Assessing nurses’ adherence to the see-and-treat guidelines of Botswana's national cervical cancer prevention programme

Abstract

The see-and-treat approach for cervical cancer screening (VIA followed by immediate cryotherapy) was first pilot tested in Botswana in 2009. Botswana’s Ministry of Health and the Botswana-UPenn Partnership collaborated to expand see-and-treat to 5 additional sites throughout the country in 2014. The purpose of this study was to evaluate whether nurses’ adherence to guideline-based screening was maintained during scale-up. Therefore, we compared nurses’ adherence between the pilot and scaled-up sites and determined main drivers of nonadherence across all sites.We conducted a retrospective review of 6644 medical charts from Botswana’s National Cervical Cancer Prevention Programme between February 2014 and October 2015. Using multivariable regression modeled with generalized estimating equations, we determined if nurses’ adherence to the see-and-treat guideline differed between the pilot and scale-up sites after controlling for significant covariates. Overall, adherence to the guideline was high (88.4%). Although the scaled-up sites had higher adherence compared to the pilot site (90.9% vs. 80.2%, respectively), the difference between sites was not statistically significant in the multivariable model (P=0.221). Of the non-adherent clinical encounters, the 3 most frequent visit types were VIA not performed (178, 23.3%), VIA negative: HIV unknown (163, 21.3%), and VIA negative: HIV negative (144, 18.9%). The most common reason for non-adherence was misspecification of follow-up times. Despite known challenges of scaling-up health innovations in resource-limited settings, our study shows that nurses maintained guideline-adherent care in Botswana’s national see-and-treat program. The successful scale-up may have been attributable to the program’s intensive quality assurance monitoring.