slide on the structure of a sample module as given below. • Module overview • Learning objectives • Module contents Knowledge component (as key question format) Skill development (as skills checklists) Group activities (includes role play, case studies, image recognition and simulated learning) • Sample MCQs
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• Explain that each module presents key information to complement the materials in the corresponding chapter of the WHO Guidance book. Trainees are required to be well-versed with the contents of the chapter before they attend clinical sessions. • List trainees’ expectations:
Put up a flip chart with the heading "Expectations". Ask each trainee to mention at least one expectation. Note it on the flip chart. At the end, discuss how expectations will be addressed during the training.
• Display the slide listing ‘do’ and ‘don’t’ instructions for trainees and discuss. Do • Reach the training venue at least 15 minutes before the session starts each day • Be familiar with training sessions and training materials provided • Interact with facilitators as and when required and get doubts cleared • Get to know members of your group and stay with your allocated group during group activities • Listen carefully to the instructions given by facilitators for the clinical sessions • Be respectful of each other and considerate to clients • During clinical sessions, know the safety precautions beforehand and follow them How to conduct pre-training knowledge assessment • Prepare a set of 20 multiple choice questions (MCQs) from the sample MCQs listed in each module in the Trainees’ handbook before commencement of the training. (A set of sample questions is given in Annex 6). • Distribute question sheets among trainees and explain how to tick correct responses. • Allow 30 minutes for trainees to answer questions. • Allot one mark to each correct answer. Do not give negative marks. • Evaluate responses immediately after the pre-test using the knowledge assessment matrix (Box 4.1). Ask your fellow facilitators for help, if necessary. • Identify knowledge gaps from the assessment matrix and share them with other facilitators. This need not be shared with trainees at this point of time. 58 Don’t • Cross-talk among yourselves during teaching sessions • Use mobile phones or do anything to distract your colleagues during training sessions • Hesitate to ask questions • Examine a client without consulting your facilitator
5.2.2 Session 1: Introduction to cervical cancer screening Session length: 1 hour Ensure the following materials are ready before conducting the session • Flip charts with stand and marker pens • White board, marker pens, duster • Laptop, LCD projector, pointer, power source • PowerPoint presentation (Introduction to cervical cancer screening) • A copy of the WHO Guidance book • A copy of the Trainees’ handbook • A copy of the national protocol for cervical cancer screening, if any
• Welcome trainees to the session. • Display the slide with learning objectives of the module as given below. Explain the learning objectives to trainees. By the end of this module, trainees will be able to: – describe the concept of cervical cancer screening; – state the burden of cervical cancer in the population; – explain how screening for cervical cancer helps to reduce the burden of disease; – list out the various components of an organized screening programme; – describe the advantages and disadvantages of different screening tests for cervical cancer. – define the target age group and frequency of screening; – describe the protocol for cervical cancer screening of their country. • Open the WHO Guidance book to Chapter 5 – Screening and treatment of cervical precancer. Show it to the trainees. • Inform trainees that the current module is based on Sections 5.1, 5.2 and 5.3 of the chapter. Instruct them to read these sections before attending the next day’s sessions. • Inform trainees that they can find answers to key questions related to the topic in the Trainees’ handbook under Module 1– Introduction to cervical cancer screening. • Project the presentation for Module 1 – Introduction to cervical cancer screening. Discuss the contents of the slides. • Ask trainees if they have any questions or doubts. List these on the flip chart. • Respond to questions and doubts.
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Key points for discussion • Cervical cancer is a major cause of morbidity and mortality in the country/region. • Cervical cancer can be prevented by systematic screening of target populations and ensuring treatment of positive cases. • Screening should be organized rather than opportunistic or sporadic. • An organized screening programme must have a protocol that clearly indicates the target population, frequency of screening and screening test to be used. • There are several screening tests and screening options; each of these has advantages and disadvantages. • Informed consent prior to screening is necessary. The nature of the consent will depend on existing regulations.
5.2.3 Session 2: Anatomy and physiology of the female genital tract Session length: 1 hour Ensure the following materials are ready before conducting the session • Flip charts with stand and marker pens • White board, marker pens, duster • Laptop, LCD projector, pointer, power source • PowerPoint presentation (Anatomy and physiology of the female genital tract) • A copy of the WHO Guidance book • A copy of the Trainees’ handbook • ZOE model with its accessories • Any other model of female genital organs if available
• Welcome trainees to the session. • Display the slide with learning objectives of the module as given below. Explain the learning objectives to trainees. By the end of this module, trainees will be able to: – describe the anatomy of the uterine cervix and its relation to other pelvic organs; – explain the changes occurring on the epithelium lining of the cervix that are relevant to the pathogenesis of neoplasias of the cervix; – describe the physiological changes to the cervix occurring during pregnancy and menopause. 60
• Identify different parts of the female genitalia to help trainees perform various procedures • Open the WHO Guidance book to Chapter 1 – Background. Show it to the trainees. • Inform trainees that the current module is based on Section 1.2 of the chapter and instruct them to read this section before attending the next day’s sessions. • Tell them that they can find answers to key questions related to the topic in the Trainees’ handbook under Module 2 – Anatomy and physiology of female genital tract. • Project the presentation Module 2 – Anatomy and physiology of female genital tract. Discuss the contents of the slides. • Inform trainees that the following group learning activities will now begin: identification of parts of the uterus and cervix on the ZOE model; practise speculum examination on the ZOE model; recognition of microscopic anatomy on digital images. • Conduct all group learning activities as per the guidelines given earlier (Section 3.2.6). • Rotate groups such that all groups can perform the above group activities by turn. • Ask trainees if they have any questions or doubts. List these on the flip chart. • Respond to questions and doubts. Key points for discussion • Cervix is the lower part of the uterus that projects through the anterior wall of the vagina. • The cervix is covered by squamous epithelium and columnar epithelium that meet at the squamocolumnar junction (SCJ). • The columnar epithelium on the ectocervix is replaced by squamous epithelium through a process known as metaplasia. • The area of the cervix where metaplasia occurs is known as the transformation zone. • The transformation zone can be identified by certain features like crypt openings, nabothian follicles, etc. • In postmenopausal women, the SCJ moves into the endocervical canal and part of the transformation zone may not be visible.
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5.2.4 Session 3: Pathogenesis of cervical cancer with special reference to HPV infection Session length: 1 hour Ensure the following materials are ready before conducting the session • Flip charts with stand and marker pens • White board, marker pens, duster • Laptop, LCD projector, pointer, power source • PowerPoint presentation (Pathogenesis of cervical cancer with special reference to HPV infection) • A copy of the WHO Guidance book • A copy of the Trainees’ handbook • Welcome trainees to the session. • Display the slide with learning objectives of the module as given below. Explain the learning objectives to trainees. By the end of this module, trainees will be able to: – list the various risk factors for cervical cancer; – narrate the role of HPV infection in cervical cancer; – describe the mode of transmission of HPV infection; – explain the natural history of cervical cancer originating from HPV infection. • Open the WHO Guidance book to Chapter 1 – Background. Show it to the trainees. • Inform trainees that the current module is based on Section 1.3 of the chapter and instruct them to read this section before attending the next day’s sessions. • Open the Trainees’ handbook to Module 3 – Pathogenesis of cervical cancer with special reference to HPV infection. Inform trainees that they can find answers to key questions related to the topic in this module. • Project the presentation Module 3 – Pathogenesis of cervical cancer with special reference to HPV infection. Discuss the contents of the slides. • Discuss the multiple choice questions and their answers given at the end of the chapter. • Ask trainees if they have any questions or doubts. List these on the flip chart. • Respond to questions and doubts.
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Key points for discussion • Infection from high-risk HPV is a "necessary but not sufficient" cause of cervical cancer. • HPV is a very common sexually transmitted virus and the majority of infected women will clear the virus due to natural immunity. • Women who cannot clear the infection and have persistent infection with any of the high-risk types of HPV will develop cervical neoplasia. • Cervical intraepithelial neoplasia (CIN) is the premalignant condition of the cervix and is classified into CIN 1, CIN 2 and CIN 3 depending on the severity of the disease. • CIN 2 and CIN 3 lesions have high probability of progression and must be treated. CIN 1 lesions can be followed up as they are mostly transient.
5.2.5. Session 4: Counselling Session length: 2 hours Ensure the following materials are ready before conducting the session • Flip charts with stand and marker pens • White board, marker pens, duster • Laptop, LCD projector, pointer, power source • PowerPoint presentation (Counselling) • Checklist for counselling skills development • A copy of the WHO Guidance book • A copy of the Trainees’ handbook • Counselling cards and flip chart • Welcome trainees to the session • Display the slide with learning objectives of the module as given below. Explain the learning objectives to trainees. By the end of this module, trainees will be able to: – understand the concept and importance of counselling; – counsel women prior to and after screening; – counsel women prior to and after treatment of cervical precancers. • Open the WHO Guidance book to Chapter 3 – Community mobilization education and counselling. Show it to the trainees.
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• Inform trainees that the current module is based on Section 3.5: Counselling and practice sheets 3.4, 3.5, 5.1 and 5.7 and instruct them to read these sections before attending the next day’s sessions. • Inform trainees that they can find answers to key questions related to the topic in the Trainees’ handbook under Module 4 – Counselling. • Project the presentation Module 4 – Counselling. Discuss the contents of the slides. • Discuss the steps for counselling as per the checklists in the Trainees’ handbook. • Inform trainees that the following group learning activity on role play for counselling will now begin. • Conduct the role plays following the guidelines for managing a role play given in Section 3.2.3 of this manual. • Ask trainees if they have any questions or doubts and list them on the flip chart. • Respond to those questions and doubts. Examples of topics for role plays (refer to section 4.5 of the Trainees’ handbook) Role play 1: Counselling a woman to undergo VIA screening Role play 2: Counselling a woman who is negative on VIA Role play 3: Counselling a woman who is positive on VIA and is eligible for cryotherapy Role play 4: Counselling a woman with suspicion of invasive cancer on VIA
Key points for discussion • Counselling is face-to-face, confidential communication. • Counselling can be group, individual or couple counselling. • A woman should be given information on cervical cancer, screening methods and treatment procedures if the screening test is positive. • Listen to what the woman has to say and encourage her to express her concerns. • Ask open-ended questions. • Use simple language. Talk to the woman in a friendly way, develop a cordial relationship, and assure her that the conversation is confidential.
• Use supportive non-verbal communication, such as nodding and smiling and maintain good eye contact throughout.
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Day 2 5.2.6 Session 5: Screening with visual inspection using acetic acid (VIA) Session length: 1 hour 30 minutes Ensure the following materials are ready before conducting the session • Flip charts with stand and marker pens • White board, marker pens, duster • Laptop, LCD projector, pointer, power source • PowerPoint presentation (Screening with VIA) • Video on VIA procedure • Checklist for steps of VIA • A copy of the WHO Guidance book • A copy of the Trainees’ handbook • Copies of the image recognition form and image recognition skills assessment matrix • Welcome trainees to the session • Display the slide with learning objectives of the module as given below. Explain the learning objectives to the trainees. By the end of this module, trainees will be able to: – describe organization of VIA services in the clinic; – list steps of VIA procedure; – become skilled at identifying cases for appropriate management/referral; – describe benign conditions and infections of the cervix and vagina; – demonstrate how to counsel women before and after VIA; – list infection prevention practices during VIA procedure. • Open the WHO Guidance book to Chapter 5 – Screening and treatment of cervical precancer. Show it to the trainees. • Inform trainees that the current module is based on Section 5.3.2 – Visual screening methods and practice sheet 5.5 and instruct them to read these sections before attending next day’s sessions. • Inform trainees that they can find answers to key questions related to the topic in the Trainees’ handbook under Module 5 – Screening with visual inspection with acetic acid (VIA). • Project the presentation Module 5 – Screening with visual inspection with acetic acid (VIA). Discuss the contents of the slides. • Discuss the steps of VIA as per the checklists.
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• You may decide to present the video on VIA procedure after finishing the PowerPoint presentation or at a suitable time afterwards. • Project the video on VIA procedure and conduct the session as per the guidelines for video presentation given in Section 3.2.2. • Inform trainees that the group activity on image recognition will begin now for all groups. • Conduct the session as per the guidelines for conducting image recognition session given in Section 3.2.5. • Instruct trainees that for this session they are required to fill out all the on the flip charts of the second column of the image recognition form. • Ask trainees if they have any questions or doubts and list them on the flip chart. • Respond to those questions and doubts. Key points for discussion • VIA is the naked eye inspection of the cervix after application of 3–5% acetic acid. • VIA is safe, rapid, reliable, and inexpensive. • Acetic acid acts by coagulating proteins of surface epithelium. • Precancers contain greater amount of proteins, which get coagulated and give an acetowhite appearance. • Wait for at least 1 minute for acetic acid to be absorbed and acetowhite area to appear. • Distinct acetowhite opaque area indicates a positive test. • Common benign conditions of the cervix include cervicovaginal infections and inflammations, cervical polyps, leukoplakia and genital warts. • The test should be repeated on women with negative VIA test results after 5 years.
5.2.7 Session 6: HPV detection test and cervical sample collection techniques for HPV test Session length: 1 hour Ensure the following materials are ready before conducting the session • Flip charts with stand and marker pens • White board, marker pens, duster • Laptop, LCD projector, pointer, power source • PowerPoint presentation (HPV detection test and cervical sample collection techniques for HPV test) • Checklist for HPV cervical sample collection • A copy of the WHO Guidance book • A copy of the Trainees’ handbook • ZOE model with its accessories 66
• Welcome trainees to the session • Display the slide with learning objectives of the module as given below. Explain the learning objectives to the trainees. By the end of this module, trainees will be able to: – describe the organization of HPV detection services in the clinic; – competently describe collection of samples for HPV test; – describe handling, transport and storage of samples; – demonstrate how to counsel women before and after the HPV test; – list infection prevention practices during the sample collection procedure. • Open the WHO Guidance book to Chapter 5 – Screening and treatment of cervical precancer. Show it to the trainees. • Inform trainees that the current module is based on Section 5.3 (a–d) and practice sheet 5.4 and instruct them to read these sections before attending the next day’s sessions. • Inform trainees they can find answers to key questions related to the topic in the Trainees’ handbook under Module 6 – HPV detection Test and cervical sample collection techniques for HPV test. • Project the presentation Module 6 – HPV detection test and cervical sample collection techniques for HPV test. Discuss the contents of the slides. • Inform trainees that the group learning activity on cervical sample collection for HPV test on ZOE model will now begin. • Conduct the group learning activity as per guidelines given earlier (Section 3.2.6). • Rotate groups in such a way that all the groups can perform group activities by turn. • Ask trainees if they have any questions or doubts. List these on the flip chart. • Respond to questions and doubts. Key points for discussion • Majority of tests detect DNA of high-risk type HPV. • Only a few tests are available that detect HPV RNA. • Samples can be stored at room temperature for a few days. • A negative test indicates that the woman does not have high-risk HPV infection or HPV infection sufficient to cause cervical precancers. • There is no treatment for the virus itself. • Treatment is available for diseases caused by HPV infection. • Tests should be repeated after 5 years for women with negative test results.
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5.2.8 Session 7: Management of women with positive VIA or HPV test results Session length: 1 hour Ensure the following materials are ready before conducting the session • Flip charts with stand and markers • White board, marker pens, duster • Laptop, LCD projector, pointer, power source • PowerPoint presentation (Management of women with positive VIA or HPV test) • Handouts of management algorithms • A copy of the WHO Guidance book • A copy of the Trainees’ handbook • PowerPoint slides/print outs of case studies • Welcome trainees to the session • Display the slide with learning objectives of the module as given below. Explain the learning objectives to the trainees. By the end of this module, trainees will be able to: – make decisions based on the VIA findings; – make decisions based on HPV test results; – advise test positive and test negative women; – choose appropriate treatment for screen positive women; – advise appropriate follow-up after screening or treatment. • Open the WHO Guidance book to Chapter 5 – Screening and treatment of cervical precancers. Show it to the trainees. • Inform trainees that the current module is based on Section 5.7 – Linking screening and treatment in practice and Annex 7 and 8 and instruct them to read these sections before attending the next day’s sessions. • Inform trainees that they can find answers to key questions related to the topic in the Trainees’ handbook under Module 7 – Management of women with positive VIA or HPV test. • Project the presentation Module 7 – Management of women with positive VIA or HPV test. Discuss the contents of the slides. • Inform trainees that the group learning activity on case studies will now begin. For examples of topics for case studies refer to Section 7.5 of the corresponding module in the Trainees’ handbook. • Conduct the group learning activities as per the guidelines given earlier (Section 3.2.4). • Ask trainees if they have any questions or doubts. List these on the flip chart. • Respond to questions and doubts. 68
Key points for discussion • Women with positive VIA test should be treated with cryotherapy at the same visit if eligible. • Ineligible women should be referred for colposcopy. • HPV-positive women should be assessed for immediate cryotherapy or advised VIA depending on the protocol of the programme. • CIN can be treated either by an ablative method like cryotherapy or excisional method like LEEP. • Follow-up with women treated for positive VIA/HPV should be done after 1 year. • Women positive on follow-up screening should preferably be treated with LEEP/cold knife conization. • If a woman has the histology diagnosis of either CIN 3 or adenocarcinoma in situ, screening should be repeated every year for 3 consecutive years.
5.2.9 Session 8: Treatment of cervical precancers by cryotherapy and follow-up Session length: 1 hour Ensure the following materials are ready before conducting the session: • Flip charts with stand, marker pens • White board, marker pens, duster • Laptop, LCD projector, pointer, power source • PowerPoint presentation (Treatment of cervical precancers by cryotherapy and follow-up) • Video on cryotherapy procedure • Checklist for steps of cryotherapy • A copy of the WHO Guidance book • A copy of the Trainees’ handbook • Cryotherapy equipment and accessories for demonstration • Counselling cards and flip chart • Welcome trainees to the session • Display the slide with learning objectives of the module as given below. Explain the learning objectives to trainees. At the end of this module, trainees will be able to: – Describe all the parts of the cryotherapy unit 69
– identify eligibility criteria for treatment with cryotherapy; – perform the technique following correct steps; – recognize probable treatment complications; – perform appropriate follow-up after treatment; – list infection prevention practices during cryotherapy. • Offer appropriate management of complications. • Describe infection prevention practices of cryotherapy. • Open the WHO Guidance book to Chapter 5 – Screening and treatment of cervical precancer. Show it to the trainees. • Inform trainees that the current module is based on Section 5.5.1 – Cryotherapy and practice sheet 5.10 and Annex 8 and instruct them to read these sections before attending the next day’s sessions. • Inform trainees that they can find answers to key questions related to the topic in the Trainees’ handbook under Module 8 – Treatment of cervical precancers by cryotherapy and follow-up. • Project the presentation Module 8 – Treatment of cervical precancers by cryotherapy and follow-up. Discuss the contents of the slides. • You may decide to present the video after finishing the PowerPoint presentation or at a suitable time afterwards. • Project the video on cryotherapy procedure. • Conduct the session as per the guidelines for video presentation given in Section 3.2.2 • Inform trainees that the group activities on demonstration of cryotherapy equipment and role play will now begin. • Rotate groups such that all groups can perform both group activities by turn. • Conduct the demonstration of cryotherapy equipment following the guidelines for conducting demonstration sessions on equipment given in Section 3.2.7
• Conduct role plays by following the guidelines for managing a role play given in Section 3.2.3 • Ask trainees if they have any questions or doubts. List these on the flip chart. • Respond to questions and doubts. Examples of topics for role plays (refer to Trainees’ handbook, Section 8.6.3) Role play 1: Counselling a woman for follow-up care after cryotherapy Role play 2: Managing a woman who has come to the clinic with abdominal pain within one week of cryotherapy
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Key points for discussion • Cryotherapy is an ablative method for treatment of ectocervical precancerous lesions. It: – uses freezing effect of compressed refrigerant gases – N2O/ CO2; – destroys transformation zone by crystallization of water and denaturation of proteins.
• The entire lesion should be visible on the ectocervix, fully covered by cryoprobe, occupying less than 75% of the ectocervix with no suspicion of cancer. • Watery discharge or spotting can occur until 4 weeks after cryotherapy. • Complete sexual abstinence should be followed for 4 weeks after the procedure. • Follow-up is recommended at 1 year of treatment. • A woman should report immediately if foul smelling discharge, fever of more than 38 °C, heavy vaginal bleeding or severe lower abdominal pain occur within 4 weeks of treatment. • Anaesthesia is not required.
5.2.10 Session 9: Treatment of cervical precancers by cold coagulation and follow-up Session length: 45 minutes Ensure the following materials are ready before conducting the session • Flip charts with stand, markers • White board, marker pens, duster • Laptop, LCD projector, pointer, power source • PowerPoint presentation (Treatment of cervical precancers by cold coagulation and follow-up) • Video on cold coagulation procedure • Checklist for steps of cold coagulation • A copy of the Trainees’ handbook • Cold coagulation equipment and accessories for demonstration • Counselling cards and flip chart • Welcome trainees to the module • Display the slide with learning objectives of the module as given below. Explain the learning objectives to trainees.
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At the end of this module trainees will be able to: – describe all parts of the cold coagulator; – identify eligibility criteria for treatment with cold coagulation; – perform cold coagulation following the correct steps; – recognize probable treatment complications; – offer appropriate management of complications; – advise appropriate follow-up after treatment; – list infection prevention practices of cold coagulation. • Inform trainees that cold coagulation as a method of treatment of cervical pre-malignant conditions is not yet universally approved. However it can be practised in situations where cryotherapy is not feasible due to non-availability of refrigerants. • Inform trainees that they can find answers to key questions related to the topic in the Trainees’ handbook under Module 9 – Treatment of cervical precancers by cold coagulation and followup. • Project the presentation Module 9 – Treatment of cervical precancers by cold coagulation and follow-up. Discuss the contents of the slides. • You may decide to present the video after finishing the PowerPoint presentation or at a suitable time afterwards. • Project the video on the cold coagulation procedure. • Conduct the session as per the guidelines for video presentation given in Section 3.2.2 • Inform trainees that group activities on demonstration of cold coagulation equipment and role play will now begin. • Rotate groups in such a way that all groups can perform both group activities by turn. • Conduct the demonstration of cold coagulation equipment following the guidelines for conducting demonstration sessions on equipment given in Section 3.2.7 • Conduct role plays by following the guidelines for managing a role play given in Section 3.2.3 • Ask trainees if they have any questions or doubts. List these on the flip chart. • Respond to questions and doubts. Examples of topics for role plays (refer to Trainees’ handbook, section 9.6.3) Role play 1: Informed consent procedure and counselling for cold coagulation Role play 2: Counselling a woman for follow-up care after cold coagulation
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Key points for discussion • Cold coagulation is an ablative method for treatment of ectocervical precancerous lesions. • Uses metallic probes heated to 100–120 °C. • Causes thermal destruction of cervical tissue. • The entire lesion should be visible on the ectocervix, fully covered by cryoprobe, occupying less than 75% of the ectocervix, with no suspicion of cancer. • Watery discharge or spotting can occur until 4 weeks after cryotherapy. • Complete sexual abstinence should be followed for 4 weeks after the procedure. • Follow-up is recommended after 1 year of treatment. • The woman should report immediately if foul smelling discharge, fever of more than 38 °C, heavy vaginal bleeding or severe lower abdominal pain occur within 4 weeks of treatment. • Anaesthesia is not required.
5.2.11. Session 10: Infection prevention practices Session length: 45 minutes Ensure the following materials are ready before conducting the session • Flip charts with stand, markers • White board, marker pens, duster • Laptop, LCD projector, pointer, power source • PowerPoint presentation (Infection prevention practices) • A copy of the WHO Guidance book • A copy of the Trainees’ handbook • Welcome trainees to the session • Display the slide with learning objectives of the module as given below. Explain the learning objectives to the trainees. At the end of this module, trainees will be able to: – list various modes of spread of infection in a health facility; – describe steps to be taken to prevent transmission of infection; – follow standard work precautions for prevention of infection. • Open the WHO Guidance book to Chapter 5 – Screening and treatment of cervical precancer. Show it to the trainees. 73
• Inform trainees that the current module is based on Section 5.2.7 and Annex 3 of the WHO Guidance book and instruct them to read these sections before attending the next day’s session. • Inform trainees that they can find answers to key questions related to the topic in the Trainees’ handbook under Module 10 – Infection prevention practices. • Project the presentation Module 10 – Infection prevention practices. Discuss the contents of the slides. • Ask trainees if they have any questions or doubts. List these on the flip chart. • Respond to questions and doubts. Key points for discussion • Infection prevention is of paramount importance in all health interventions. • The basic steps for processing instruments, surgical gloves and other items are: Decontamination, cleaning, high pressure saturated steam sterilization, and high-level disinfection (HLD). • HLD can be done either by boiling or chemical methods using 0.5% chlorine solution or 2% glutaraldehyde. • Biomedical wastes should be disposed-off in appropriate coloured bins.
Days 3–5 5.2.12. Session 11: Ensuring quality of services and programme monitoring in cervical cancer screening Session length: 1 hour Ensure the following materials are ready before conducting the session • Flip charts with stand, marker pens • White board, marker pens, duster • Laptop, LCD projector, pointer • PowerPoint presentation (Ensuring quality of services and programme monitoring in cervical cancer screening) • A copy of the WHO Guidance book • A copy of the Trainees’ handbook • Welcome trainees to the module • Display the slide with learning objectives of the module as given below. Explain the learning objectives to trainees.
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At the end of this module, trainees will be able to: – list the different components of programme monitoring to implement efficient and safe service delivery; – describe how quality of services can be improved through programme monitoring and supervision; – describe the roles of individual service providers at the facility level. • Open the WHO Guidance book to Chapter 2 – Essentials for cervical cancer prevention and control programmes. Show it to the trainees. • Inform trainees that the current module is based on Section 2.2.3 – Programme implementation and Section 2.2.4 – Programme monitoring and evaluation and practice sheet 2.2 – Key performance and impact indicators. Instruct them to read these sections before attending next day’s sessions.
• Inform trainees that they can find answers to key questions related to the topic in the Trainees’ handbook under Module 11 – Ensuring quality of services and programme monitoring in cervical cancer screening. • Project the presentation Module 11– Ensuring quality of services and programme monitoring in cervical cancer screening. Discuss the contents of the slides. • Ask trainees if they have any questions or doubts. List these on the flip chart. • Respond to questions and doubts. Key points for discussion • Programme monitoring is the continuous oversight of all activities related to the programme to ensure that services are delivered according to the plans and the programme achieves its objectives. • A system of supportive supervision is essential to ensure adherence to the performance standards by all providers at all times. • Good quality standards for screening services at the facility should be maintained. • Screening rate, screening test positivity rate, treatment rate, coverage of target population, age specific cervical cancer incidence are performance indicators and should be monitored.
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Demonstration sessions Conduct all the demonstration sessions following the instructions given in the guidelines for conducting demonstration sessions on preparation of consumables included under Section 3.3.1 of the guidelines for conducting clinic-based training. Preparation of dilute acetic acid Session outline • Introduction to the ingredients and consumables • Method of preparation • Storage and use • Precautions Preparation of 0.5% chlorine solution Session outline • Introduction to the ingredients and consumables • Method of preparation • Storage and use • Precautions
Simulated learning session Conduct the session following the instructions given in the guidelines for simulated learning sessions included under Section 3.3.2 of the guidelines for conducting clinic-based training. Simulation of cryotherapy procedure Session outline • Setting-up of equipment • Contents of the instrument trolley • Step-by-step cryotherapy procedure • Precautions • Troubleshooting • Decontamination and sterilization Simulation of cold coagulation procedure Session outline • Setting-up of equipment • Contents of the instrument trolley • Step-by-step cold coagulation procedure • Precautions • Troubleshooting 76 • Decontamination and sterilization
Clinical skills training sessions Conduct all the clinical skills training sessions following instructions given in the guidelines for clinical skills training included under Section 3.3.3 of guidelines for conducting clinic-based training. All clinical skills training sessions should be of at least 2 hours duration each and should include time for discussion. Additional time may be allowed depending on the number of clients present on the day. Clinical skills training session – Counselling Session outline • Building rapport • History taking and review of available clinical information • Counselling strategies • Counselling messages Clinical skills training session – VIA Session outline • Counselling • History taking and review of available clinical information • Getting equipment and instruments ready • Steps of VIA • Interpretation of findings • Documentation • Post-procedure counselling/referral • Decontamination and sterilization Clinical skills training session – Cervical sample collection for the HPV test Session outline • Counselling • History taking and review of available clinical information • Getting equipment and instruments ready • Steps of cervical sample collection for the HPV test • Storage and transportation • Documentation • Decontamination and sterilization 77
Clinical skills training session – Cryotherapy Session outline • Counselling • History taking and review of available clinical information • VIA and interpretation of findings • Determining eligibility for treatment • Informed consent procedure • Getting equipment and instruments ready • Step-by-step cryotherapy procedure • Documentation • Post-procedure counselling/referral • Care of equipment and instruments Clinical skills training session – Cold coagulation Session outline • Counselling • History taking and review of available clinical information • VIA and interpretation of findings • Determining eligibility for treatment • Informed consent procedure • Getting equipment and instruments ready • Step-by-step cold coagulation procedure • Documentation • Post-procedure counselling/referral • Care of equipment and instruments
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Day 6 Mid-course assessment • Preparation for mid-course assessment can be started on Day 5. Explain the procedure and components of mid-course assessment to the trainees. Explain the assessment process (knowledge assessment and skills assessment). • Set the following time limits for each assessment section: Knowledge assessment – 60 minutes (Mid-course assessment questionnaire – 30 minutes, Digital image assessment – 30 minutes). Discussion time following knowledge assessment – 30 minutes. Clinical skill assessment – Minimum 3 hours (time may be altered depending on the number of available clients that day); use simulators if adequate number of cases are not available. • Review of filled in mid-course knowledge assessment questionnaires and image recognition forms and assessment matrix sheets – 30 minutes. • Discussion time following clinical skill assessment – 30 minutes. • Conduct the knowledge and clinical skills assessment following the instructions given in Section 4 – Assessment of trainees.
Days 7–8 Conduct clinical skills training sessions on VIA, HPV sample collection technique, cryotherapy, cold coagulation as done on Days 3–5
Day 9 Final assessment • Preparation of post-course assessment can be initiated on Day 8. Explain the procedure and components of post-course assessment to the trainees. Explain the assessment process (knowledge assessment and skills assessment). Final assessment – Clinical skills • Display the slide containing the following objectives of final assessment: Assess the effectiveness of training in enhancing the knowledge and related skills of trainees. Determine how competently trainees would be able to provide VIA, HPV test and treatment services when they return to their own place of work. 79
• Inform trainees of the following time limits: Knowledge assessment – 60 minutes (MCQs – 30 minutes, digital image assessment – 30 minutes). Clinical skill assessment – 2 hours each for morning and afternoon sessions (or depending on the number of available clients that day), including time for discussion. • Conduct the knowledge and clinical skills assessment following the instructions given in Section 4 – Assessment of trainees. • Review the filled in multiple choice questionnaire, image recognition forms and assessment matrix sheets. Next steps and action plan • Discuss next steps and action plan after the clinical skills assessment on Day 9. • Ask trainees to assemble in the classroom. • Explain the importance of continued practise to maintain their newly acquired skills. • Stress on the importance of initiating VIA and treatment services at their respective facilities as soon as possible to maintain the acquired skills. • Request trainees to contact their facility in-charge after returning so that their services can be appropriately utilized.
Day 10 Final assessment of clinical skills (continued): • Set the following time limits for each assessment section: Clinical skills assessment – 3 hours (or depending on the number of available clients that day) including discussion time following clinical skills assessment. • Conduct the skills assessment session following the instructions given in the assessment of trainees (Section 4.3).
5.3 Feedback session Ensure the following materials are ready before conducting the session • Training feedback forms • Flip charts with stand • White board, marker pens, duster
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•
Display the session objectives To assess whether the training was useful to trainees To evaluate the training methodology To find the gaps in training processes and improve quality of future trainings
• Distribute feedback forms and allow 15 minutes for completing the form. • Inform trainees that they need not write their names on the feedback forms. • Collect completed forms and invite trainees to verbally share their opinions. • Listen carefully to negative feedback and write it on a flip chart. • Discuss each point. Also discuss how the training can be improved in future. • Conclude the session by thanking trainees for their participation.
5.4 Certification and closing
• Based on the final assessment score, identify trainees eligible for certification. • Write down the name of eligible trainees on the certificates and keep them ready for the session. • Call out the names of trainees one-by-one and hand them their certificates. • Discuss plans for reorientation training of trainees who did not qualify for certification. • Acknowledge participation of all those who contributed towards making the training a success, Thank trainees and close the session.
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Section 6: Annex
Annex 6.1 Trainees' feedback form Training of midwives, paramedical workers, nurses and clinicians in VIA, HPV detection tests and cryotherapy We value your comments to evaluate and improve our training. Please take time to complete the feedback form:
Part A: Rate the following as per the scale starting from 1 (sub-standard) to 9 (excellent) Training contents and materials 1. Relevance and quality of presentations and printed material 2. Quality of practical demonstrations 3. Adequate exposure to clinical procedures 4. The number of cases for clinical procedures 5. Time spent for demonstration of procedures 6. Overall time for the sessions and course Comments. __________________________________________________________________________ Facilitators 7. Expertise on the topic 1 2 3 4 5 6 7 8 9 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 8 8 8 9 9 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 8 8 8 8 9 9 9 9
8. Facilitators’ ability to stay focused on the topic 1 9. Time allowed for me to ask all my questions 10. My questions were appropriately answered 11. Assistance during the demonstration of procedures Comments. 1 1
1 2 3 4 5 6 7 8 9
__________________________________________________________________________
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Training venue 12. Cleanliness and comfort of the venue 13. Air-conditioning or heating settings 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 8 8 8 9 9 9
14. Projection equipment settings (focus and view) 1 15. The provision of food and drinks 1
16. Clinical training facility adequately equipped 1 Comments.
__________________________________________________________________________
Part B: List 3 skills (or knowledge) you have improved upon during this training 1. 2. 3. How do you propose to apply the skills learnt during the training at your own facility? (Encircle the appropriate response (s)) 1. I am already working at the screening/cryotherapy services at my facility and my quality of work will improve 2. I will join the existing screening/cryotherapy services at my facility 3. I will initiate the screening/cryotherapy services at my facility 4. I will train my colleagues and support staff at my facility Suggestions for making this training more effective in the future 1. 2. 3.
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Annex 6.2 Sample questionnaire for knowledge assessment 1. Screening is defined as: a) Application of a test on an apparently asymptomatic healthy population to identify those with high risk of developing the disease that the test can detect b) Application of a test on symptomatic men and women to treat a particular disease c) A test that can detect the presence of a gene in cancer patients d) Identification of patients who require immediate attention in a busy emergency room
2. Which of the following is not the screening test for cervical cancer? a) Pap test b) VIA c) Colposcopy d) HPV DNA
3. All of the following are risk factors for cervical cancer, except: a) Multiple sexual partners b) HIV infection c) Smoking d) Bacterial vaginosis
4. Human papillomavirus (HPV) is: a) A DNA virus b) A RNA virus c) Infects columnar epithelium only d) Causes only warts
5. Counselling should involve all, except: a) Confidentiality b) Privacy c) Paraphrasing d) Constant use of medical terminology
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6. During counselling prior to VIA, the client should be told about: a) Importance of VIA b) Available treatment options if VIA is positive c) Possibility of missing precancers or invasive cancer on VIA d) All of the above
7. After using the speculum, it should be decontaminated for 10 minutes by soaking it in: a) 1.0% savlon solution b) 0.5% chlorhexidinegluconate solution c) 0.5% chlorine solution d) 70% ethyl alcohol solution
8. Sterilization destroys: a) Bacteria b) Viruses c) Bacterial endospores d) All of the above
9. All the following are true for the anatomy of the cervix, except: a) Cervix is 1–2 cm in length b) Cervix is the lower one third of the uterus c) External os is slit like in multiparous women d) Cervix has supravaginal and infravaginal portions
10. The abnormal changes of the cervix such as dysplasia almost always develop in the: a) Ectocervix b) Transformation zone c) Endocervix d) Cervical os
11. Which of the following are high risk HPV viruses? a) 16, 18, 31, 33 b) 6, 11, 45, 46 c) 16, 11, 31, 42 d) 19, 32, 42, 43
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12. Which of following is an impact indicator for a cervical cancer screening programme? a) VIA positivity rate b) Proportion of screen positive women treated in the same sitting c) Proportion of screen positive women ineligible for cryotherapy d) Reduction of incidence of cervical cancer
13. The following are false statements about disposal of biomedical waste: a) Yellow for human anatomical waste b) Red for discarded medicines c) Blue for sharps d) Black for chemical wastes
14. What are the methods for instrument processing? a) Steam sterilization b) Chemical sterilization c) High-level disinfection d) All of the above
15. Which of the following is a false statement about post cryotherapy advice? a) Complete sexual abstinence for 4 weeks b) Report immediately if light bleeding occurs c) Use sanitary napkin for the few days after treatment d) Report if purulent vaginal discharge occurs
16. All the following statements are true for cervical cancer, except: a) 2nd most common cancer among Asian women b) More common in women who have never had sexual relations c) Has a curable precancerous stage d) Mortality can be significantly reduced by systematic screening of women
17. Which of the following is false about the transformation zone? a) Most precancers/cancers of the cervix arise from the transformation zone b) Crypt openings are normal findings of the transformation zone c) TZ is fully visible in Type 3 TZ d) Whole of TZ should be visible for satisfactory colposcopy
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18. The following statements about HPV vaccines are true, except: a) Against HPV 16,18 b) Given by intramuscular route c) Can be used to treat CIN lesions d) Recommended in age group of 9–13 years
19. What percentage of cervical cancer is caused by HPV 16/18? a) 20–40% b) 30–50% c) 60–70% d) More than 90%
Answer key 1 – b 6 – a 11 – a 16 – b 2 – c 7 – c 12 – d 17 – c 3 – d 8 – d 13 – a 18 – c 4 – a 9 – a 14 – d 19 – d 5–d 10 – b 15 – b
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Annex 6.3 Sample informed consent form for visual inspection with acetic acid (VIA) Test Please read the information carefully. After reading this if you have any doubts or questions, please do not hesitate to ask any of us.
Why are you here? You are here today to have a special test that can detect an abnormal change on the cervix (lower part of the womb). Such change may turn into cancer if not treated and is known as cervical precancer. The test is known as VIA and involves examination of the surface of the cervix after application of 3–5% dilute acetic acid (vinegar). The test can detect or rule out the presence of precancer of the cervix. The test can also detect cancer of cervix.
How will the test be done? The procedure usually takes five to 10 minutes to be completed. You will be made to lie down on the examination table with your legs folded at the knees. A small spoon-like instrument (speculum) will be placed in your vagina to expose the cervix. A mild solution of vinegar will be applied on the surface of your cervix for 1 minute. If there is any precancer or cancer that will be obvious as a white patch and we will be able to tell you the result immediately after the test. The test generally does not cause any pain and is safe. You may feel mild irritation during application of the vinegar solution but it is harmless and goes away on its own after a few minutes. If your VIA test is positive (cervix shows precancer change) you will be advised other tests like colposcopy (a procedure that involves magnified inspection of the cervix with an instrument named colposcope) and/or cervical biopsy (a procedure where a small piece of tissue from the abnormal area on the cervix is taken for examination). If your colposcopy and/or biopsy tests are abnormal then you will be advised to take appropriate treatment.
What should you do after the test? Generally there is no pain or discomfort after the procedure and you may continue with your normal day-to-day activities. No precautions are necessary. If the test results are normal you need to come back for the same test after three years unless you cross 49 years of age. If the test is positive we will explain to you where to go for further check-up and treatment.
What problems can occur during or after the test? As stated above, you may experience brief, mild discomfort during the placement of the speculum in your vagina or during application of a dilute solution of acetic acid (vinegar). Sometimes, slight vaginal bleeding (spotting) may occur.
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Consent for VIA I acknowledge that Dr/Mr/Ms .…………………………… has explained the proposed procedure to me and has answered questions to my satisfaction. The risks and the consequences of the test have been explained to me. I hereby consent to the VIA test.
………………………… Name
………………………… Signature
………………………… Date
………………………… Witness’ name
………………………… Witness’ signature
………………………… Date
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Annex 6.4 Sample informed consent form for VIA test and cryotherapy Please read the information carefully. After reading this if you have any doubts or questions, please do not hesitate to ask any of us.
Why are you here? You are here today to have a special test that can detect an abnormal change on the cervix (lower part of the womb). Such change may turn into cancer if not treated and is known as cervical precancer. The test is known as VIA and involves examination of the surface of the cervix after application of 3–5% dilute acetic acid (vinegar). The test can detect or rule out the presence of precancer of the cervix. The test can also detect cancer of the cervix. If the test suspects precancer you may also choose to have your treatment done today.
How will the test be done? The procedure usually takes five to 10 minutes to be completed. You will be made to lie down on the examination table with your legs folded at the knees. A small spoon-like instrument (speculum) will be placed in your vagina to expose the cervix. A mild solution of vinegar will be applied on the surface of your cervix for 1 minute. If there is any precancer or cancer that will be obvious as a white patch and we will be able to tell you the result immediately after the test. The test generally does not cause any pain and is safe. You may feel mild irritation during application of the vinegar solution but it is harmless and goes away on its own after a few minutes.
What problems can occur during or after the test? As stated above, you may experience brief, mild discomfort during the placement of the speculum in your vagina or during application of the dilute solution of acetic acid (vinegar). Sometime slight vaginal bleeding (spotting) may occur after the test.
What should you do if the test is normal? If your VIA test is normal (cervix does not show any precancer change or cancer) you will be advised to have the same test repeated every 3 years till you cross the age of 49 years. Generally there is no pain or discomfort after the procedure and you may continue with your day-to-day normal activities. No precautions are necessary.
What happens if the test is positive? If the test is positive your doctor/nurse will first assess if you can be treated here today. Treatment of precancer is done with a special technique called cryotherapy. The surface of your cervix will be cooled to freezing temperature using a special machine. Sometimes the change on the cervix is big in size and cryotherapy may not be the right method to treat this condition. In that case you will be asked to visit a centre where further check-up and treatment will be done. 92
How will cryotherapy be done? Cryotherapy will be done immediately after the VIA test. The doctor or nurse who does the test will let you know about the test result. If you agree to continue with the treatment, the equipment will be set-up. This may take a few minutes. Once the treatment starts you may hear a hissing sound of the gas passing through the machine. The whole procedure will be completed in approximately 15 minutes. After the treatment is over you will be asked to lie down for 5–10 minutes.
What problems can occur during or after cryotherapy? During treatment you may have a mild cramp in your lower abdomen. You can go back home and continue with your day-to-day work. Sometimes you may feel a little dizzy immediately after the treatment and you may have to lie down for another 10 to 15 minutes. You will have a watery vaginal discharge that may last up to 2–3 weeks. This is expected and not to be worried about. Please use a sanitary napkin as long as necessary. In very rare cases, you may have infection or bleeding. You must contact us or any other doctor if you have high fever, a lot of foul smelling vaginal discharge, moderate to severe lower abdominal pain or bleeding more than your average menstrual flow within a month. If you do not have any problems you should come back for the test after 1 year.
Do you have to take any precautions to prevent complications? You should not perform vaginal douching or use tampons for a month after the treatment. You need to avoid sexual intercourse for one month. You must ask you partner to use condoms in case sexual contact is unavoidable.
Consent for VIA and cryotherapy I acknowledge that Dr/Mr/Ms. .…………………………… has explained the proposed procedure to me and has answered questions to my satisfaction. The risks and consequences of the test and the treatment have been explained to me. I hereby consent to the VIA test and also cryotherapy if necessary.
………………………… Name
………………………… Signature
………………………… Date
………………………… Witness’ name
………………………… Witness’ signature
………………………… Date
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Annex 6.5 Checklists for counselling The same will be used as assessment sheets during training and assessment
Note to facilitators Rate the performance of each step using the following rating scale: • 1 – Step or sequence not performed correctly (needs improvement) • 2 – Step or sequence partly performed • 3 – Step or task efficiently and precisely performed in the proper sequence To be considered competent for a particular procedure a trainee must perform critical steps efficiently and precisely (Rating–3) and obtain Rating 2 and above in at least 80% of all the steps (including the critical ones).
Checklist 1: Steps for counselling a woman for VIA and further if VIA test is negative Skills checklist: Counselling skills in VIA Steps Cases Counselling prior to VIA 1. Greet the woman respectfully and introduce yourself 2. Provide general information about preventing cancer by early detection 3. Explain the importance of cervical cancer screening 4. Explain how VIA test and cryotherapy can prevent cervical cancer 5. Give information about the pelvic examination and how it is done 6. Describe how VIA test is done and the possible test results 7. Explain the treatment options if VIA test is not normal 8. Respond to the woman’s possible concerns about: • Pelvic examination • VIA test • Cryotherapy 94 1 2 3 4
Skills checklist: Counselling skills in VIA 9. Ask about any religious belief or attitude that may affect the woman’s decision to undergo VIA test Post VIA Counselling: VIA test is negative 10. Help the woman to get up from the table and be comfortably seated 11. Discuss the results of VIA test and the significance of a negative test 12. Tell her when to return for the next screening 13. Tell her to contact the clinic immediately if any symptoms like postcoital bleeding, intermenstrual bleeding or foul smelling discharge per vaginum occur 14. Assure the woman that she can return to the clinic for any medical advice or attention if required 15. Tell her to maintain her records carefully *The highlighted texts are considered critical Score achieved: Facilitator’s remarks Facilitator’s signature
Checklist 2: Steps for counselling a woman for VIA and further for cryotherapy (if eligible) if VIA is positive Skills checklist: Counselling skills in VIA and cryotherapy Steps Cases Counselling prior to VIA 1. Greet the woman respectfully and introduce yourself 2. Provide general information about preventing cancer by early detection 3. Explain the importance of cervical cancer screening 1 2 3 4
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Skills checklist: Counselling skills in VIA and cryotherapy 4. Explain how VIA test and cryotherapy can prevent cervical cancer 5. Give information about pelvic examination and how it is done 6. Describe how VIA test is done and the possible test results 7. Explain the treatment options if VIA test is not normal 8. Respond to the woman’s possible concerns about: • Pelvic examination • VIA test • Cryotherapy 9. Ask about any religious belief or attitude that may affect the woman’s decision to take the VIA test Post VIA Counselling: If VIA test is positive and the woman is eligible for cryotherapy 10. After completing VIA, ask the woman if she is more comfortable discussing the test results while lying down or sitting up on the table 11. Ask her if she would prefer to have her husband/partner or any other family member present with her 12. Inform her about the VIA test findings and the significance of the positive test 13. Give her(along with any family member preferably husband/partner) detailed information about how treatment will benefit her 14. Tell her how she will benefit by getting cryotherapy in the same sitting 15. If the woman is not ready to have treatment on the same day, give her the option of coming back on another specified day. Emphasize the need for treatment 16. Give detailed information about the cryotherapy procedure 17. Explain the side effects she may experience during and after the procedure 18. Encourage the woman to ask questions and respond with care 19. Give the woman some time to decide 96
20. Obtain informed consent for cryotherapy Post-Cryotherapy counselling 21. Provide the woman with instructions for self-care at home 22. Ask her to seek medical attention if she experiences the following within 4 weeks of cryotherapy • Fever with shaking chills and/or >38 °C temperature • Foul smelling purulent discharge • Severe lower abdominal pain/cramps • Vaginal bleeding >2 days or with clots other than expected menstrual bleeding 23. Advise complete sexual abstinence for 4 weeks and if complete abstinence is not possible, provide instructions for using condoms/sanitary pads 24. Tell her to maintain her records carefully 25. Ensure that the woman has understood the instructions fully 26. Answer any questions 27. Schedule a follow-up visit *The highlighted texts are considered critical Score achieved: Facilitator’s remarks Facilitator’s signature
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Checklist 3: Steps for counselling a woman for VIA and further referral to a higher centre (if VIA is positive and the woman is ineligible for cryotherapy) Skills checklist: Counselling skills in VIA and referral Steps Cases Counselling Prior to VIA 1. Greet the woman respectfully and introduce yourself 2. Provide general information about preventing cancer by early detection 3. Explain the importance of cervical cancer screening 4. Explain how VIA test and cryotherapy can prevent cervical cancer 5. Give information about the pelvic examination and how it is done 6. Describe how VIA test is done and the possible test results 7. Explain the treatment options if VIA test is not normal 8. Respond to the woman’s possible concerns about • Pelvic examination • VIA test • Cryotherapy 9. Ask about any religious belief or attitude that may affect the woman’s decision to undergo VIA test Post VIA Counselling: VIA test is positive and the woman is not eligible for cryotherapy 10. Help the woman to get up from the table and be comfortably seated 11. Ask her if she would like her husband/partner or any other family members to be present with her 12. Inform her about the VIA test findings and the significance of a positive test 13. Explain the treatment required and how treatment will benefit her 14. Give detailed information of the referral centre (including clinic days and timings) that she needs to visit for further check-ups 15. Explain in brief that she will undergo colposcopy and may requre treatment if abnormalities are suspected on colposcopy 98 1 2 3 4
16. Inform the woman if cancer is suspected on VIA and explain the necessity of early treatment to her. Give specific information on the nearest centre where she can get cancer treatment facilities 17. Tell her that she should preferably be accompanied by her husband/partner or any other family member at her next visit 18. Tell her to maintain her records carefully 19. Encourage the woman to ask questions. Answer questions with care *The highlighted steps are considered critical Score achieved: Facilitator’s remarks Facilitator’s signature
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Annex 6.6 Checklist for VIA The same will be used as assessment sheets during training and assessment
Note to facilitators Rate the performance of each step using the following rating scale: • 1 – Step or sequence not performed correctly (needs improvement) • 2 – Step or sequence partly performed • 3 – Step or task efficiently and precisely performed in the proper sequence To be considered competent for a particular procedure a trainee must perform the critical steps efficiently and precisely (Rating – 3) and obtain Rating 2 and above in at least 80% of all the steps (including the critical ones).
Skills Checklist: VIA Steps Preparation for VIA 1. 2. 3. 4. Keep necessary equipment ready (see list of equipment) Check availability of consumables (see list of consumables) Ensure that the light source is ready to use Arrange instruments and supplies on a high-level disinfected tray or container Cases 1 2 3 4
Counselling and consent 5. Follow checklist 4.6 for counselling
History Taking (Ask questions/check records) 6. 7. 8. 9. Personal information: name, age, husband’s name, address, telephone number and LMP Obstetric history History of past illness History of previous cervical cancer screening test (s)
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10. Ask for any of the following symptoms: Persistent foul smelling white discharge, post-coital bleeding, post-menopausal bleeding, irregular menstrual bleeding 11. Record all relevant information on the case record form Step-wise VIA procedure 12. Check that the woman has emptied her bladder 13. Help her onto the examination table, help her to be undressed and drape her 14. Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry them 15. Put one pair of new examination disposable gloves on both hands 16. Inspect external genitalia and check urethral opening for discharge 17. Select a speculum of appropriate size and lubricate the blades with lubricant jelly or saline 18. Insert the speculum and adjust it so that the entire cervix can be seen 19. Fix the speculum blades in the open position so that the speculum remains in place with the cervix in view 20. Adjust the light source so that you can see the cervix clearly 21. Examine the cervix for cervicitis, ectropion, nabothian cysts, growth, ulcers or contact bleeding 22. Identify the cervical os, squamocolumnar junction (SCJ) and transformation zone 23. Soak a clean swab in 3–5% acetic acid and apply it to the cervix 24. Wait for 1 minute for the acetic acid to be absorbed and any acetowhite change to appear 25. Inspect the SCJ carefully 26. Look for any new white patch (acetowhite area) appearing on the cervix 27. If there is an acetowhite area, look for the following features
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28. Density 29. Margin characteristics 30. Location in relation to SCJ or external os 31. Number of quadrants involved 32. When visual inspection has been completed, use a fresh swab to remove any remaining acetic acid from the cervix and vagina and dispose-off the swab 33. Remove the speculum 34. Help the woman to get up from the examination table and sit comfortably Post-VIA Tasks 35. Dispose-off the swabs in appropriate disposal bags 36. Immerse the speculum in 0.5% chlorine solution 37. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out 38. Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry 39. Record the VIA test results and other findings in the woman’s case record form 40. a. If acetowhite change is present, draw a map of the cervix and the diseased area on the record 41. a. If VIA test is negative, follow Checklist 4.6.1 for counselling 42. b. If VIA test is positive or cancer is suspected, follow Checklist 4.6.2 or 4.6.3 as appropriate for counselling *The highlighted steps are considered as critical Score achieved: Facilitator’s remarks Facilitator’s signature
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Annex 6.7 Checklist for cervical sample collection technique for HPV test The same will be used as assessment sheets during training and assessment
Note to facilitators Rate the performance of each step using the following rating scale: • 1 – Step or sequence not performed correctly (needs improvement) • 2 – Step or sequence partly performed • 3 – Step or task efficiently and precisely performed in the proper sequence To be considered competent for a particular procedure a trainee must perform the critical steps efficiently and precisely (Rating – 3) and obtain Rating 2 and above in at least 80% of all the steps (including the critical ones).
Skills checklist: Cervical sample collection technique for HPV test Steps Preparation for HPV Test 1. Keep necessary equipment ready as per box 2. Check availability of consumables as per box 3. Ensure that the light source is ready to use 4. Arrange instruments and supplies on a high-level disinfected tray or container Counselling 5. Greet the woman respectfully and introduce yourself 6. Make the woman sit comfortably and tell her about the necessity of HPV test and the procedure 7. Inform what the test results might be and what follow-up or treatment might be necessary 8. Listen to her problems and concerns and respond to her queries 9. Obtain informed consent if required by the regulations History taking (ask questions/check records) Cases 1 2 3 4
10. Personal information: Name, age, husband’s name, address, telephone number and LMP 11. Obstetric history 103
12. History of past illnesses 13. History of previous cervical cancer screening test (s) 14. Ask for any of the following symptoms: Persistent foul smelling white discharge, post-coital bleeding, post-menopausal bleeding, irregular menstrual bleeding 15. Record all relevant information on a case record form Step wise cervical sample collection procedure for Hpv test 16. Fill out the HPV test requisition form 17. Label the sample collection vial with the patient’s name, screening ID, date of sample collection 18. Check that the woman has emptied her bladder 19. Help her onto the examining table, help her to be undressed and drape her 20. Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry 21. Put one pair of new examination disposable gloves on both hands 22. Inspect external genitalia and check urethral opening for discharge 23. Select speculum of appropriate size and lubricate the blades with warm water only and NOT lubricant jelly 24. Insert speculum and adjust it so that the entire cervix can be seen 25. Fix the speculum blades in the open position so that the speculum remains in place with the cervix in view 26. Adjust the light source so that you can see the cervix clearly 27. Examine the cervix for cervicitis, ectropion, nabothian cysts, growth, ulcers or contact bleeding 28. If large quantity of discharge or mucus is present, gently remove by dabbing with a dry cotton swab without disturbing the epithelium 29. Identify the external os of the cervix 30. Insert the sample collection brush/broom into the external os till the outer bristles touch the ectocervix (Do not insert the brush/broom completely into the endocervical canal) 31. Gently rotate the brush/broom in a clock-wise direction 3–5 times (check manufacturer’s instructions)
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32. Remove the brush/broom from the canal while avoiding contact with the outside of the specimen transport tube/vial or any other object 33. Insert the end of the brush/broom into the specimen transport tube/vial 34. If using a brush – snap off the shaft of the brush at the score line, leaving the end of the brush inside the tube 35. If using a broom – detach the broom from the end of the shaft leaving it inside the vial 36. Replace/tighten the cap on the tube/vial securely 37. Place the tube/vial in the specimen bag/container for transport to the laboratory 38. Remove the speculum 39. Help the woman to get up from the examination table and sit comfortably Post-HPV sample collection procedure tasks 40. Dispose-off the swabs in appropriate disposal bags 41. Immerse the speculum in 0.5% chlorine solution 42. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out 43 Wash hands thoroughly with soap and water and dry with clean, dry cloth or air dry 44. Arrange for specimen transfer to the laboratory as per instructions of the test kit manufacturer 45. Inform the woman when (day/time) to collect the test report 46. Discuss the necessity of referral and/or treatment with her if the test report is positive *The highlighted steps are considered as critical Score achieved: Facilitator’s remarks Facilitator’s signature
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Annex 6.8 Checklist for cryotherapy The same will be used as assessment sheets during training and assessment
Note to facilitators Rate the performance of each step using the following rating scale: 1 – Step or sequence not performed correctly (needs improvement) 2 – Step or sequence partly performed 3 – Step or task efficiently and precisely performed in the proper sequence To be considered competent for a particular procedure a trainee must perform the critical steps efficiently and precisely (Rating – 3) and obtain Rating 2 and above in at least 80% of all the steps (including the critical ones).
Skills checklist: Cryotherapy Steps Cases Pre-cryotherapy counselling 1. Greet the woman respectfully and introduce yourself 2. Explain to the woman why the treatment is recommended and describe the procedure 3. Exclude pregnancy by asking LMP or if amenorrhoea is present. Do a urine pregnancy test if necessary 4. Tell her about what side effects to expect and the alternatives to cryotherapy 5. Obtain informed consent for cryotherapy Getting ready 6. Check that instruments, supplies and light source are available and ready to use 7. Check that cryotherapy instrument and gas tanks are ready for use 8. Tell the woman what is going to be done and encourage her to ask questions 9. Check that the woman recently (not more than 30 minutes previously) has emptied her bladder 10. Help her on to the examination table and drape her 11. Wash hands thoroughly and air dry them 106 1 2 3 4
12. Put on new examination or high-level disinfected surgical gloves 13. Arrange instruments and supplies on a high-level disinfected tray or container Cryotherapy 14. Insert an appropriate sized speculum and fix blades so that the entire cervix can be seen clearly 15. Move the light source so that the cervix can be visualized clearly 16. Apply 5% dilute acetic acid and identify: • SCJ • TZ and area to treat • Limits of the lesion 17. Choose the correct size of cryotherapy probe so that the entire lesion is covered 18. Smear the cryoprobe tip with saline or any lubricant jelly 19. Apply cryoprobe with tip of the probe placed on the external os of the cervix 20. Take precautions so that the cryoprobe tip does not inadvertently touch any part of the vagina 21. Check for adequate pressure(40–70 kg per cm2) in the gas tank indicated by green zone in most models of the equipment 22. Press the trigger of the cryogun to release gas and keep it pressed for 3 minutes 23. Inspect the cervix to ensure that the ice ball forming on the cervix extends outside the rim of the cryoprobe by 4–5 mm 24. Release the trigger and let the ice thaw for 5 minutes 25. Repeat the procedure of freezing for another 3 minutes 26. Release the trigger to stop gas flowing and wait for cryo-tip to detach from the cervix of its own 27. Remove the cryoprobe from vagina 28. Remove the speculum and place it in 0.5% chlorine solution for 10 minutes 107
Post-cryotherapy tasks 29. Close the gas cylinder valve 30. Detach the cryoprobe, clean it and put it in chemical disinfectant 31. Decontaminate the cryotherapy unit with alcohol 32. Immerse both gloved hands in 0.5% chlorine solution Remove gloves by turning them inside out: • If disposing off the gloves, place them in a leak-proof container or plastic bag. • If reusing surgical gloves, submerge them in 0.5% chlorine solution for 10 minutes for decontamination 33. Wash hands thoroughly with soap and water and air dry them 34. Check to be sure that the woman is not having excessive cramps 35. Advise about post-treatment care and follow-up instructions 36. Complete the documentations to record the treatment *The highlighted steps are considered critical Score achieved: Facilitator’s remarks Facilitator’s signature
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Annex 6.9 Checklist for cold coagulation The same will be used as assessment sheets during training and assessment
Note to facilitators Rate the performance of each step using the following rating scale: • 1 – Step or sequence not performed correctly (needs improvement) • 2 – Step or sequence partly performed • 3 – Step or task efficiently and precisely performed in the proper sequence To be considered competent for a particular procedure a trainee must perform the critical steps efficiently and precisely (Rating–3) and obtain Rating 2 and above in at least 80% of all the steps (including the critical ones).
Skills checklist: Cold coagulation Steps Cases Counselling before cold coagulation 1. Greet the woman respectfully and introduce yourself 2. Explain to the woman why the treatment is recommended and describe the procedure 3. Exclude pregnancy by asking LMP and do urine pregnancy test if amenorrhoea is present 4. Tell her about what side effects to expect and the alternatives to cold coagulation 5. Obtain informed consent for cold coagulation Getting ready 6. Check that instruments, supplies and light source are available and ready to use 7. Check for electricity supply 8. Check that the cold coagulator is connected to an electricity source and is ready for use 9. Tell the woman what is going to be done and encourage her to ask questions 10. Check that the woman has recently (not more than 30 minutes earlier) emptied her bladder 109 1 2 3 4
11. Help her on to the examination table and drape her 12. Wash hands thoroughly with soap and water and air dry them 13. Put on new examination or high-level disinfected surgical gloves 14. Arrange instruments and supplies on a high-level disinfected tray or container Cold coagulation 15. Insert an appropriate sized speculum and fix the blades so that the entire cervix can be seen clearly 16. Move the light source so that the cervix can be visualized clearly 17. Apply 3–5% dilute acetic acid and identify: • Squamo-columnar junction • Limits of the lesion • TZ and area to treat 18. Set the cold coagulator at 100°C 19. Apply the cold coagulator probe on the area of the cervix to be treated and heat for 45 seconds at 100°C 20. Check if the entire TZ has been treated. If not, then repeat the procedure so as to treat the entire TZ including the lesion on the ectocervix.(1–5 overlapping applications of 45 seconds each can be used) 21. Remove the probe gently taking care not to touch the vulva or vagina with the probe to avoid unnecessary burns 22. Remove the speculum and place it in 0.5% chlorine solution for 10 minutes Tasks following the cold coagulation procedure 23. Clean the probe by scrubbing it gently with a cotton swab and wash with clean water 24. Set coagulator at 120 °C and heat probe for 45 seconds 25. Decontaminate cold coagulator unit by wiping with alcohol
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26. Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out • If disposing off the gloves, place them in a leak-proof container or plastic bag. • If reusing surgical gloves, submerge them in 0.5% chlorine solution for 10 minutes for decontamination 27. Wash hands thoroughly with soap and water and air dry them 28. Check to be sure the woman is not having excessive cramps 29. Advise about post-treatment care and follow-up instructions 30. Complete the documentation to record the treatment *The highlighted steps are considered critical Score achieved Facilitator’s remarks Facilitator’s signature
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