Introduction Introduction 12
The reorganized chapter is: Chapter 5: Screening and treatment of cervical pre-cancer. Chapter 5 now consolidates information from what were two chapters: screening for cervical precancer and treatment for cervical pre-cancer. This consolidation was done because screening without treatment of pre-cancer is not an intervention that will reduce the incidence of cervical cancer or the associated mortality. Additionally, research on the screen-and-treat approach to cervical cancer prevention and control has markedly advanced since the last edition of this guide.
The two other substantially revised chapters are: Chapter 6 (Diagnosis and treatment of invasive cervical cancer) and Chapter 7 (Palliative care). These chapters do not include WHO recommendations because WHO guidelines on these subjects are currently being prepared. These two chapters have been revised to reflect the current available evidence.

# Scope and objectives
This guide's principal objective is to assist those responsible for providing services aimed at reducing the burden of cervical cancer on women, their communities and health systems. It focuses on the knowledge, best practices and communication skills needed by health-care providers working at community and primary and secondary levels of care to offer quality services for prevention, screening, treatment and palliative care for cervical cancer: the full continuum of care.
The four levels of care referred to throughout this guide are:
- Community - Health centre or primary care level - District hospital or secondary care level - Central or referral hospital or tertiary care level.

# Introduction Introduction
National-level decision-makers will find updated evidence-based information in this guide on what works in cervical cancer prevention and control programmes, which may be of use as a basis for updating their own guidelines and protocols.
Introduction Introduction 14
- information on services at each of the four levels of the health-care system, where applicable; - counselling messages to help providers communicate with patients about the services they have received and the follow-up they will need (Chapters 6 and 7 contain suggestions intended to assist specialist providers at tertiary-level facilities to have effective two-way conversations with patients, their families and support circles); - a list of further reading.
The practice sheets, provided after the chapters, are designed as:
- reminders for providers on the important elements to include when describing, providing counselling about, and/or performing a specific procedure or component of care (including answers to many frequently asked questions); and/or - checklists to help providers assure the availability of necessary items before starting an activity (e.g. before conducting an HPV vaccination session), or to document competency as part of supportive supervision (e.g. the correct way to perform cryotherapy).
The chapters on cervical cancer treatment and palliative care (Chapters 6 and 7) are supplemented by practice sheets for trained lower-and mid-level providers so that they have clear information as a basis for explaining to patients and their families what services they can expect at specialist hospitals when they are referred for further testing and/or treatment.
The practice sheets can be individually copied or adapted. Please note that they are not intended to be used by a novice as a way of learning to carry out a procedure.
Introduction Introduction are applied. With the increasing availability of HPV vaccines in more countries, paediatricians and educators also play a key role in the provision of cervical cancer prevention services. The new simpler technologies (as used in the screen-andtreat approach) offer opportunities for task shifting within the team of health-care providers.
Some possible roles for providers at different levels of the health-care system are as follows:
- Community health workers (CHWs) may be involved in raising awareness about cervical cancer in the community, motivating and assisting women to use services, and following up with those who have received a positive screening test result and those who have been treated at higher levels of care when they return home. - Primary care providers can promote services and conduct screening, follow-up and counselling, and can refer their patients to higher-level facilities as necessary, including provision of clear information about what to expect at those facilities. - Secondary care (district-level) providers perform a range of diagnostic and treatment services, and refer patients to both higher and lower levels of care. As outlined above, these providers may also be charged with programme considerations. - Tertiary care providers manage patients with invasive and advanced disease, and refer them back to lower (primary and secondary) levels of care, when appropriate.

# Using the guide
As with the first edition, this revised guide provides broadly applicable information that can be adapted to local health systems as well as to local needs, language and culture.
This guide and its recommendations can be used at the national level as a basis for developing or adapting national guidelines, for modifying policies and practices, and/ or for updating programmes, so that they are clearly in line with WHO's internationally recognized evidence-based standards.
Introduction Introduction 16
It may also be used for the development of human resources for health, as a reference when developing training courses and support materials for communitybased and other workers newly involved in cervical cancer services at the local level.
This guide can be used as a whole, or users can focus on the sections that are relevant to their area and level of practice.

# Guideline dissemination
These guidelines will be available online at the WHO Library database and there will be a link on WHO's Sexual and Reproductive Health web page and in the WHO Reproductive Health Library (RHL), an electronic review journal. 1 The publication will also be announced in the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) WHO Reproductive Health Update, 2 which reaches more than 2000 subscribers and numerous organizations with whom we are working. Many of these organizations will also copy the announcement in their newsletters.
The guidelines will be distributed in print to subscribers to WHO publications, to the WHO mailing list for mandatory free distribution (national chief health executives, ministers of health or directors-general of health, depository libraries for WHO publications, WHO representatives/liaison officers, WHO/HQ library, WHO regional offices, and off-site office libraries), additional non-mandatory free recipients (competent national authorities for sexual and reproductive health, cancer control programmes, national research centres in reproductive health, and WHO collaborating centres), WHO staff at headquarters, regional and country offices and elsewhere, concerned NGOs, medical societies concerned with cancer control and/ or sexual and reproductive health, scientific journals (including general medical journals and journals specialized on sexual and reproductive health or cancer), international organizations, and donors, potential donors, potential publishers of translated versions, as well as all those who contributed to the documents, 3 and the International Federation of Gynecology and Obstetrics (FIGO) World Congress, 4 among others. A number of webinars are also planned in 2015 and 2016 in each of the WHO regions with the Cervical Cancer Action group. 5 Introduction
Regional workshops are already planned in the Americas and Africa to present the new WHO guidelines to a number of stakeholders involved in national programme planning in 2015. The other regions will be covered in 2016-2017.
If requested by WHO regional offices, countries will be supported to adapt the guideline to their country-specific needs and to integrate the material with existing national guidelines. Adaptation will be done by organizing regional, sub-regional and country-level workshops for discussion of the key elements of the guidelines, in order to adapt them to the national epidemiologic, cultural and socioeconomic context. Initially, the guidelines will be available in English only and translations will be developed subject to the availability of funding. Translation into non-UN languages and publication in these languages by third parties will be encouraged. Community Level This level includes individuals and organizations; community-based, faith-based and other nongovernmental organizations; and community and home-based palliative care services. Also included are health posts, which are usually staffed by an auxiliary nurse or community health worker.
Health Centre -Primary Care Level A health centre is a primary care facility with trained staff and regular working hours. Maternity and minimal laboratory services may be available.
Providers at this level include nurses, auxiliary nurses or nursing assistants, counsellors, health educators, medical assistants, clinical officers and, sometimes, physicians.
District Hospital -Secondary Care Level Typically, a hospital at this level provides general medical, paediatric and maternity services, general surgery, inpatient and outpatient care, and specialized care in some specific areas. Patients may be referred to this level from health centres and private practitioners in the district. Laboratory services may include cytology and histopathology.
Providers include generalist physicians or clinical officers, nurses, pharmacy technicians or dispensing clerks, medical assistants, nurse assistants and laboratory technology assistants, and possibly a gynaecologist and a cytotechnologist. Private and mission hospitals are often present at this level.
Central Or Referral Hospital -Tertiary Care Level Tertiary care hospitals provide specialized care for complex cases and acutely ill patients, including surgery, radiotherapy and multiple outpatient and inpatient services. General medical, acute and chronic care clinics are offered. The most complete public-sector diagnostic and reference laboratory services are available with pathologists and cytotechnologists, radiology and diagnostic imaging. Providers may include gynaecologists, oncologists and radiotherapists, as well as those present at lower levels of care.

# Essential reading
Alliance for Cervical Cancer Prevention (ACCP). Planning and implementing cervical cancer prevention and control programs: a manual for managers. - Cervical cancer is a largely preventable disease, but worldwide it is one of the leading causes of cancer death in women. Most deaths occur in low-to middleincome countries. - The primary cause of cervical pre-cancer and cancer is persistent or chronic infection with one or more of the "high-risk" (or oncogenic) types of human papillomavirus (HPV). - HPV is the most common infection acquired during sexual relations, usually early in sexual life. - In most women and men who become infected with HPV, these infections will resolve spontaneously. - A minority of HPV infections persist; in women this may lead to cervical pre-cancer, which, if not treated, may progress to cancer 10 to 20 years later. - Women living with HIV are more likely to develop persistent HPV infections at an earlier age and to develop cancer sooner. - Basic knowledge of women's pelvic anatomy and the natural history of cervical cancer gives health-care providers at primary and secondary levels the knowledge base to effectively communicate and raise the understanding of cervical cancer prevention in women, families and communities.

# About this chapter
This chapter is based on the following WHO guidelines:
Cervical cancer screening in developing countries: report of a WHO consultation. Geneva: WHO; 2002 (). WHO guidance note: comprehensive cervical cancer prevention and control: a healthier future for girls and women. Geneva: WHO; 2013 (/ bitstream/10665/78128/3/9789241505147_eng.pdf). Other articles and publications on which the chapter is based can be found under Further reading, at the end of the chapter. This chapter has three sections. Section 1.1, Why focus on cervical cancer?, summarizes global statistics and the large disparities within and between countries in the rates of new cases diagnosed (incidence) and deaths recorded (mortality) each year. This information illustrates the burden that cervical cancer places on women and on health services, and the reasons why universal access to preventive services is of the utmost importance.
1 Section 1.2, Female pelvic anatomy and physiology, illustrates women's pelvic anatomy and describes the changes to the cervix that take place across the lifespan, from infancy to postmenopause. It also explains how these changes relate to cervical cancer prevention. Basic knowledge of women's reproductive anatomy gives health-care providers helpful tools for communicating with women, families and communities about cervical cancer prevention services (see Chapter 3). Section 1.3, Natural history of cancer of the cervix, provides information on the very slow progression of changes caused by persistent HPV infection. Health-care providers need to understand these sequential changes to be able to explain to the community why we have the opportunity to prevent most cervical cancer from occurring, and thus avoid the suffering and premature deaths that it causes.
- 1 Why focus on cervical cancer?

# Reasons to focus on cervical cancer
The reasons to focus on cervical cancer include: - Worldwide, 266 000 women die of cervical cancer each year. It is the leading cause of cancer deaths in Eastern and Central Africa. - The majority of these deaths can be prevented through universal access to comprehensive cervical cancer prevention and control programmes, which have the potential to reach all girls with human papillomavirus (HPV) vaccination and all women who are at risk with screening and treatment for pre-cancer. - We know what causes cervical cancer: almost all cases are caused by a persistent (very long-lasting) infection with one or more of the "high-risk" (or oncogenic) types of HPV. - We understand the natural history of HPV infection and the very slow progression of the disease in immunocompetent women, from normal (healthy) to pre-cancer, to invasive cancer, which is potentially fatal. - The 10-to 20-year lag between pre-cancer and cancer offers ample opportunity to screen, detect and treat pre-cancer and avoid its progression to cancer. However, immunocompromised women (e.g. those living with HIV) progress more frequently and more quickly to pre-cancer and cancer. - There are several available and affordable tests that can effectively detect precancer, as well as several affordable treatment options. - HPV vaccines are now available; if given to all girls before they are sexually active, they can prevent a large portion of cervical cancer. - Until there is universal access to cervical cancer prevention and control programmes, which will require addressing present inequities, the large disparities in incidence rates and mortality rates that exist in different settings will continue to be ample evidence of lack of comprehensive and effective services.

# Global epidemiology of cervical cancer
Epidemiology is the study of the distribution and determinants of health-related states or events (including disease), and the application of this study to the control of diseases and other health problems.

# a. Numbers and comparisons between countries
Cervical cancer is the most common cancer among women in 45 countries of the world, and it kills more women than any other form of cancer in 55 countries. These include many countries in sub-Saharan Africa, many in Asia (including India), and some Central and South American countries. The maps in Figures 1.1 and 1.2 illustrate global differences in incidence and mortality rates between countries and regions of the world. These maps do not include the wide disparities in incidence and mortality between areas within specific countries, which are related to socioeconomic and geographic variation, gender bias and culturally determined factors that can all severely restrict access to preventive services among some groups of women.
Further, the following data clearly illustrate the great differences found between women living in high-income versus low-to middle-income countries:
- In 2012, 528 000 new cases of cervical cancer were diagnosed worldwide; of these, a large majority, about 85% occurred in less developed regions. - In the same year, 266 000 women died of cervical cancer worldwide; almost 9 out of every 10 of these, or 231 000 women in total, lived and died in low-to middleincome countries. In contrast, 35 000, or just 1 out of every 10 of these women, lived and died in high-income countries.
The main reason for these disparities is the relative lack of effective prevention and early detection and treatment programmes, and the lack of equal access to such programmes. Without these interventions, cervical cancer is usually only detected when it is already at an advanced stage so that it is too late for effective treatment, and therefore mortality is high.

# b. Changes observed in numbers of cases diagnosed and deaths in the last 30 years
Over the last 30 years, cervical cancer incidence and mortality rates have fallen in countries where social and economic status has improved. This is largely a result of the implementation of secondary prevention efforts, which include effective screening, early diagnosis and treatment for pre-cancer and early cancer.
To summarize this section of Chapter 1, the statistics that have been presented here reflect a shocking neglect of women in low-and middle-income countries, making it imperative to establish effective services for all.     An understanding of the anatomy of the female pelvic structures will help health-care providers involved in cervical cancer programmes to:
- perform their tasks, including community education, screening, diagnosis and treatment of pre-cancer; - refer women who have lesions that cannot be managed at the provider's level to appropriate higher-level facilities; - interpret laboratory and treatment procedure reports and clinical recommendations received from providers at higher levels of the health-care system; - educate and provide one-on-one counselling to each patient (and her family if she requests this) about her condition and the plan for her follow-up care; and - communicate effectively with providers at all levels of care, including community health workers and tertiary-level referral providers.
See Introduction for descriptions of the different levels of health-care services and the providers at each level.

# Identification of the external and internal organs a. The external organs
The external organs include those visible with the naked eye and those visible using a speculum. Figure 1.3 shows the area seen when a woman of reproductive age spreads her legs. This includes the vulva (the area between the upper border in figure and the level of the Bartholin glands), the perineum and the anus. The vulva comprises the vaginal opening (introitus), which, with nearby structures, is protected by the major and minor labia. The clitoris is a small and very sensitive organ that enhances sexual pleasure. The urinary opening (urethra) is a very small opening above the introitus. The perineum is the area between the vaginal opening and the anus. Bartholin glands produce clear mucus which lubricate the introitus when a woman is sexually stimulated.

# b. The internal organs
The organs inside the pelvis are not visible except when exposed by an incision or laparoscopy. As shown in Figure 1.4, the urinary bladder and urethra are behind the pubic bone and in front of the vagina and cervix. The body of the uterus is above the cervix and the bottom of the colon and rectum are behind the genital structures.
The uterus is held in place by thickenings or ligaments in the lining of the abdomen (peritoneum). The ureters (thin tubes that carry urine from the kidneys to the bladder) are on either side of the uterus but are not shown in these figures. The vagina is an elastic muscular tube with multiple folds, leading from the introitus to the cervix. The lower portion of the cervix (ectocervix) protrudes into the upper end of the vagina and the vaginal area surrounding it is called the vaginal fornix.

# b. Cervix
The cervix is the lower third of the uterus. In a non-pregnant woman of fertile age, it measures approximately 3 cm in length and 2.5 cm in diameter. The lower part of the cervix (ectocervix) lies within the vagina and is visible with a speculum; the upper two thirds of the cervix (endocervix) lies above the vagina and is not visible. Most cervical cancers originate in the area where the endocervix and ectocervix join. Figure 1.5 shows the uterus and the relative size of the cervix as part of the uterus in a woman of reproductive age. The cervix is composed of dense fibro-muscular tissue. The cervical canal runs through the centre of the cervix from the internal os (the opening at the entrance to the cavity of the uterus) to the external os (the opening in the cervix seen with a speculum).
Figure 1.6 is a slightly enlarged photograph of the cervix as seen with a speculum in place. It shows the slightly irregular opening to the cervical canal, or external os, in a woman of reproductive age who has not had any vaginal deliveries. In a woman who has had one or more deliveries, the os would look like a wide, mouth-like, irregular slit. In this figure, the darker area surrounding the os is an extension of the columnar epithelium lining the canal; the lighter area around it is composed of stratified squamous epithelium extending from the vagina. The line where the two epithelia join is the squamocolumnar junction (SCJ). Please see later sections for a more detailed description of the cervical epithelia and normal changes that occur during the reproductive years (section 1.2.4), and for a description of the changes in the appearance of the cervix across a woman's lifespan (section 1.2.5). Those sections serve as an important preamble to section 1.3: Natural history of cancer of the cervix.

# c. Uterus
The uterus or womb is a thick-walled, pear-shaped, hollow, muscular organ. When not enlarged by pregnancy or a tumour, the uterus measures approximately 10 cm from its top (fundus) to the bottom of the ectocervix (see Figure 1.5). It is supported by several ligaments formed by thickenings of the peritoneum (the very thin membrane lining of the abdominal wall), which are attached to the pelvic wall. The area between the uterus and the pelvic wall is the parametrium.
The cavity of the uterus is lined by the endometrium, a layer of epithelium that contains many glands; the endometrium undergoes dramatic changes during the menstrual cycle and during pregnancy.

# d. Ovaries
The ovaries are paired organs on either side of the pelvis. With few exceptions, in a woman who is having natural monthly periods, an egg is produced by either one of the ovaries (ovulation) every month.

# e. Fallopian tubes
The fallopian tubes are thin hollow tubes and are the route used by the egg to travel from the ovary to the uterus. It is in the fallopian tube that fertilization of the egg takes place if the woman has intercourse in the days immediately before and/or after ovulation without contraception. f. Blood and lymphatic structures in the pelvis The arteries and veins that supply the uterus and cervix descend on both sides along the length of the cervix. It is important to keep the vessel location in mind to avoid injecting local anaesthetic into a vessel when applying cervical anaesthesia.
The lymph nodes and ducts draining the pelvic organs lie close to the blood vessels and may act as a pathway for the spread of cervical cancer. In late stages of cancer, large tumours may block lymphatic drainage and cause the legs to swell (lymphoedema).

# g. Nervous system of the pelvic region
The ectocervix has no pain nerve endings; thus, procedures involving only this area (e.g. biopsy and cryotherapy) are well tolerated without anaesthesia. In contrast, the endocervix has many sensory nerve endings that will cause a woman to feel pain during procedures involving this area (e.g. endocervical curettage, injury and stretching).
Networks of nerves are also present within the cervix; these nerves are part of the autonomic nervous system, which is involved in the control of the heart rate, blood pressure and other bodily functions. Procedures involving the endocervical canal, such as insertion of an endocervical speculum or curette, may stimulate these nerves and cause a vasovagal reaction, characterized by sweating, slow heart rate, low blood pressure and fainting.
A paracervical block, to produce local anaesthesia for certain procedures, is performed by injecting anaesthetic at various points in the body of the ectocervix or the vaginal fornices, but avoiding inserting the needle at 3 and 9 o'clock, where vessels are present. 1.2.4 The cervical epithelia and normal changes during the reproductive years

# a. Description of the cervical epithelia
The surface of the cervix is lined by two types of epithelium, which is the lining that is found on skin and inside hollow organs. The ectocervix is covered by the strong, protective, stratified (multi-layered) squamous epithelium, which is a continuation of the vaginal covering. The canal is covered by a single layer of tall columnar cellsthe columnar epithelium -which lines the cervical canal (see Figures 1.7 and 1.8).  The stratified squamous epithelium, as shown in Figure 1.8, consists of a plump, deep layer topped by multiple layers of increasingly tile-like, flatter cells.
The columnar epithelium, a single layer of tall cells, lines the cervical canal and extends outwards to a variable portion of the ectocervix. It is much thinner and more fragile than the squamous epithelium of the ectocervix and contains multiple glands that lubricate the canal.
The squamocolumnar junction (SCJ) is where the two types of epithelia meet. The SCJ is seen in Figure 1.8 as a sharp line with a step caused by the different thicknesses of the two epithelia. The location of the SCJ varies with a woman's age, hormonal status, history of birth trauma, pregnancy status and use of oral contraceptives.
Chapter 1. Background 1 b. Normal changes in the cervical epithelia during a woman's reproductive years When exposed to the acidic environment of the vagina, the more fragile columnar epithelium that extends out from the cervical canal onto the face of the cervix is replaced by more sturdy squamous epithelium. This normal replacement process is termed squamous metaplasia; it gives rise to a second SCJ. The area of variable size between the original and the new SCJs is the transformation zone.
As we will describe in the next section of this chapter, on the natural history of cancer of the cervix (section 1.3), the cells of the transformation zone are particularly vulnerable to HPV infection and it is here that most squamous cell carcinoma develops. Figure 1.9 depicts the face of the cervix of a woman who has had one or more vaginal births. It shows the normal changes that now include the squamous metaplastic epithelium, the transformation zone and both SCJs.

# Normal changes in the appearance of the cervix as a woman ages
In addition to the epithelial changes on the cervix described in section 1.2.4, the appearance of the cervix also undergoes striking changes from birth to postmenopause. Figure 1.10 is composed of schematic drawings showing these age-induced changes in the cervix, although it should be noted that in real life the appearance and demarcation of a woman's cervix at different life-stages is not quite as neat as shown.

# a. From birth to prepuberty
The original SCJ is present in girls at birth, and is found at or near the external os.

# b. From menarche to early reproductive age
At puberty when the ovaries begin to secrete estrogen, the cervix grows in size; columnar cells from the endocervix and the original SCJ become visible on the ectocervix.

# c. In women in their 30s
Under the influence of estrogen, the normal maturing process or squamous metaplasia has occurred and the original and new SCJs are both in place. The transformation zone is the area between the two SCJs.

# d. In perimenopausal women
As women age and the influence of estrogen decreases around the time of menopause, the cervix shrinks, and the columnar epithelium and transformation zone retreat back from the ectocervix into the cervical canal. e. In postmenopausal women Without estrogen stimulation, the original SCJ is still visible on speculum examination, but the new SCJ and a variable portion of the metaplastic epithelium of the transformation zone have retreated into the cervical canal.
Progressive changes may be uneven, however, and in some postmenopausal women, their cervix may look like the previous figure (perimenopausal), with the new SCJ still partly or completely visible.
- 3 Natural history of cancer of the cervix
- 3.1 What is cancer?
Cancer is a term used for the malignant, autonomous and uncontrolled growth of cells and tissues. Such growth forms tumours, which may invade the tissues around the cancer and cause new growths similar to the original cancer in distant parts of the body, called metastases. As cancer grows, it destroys normal tissues and competes for nutrients and oxygen.

# What is cervical cancer?
Persistent infection with cancer-causing HPV types is the cause of most cervical cancer. Ninety per cent of cervical cancers are squamous cell cancers and initiate in the transformation zone of the ectocervix; the other 10% are adenocarcinomas, which arise in the glandular columnar layer of the endocervix.
As stated in section 1.1 of this chapter, cervical cancer is preventable by vaccinating young girls against the human papillomaviruses that cause it and by screening for and treating precancerous lesions in women, since these lesions precede cancer by many years. In addition, if detected early and treated, cervical cancer can still be cured.

# What is cervical pre-cancer?
Cervical pre-cancer is a distinct change in the epithelial cells of the transformation zone of the cervix; the cells begin developing in an abnormal fashion in the presence of persistent or long-term HPV infection.
With the majority of cancers, even if they have a precursor stage, it is too short to be noticed and not amenable to easy diagnosis and treatment. Cervical cancer is one of the very few cancers where a precursor stage (pre-cancer) lasts many years before becoming invasive cancer, providing ample opportunity for detection and treatment.
Unfortunately, although preventable, there are still large numbers of women who die of cervical cancer in many countries (see section 1.1). This is because they lack access to services for prevention and treatment -a problem that may be caused 1 by many factors, such as barriers that limit their access to services (e.g. hours of operation, distance, lack of transportation) as well as prevailing cultural and gender barriers. In most cases, though, the overarching cause is poverty.

# HPV infection and cofactors that facilitate persistent infections
The primary cause of cervical pre-cancer and squamous cervical cancer is symptomfree, persistent or chronic infection with one or more of the high-risk (cancer-causing or oncogenic) types of HPV. HPV is the most common sexually transmitted infection.
Of the more than 100 numbered types of HPV, most of them are not associated with cervical cancer. Seven out of 10 (70%) of all cervical cancer cases reported throughout the world are caused by only two types of HPV: 16 and 18. Another four high-risk HPV types -31, 33, 45 and 58 -are less commonly found to be associated with cervical cancer, with particular types being more prevalent than others in certain geographical areas.
Two low-risk types of HPV (6 and 11) do not cause cervical cancer but are the cause of most genital warts or condylomas.
Almost all women and men are infected with HPV shortly after initiating sexual activity. Penetration of the vagina by the penis does not have to occur because the virus can be transmitted by skin-to-skin contact of the genital areas near the penis and vagina.
As in women, HPV infections in men are also commonly without symptoms and most infections are short-lived. Men can develop cancer of the anus; this is most commonly associated with HPV type 16, and is more common in men who have sex with men. As in women, HPV types 6 and 11 cause the majority of male genital warts.
In women, during puberty and pregnancy, the transformation zone on the ectocervix is enlarged. Exposure to HPV at these times may facilitate infection and may explain the associations between squamous cell cervical cancer and early sexual activity, young age at first birth, and a history of multiple pregnancies. Behaviours that can also increase the risk of HPV infection (and thus cervical cancer) include having multiple partners, and having partners with multiple partners.
While infection with a high-risk HPV type is the underlying cause of almost all cases of cervical cancer, it is NOT the case that these infections almost always cause cancer. In fact, most women infected with high-risk HPV do not develop cancer because most infections, regardless of HPV type, are short-lived; the body eliminates them spontaneously in less than two years. Infection with high-risk HPV only persists (becomes chronic) in a small percentage of women, and only a small percentage of these chronic infections can progress to pre-cancer; of these, even fewer will Chapter 1. Background 1 progress to invasive cancer. Thus, it is estimated that no more than 2% of all women in low-resource countries will develop cervical cancer during their lifetimes.
The conditions (cofactors) that may lead HPV infection to persist and progress to cancer are not well understood, but the following risk factors probably play a role:
- HPV type -its oncogenicity or cancer-causing strength;
- immune status -people who are immunocompromised, such as those living with HIV, are more likely to have persistent HPV infections and a more rapid progression to pre-cancer and cancer; - coinfection with other sexually transmitted agents, such as those that cause herpes simplex, chlamydia and gonorrhoea; - parity (number of babies born) and young age at first birth; - tobacco smoking; - use of oral contraceptives for over five years.
The last cofactor, use of oral contraceptives (OCs) for over five years, is the weakest. This was studied extensively by a WHO expert group, which concluded that the great benefits conferred by use of a very effective contraceptive method for preventing unplanned and unwanted pregnancies (with consequent prevention of morbidity and mortality associated with these pregnancies) far outweigh the extremely small potential for an increased risk of cervical cancer that may result from OC use. Thus, it is not in the woman's interest to discourage or prevent her from using OCs. All that is needed is for these women, like all other women, to be screened for cervical cancer.

# The development of pre-cancer
After entering cervical epithelial cells, high-risk HPV infection interferes with their normal functions, leading to changes characteristic of pre-cancer (also called dysplasia). See Annex 4 for terminology. Figure 1.11 depicts the timeline of the progression from a normal (uninfected) cervix to HPV-infected cervix to pre-cancer and invasive cancer. Note that changes occur in both directions because a large proportion of HPV-infected cells return to a normal state and a large proportion of cervical pre-cancers do not become cancer. Figure 1.12 illustrates normal cervical squamous epithelium on the left and progressively thicker layers of new abnormal small cells involving the epithelium in the large intermediate section. As this section in the middle involves more and more of the thickness of the normal epithelium, the epithelium is considered to have mild, then moderate, and finally severe pre-cancer. This sequence leads to invasive cancer if the abnormal cells invade the bottom layer of the epithelium (basement membrane), as shown on the right of the figure. There are four, usually sequential, routes through which invasive cancer progresses. i. Within the cervix: Spread occurs from a tiny focus of microinvasive cancer until it involves the entire cervix, which can enlarge to 8 cm or more in diameter. The cancer can be ulcerating, exophytic (growing outwards) or infiltrating (invading inwards). ii. To adjacent structures: Direct spread in all directions is possible -downwards to the vagina, upwards into the uterus, sideways into the tissues supporting the uterus in the pelvis and the ureters, backwards to the rectum, and forwards to the bladder. iii. Lymphatic: Spread to pelvic lymph nodes occurs in 15% of cases when the cancer is still confined to the cervix, and increases as the cancer spreads. Lymph-node metastases are at first confined to the pelvis and are later found in the chain of nodes along the aorta, eventually reaching the space above the collarbone (supraclavicular fossa). The lymph nodes, once invaded with cancer, are enlarged and, if close to the skin, can be palpated. For example, if the cancer has advanced into the lower third of the vagina, the groin nodes may become involved and will be palpably enlarged, and the supracervical nodes will also feel noticeably enlarged. iv. Distant metastases through the bloodstream and lymph channels. Cervical cancer cells may spread through the blood stream and lymphatic system to develop distant metastases in the liver, bone, lung and brain. While invasive cancer initially remains confined within the pelvic area, many cases can still be cured with appropriate treatment. If left untreated, however, cervical cancer progresses in a predictable manner and will almost always lead to death (see Chapter 6 for information on diagnosis and treatment of invasive cervical cancer).

# Cervical cancer and human immunodeficiency virus (HIV) infection
Cervical cancer is a defining illness of acquired immunodeficiency syndrome (AIDS) 1 in patients with HIV.
Women living with HIV and other immunocompromised women have a higher prevalence of HPV (the risk of infection increases with the degree of immunosuppression) and a higher prevalence of persistent HPV infection and infection with multiple high-risk HPV types.  This increased susceptibility to HPV infection leads to: - a greater risk of pre-cancer and cancer at younger ages, which increases with the degree of immunosuppression; - an increased risk of developing invasive disease up to 10 years earlier than in women not infected with HIV; and - more frequent presentation with advanced disease with smaller chance of survival for five years.
The above points strongly suggest the need to develop specific vaccination, screening and treatment protocols for women living with HIV and for all women living in countries or regions with a high prevalence of HIV. Existing protocols are based on experience, and studies are ongoing to determine whether or not these protocols include the best possible practices.
For information specific to women living with HIV, see Chapter 5, sections 5.2.5 and 5.4.6; Chapter 6, section 6.6.2; and Annex 9. - Development of any national cervical cancer prevention and control programme should be done in accordance with the WHO framework of the "six building blocks" to strengthen the overall health system. - Cervical cancer prevention and control programmes are developed and designed to decrease cervical cancer incidence, morbidity and mortality. - There are large inequities in access to effective cervical cancer screening and treatment; invasive cervical cancer predominantly affects women who lack access to these services. - A comprehensive programme should include primary, secondary and tertiary prevention activities (including treatment), and access to palliative care. - Screening services must be linked to treatment and post-treatment follow-up.
- Monitoring and evaluation are essential components of cervical cancer prevention and control programmes.
The aim of this chapter is to give an overview of how a national cervical cancer prevention and control programme is developed by national decision-makers, and to provide the basic information needed by health-care managers and providers for implementing such a programme at the patient and community levels.
This chapter has two main sections. Section 2.1, What is a comprehensive cervical cancer prevention and control programme?, describes the overall purpose of a comprehensive cervical cancer prevention and control programme and how it should be organized in order to have an impact on the burden of this disease. To be successful, a national programme should include the following key components: primary, secondary and tertiary preventive services, including treatment for precancer and cancer, and palliative care.
Section 2.2, National cervical cancer prevention and control programmes, describes the phases of a national programme: (1) national policy development and establishment of a programme management structure, (2) programme planning and preparation, including an effective referral system, (3) programme implementation, and ( 4) programme monitoring and evaluation, which must operate across all levels of care. This section provides operational guidelines on the various interventions needed at each level to achieve the goal of reducing the burden imposed by cervical cancer at the individual, community and national levels. Included in this chapter are tables summarizing commonly encountered challenges to programme planning and implementation and possible options for reducing or eliminating their negative effects. This chapter also includes a list of further reading and useful websites, and links to two practice sheets: a planning and implementation checklist, and descriptions of key performance and impact indicators for national cervical cancer prevention and control programmes.
- 1 What is a comprehensive cervical cancer prevention and control programme?
Any specific national health programme is embedded within a national health system. According to WHO, a strong health system should be built on six building blocks (see Box 2.1). Programme planners should be encouraged to use the WHO framework as a basis for building a national cervical cancer prevention and control programme. A cervical cancer prevention and control programme comprises an organized set of activities aimed at preventing and reducing morbidity and mortality from cervical cancer. It is part of the priority actions as stated in the Global action plan for the prevention and control of NCDs 2013-2020. 1 The programme provides a plan of action with details on what work is to be done, by whom and when, as well as information about what means or resources will be used to implement the programme. The achievement of the programme is assessed periodically using a The goal of any comprehensive cervical cancer prevention and control programme is to reduce the burden of cervical cancer by (i) reducing human papillomavirus (HPV) infections, (ii) detecting and treating cervical pre-cancer lesions, and (iii) providing timely treatment and palliative care for invasive cancer, as depicted in Figure 2.1.

# Key components of comprehensive cervical cancer prevention and control
A comprehensive programme includes three interdependent components: primary, secondary and tertiary prevention (see Figure 2.1). The interventions included in each component are described in this section.

# a. Primary prevention: reduce the risk of HPV infection
The public health goal is to reduce HPV infections, because persistent HPV infections can cause cervical cancer.

# Interventions include:
- vaccinations for girls aged 9-13 years (or the age range referred to in national guidelines) before they initiate sexual activity; - healthy sexuality education for boys and girls, tailored as appropriate to age and culture, with the aim of reducing the risk of HPV transmission (along with other sexually transmitted infections, including HIV) -essential messages should include delay of sexual initiation, and reduction of high-risk sexual behaviours; - condom promotion or provision for those who are sexually active;
- male circumcision where relevant and appropriate.
For further details on HPV vaccination, see Chapter 4, and for information on HPV infection, see Chapter 1, section 1.3.4.

# b. Secondary prevention: screening for and treating pre-cancer
The public health goal is to decrease the incidence and prevalence of cervical cancer and the associated mortality, by intercepting the progress from pre-cancer to invasive cancer.

# Interventions include:
- counselling and information sharing;
- screening for all women aged 30-49 years (or ages determined by national standards) to identify precancerous lesions, which are usually asymptomatic; - treatment of identified precancerous lesions before they progress to invasive cancer.
Even for women who have received an HPV vaccination, it is important to continue screening and treatment when they reach the target age.
For further details about screening and treatment of cervical pre-cancer, see Chapter 5.

# c. Tertiary prevention: treatment of invasive cervical cancer
The public health goal is to decrease the number of deaths due to cervical cancer.

# Interventions include:
- a referral mechanism from primary care providers to facilities that offer cancer diagnosis and treatment;
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- accurate and timely cancer diagnosis, by exploring the extent of invasion;
- treatment appropriate to each stage, based on diagnosis: -Early cancer: If the cancer is limited to the cervix and areas around it (the pelvic area), treatment can result in cure; provide the most appropriate available treatment and offer assistance with symptoms associated with cancer or its treatment. -Advanced cancer: If the cancer involves tissues beyond the cervix and pelvic area and/or metastases, treatment can improve quality of life, control symptoms and minimize suffering; provide the most effective available treatment and palliative care in tertiary facilities and at the community level, including access to opioids. - palliative care to relieve pain and suffering.
For further details about diagnosis and treatment of invasive cancer, and palliative care, see Chapters 6 and 7, respectively.

# d. The context for delivering the prevention components
The above three prevention components are planned and implemented in conjunction with:
- a structured national approach to community education and mobilization strategies (see Chapter 3 for details); and - a national monitoring and evaluation system (described in this chapter, section 2.2.3).

# National cervical cancer prevention and control programmes
The objective of a national programme will be to decrease the incidence and prevalence of cervical cancer and associated mortality in the country.
The development and implementation of a national cervical cancer prevention and control programme includes the following phases: 1. national policy development and establishment of a programme management structure 2. programme planning and preparation 3. programme implementation 4. programme monitoring and evaluation. Chapter 2. Essentials for cervical cancer prevention and control programmes 2 Chapter 2. Essentials for cervical cancer prevention and control programmes 55 2.2.1 National policy development and establishment of a programme management structure a. National policy development The policy development phase involves deciding on nationally appropriate and feasible options for prevention and control, giving careful consideration to scalability and sustainability, and developing national guidelines based on these policy decisions. This phase needs to use a cyclical process, since policies need to be updated regularly, as new evidence-based data become available. Service delivery, training, and monitoring and evaluation (M&E) all need to be adapted to the updated policies.

# Decisions on national priorities
Vital policy decisions should be carefully drafted based on the national burden of disease, availability of financial and human resources, and the existing structure, quality and coverage of the health-care and education systems. All decisions need to be examined and tailored to make them sustainable and applicable to the real situation in the country. Participants in this phase include national-level policy-makers and decision-makers and political and technical personnel from the country's Ministry of Health (MOH), as well as representatives of professional medical associations, such as the obstetric/gynaecology association, medical oncology association, nurses association, etc.
Areas for policy discussions and decisions may include the following: - Review and, if necessary, update existing national guidelines and protocols for health workers at all levels. - Conduct policy dialogue and build consensus with stakeholders, including healthcare providers, public health authorities, health insurance executives and medical professional associations, among others. - Gather and review country data to answer these key questions:
- Where is the problem?
-What should the priority areas be in addressing the problem? -What are the costs of delivering the services and how will they be financed? - Assess the affordability, cost-effectiveness and sustainability of introducing HPV vaccines and the screen-and-treat approach to cervical cancer prevention and control, as well as of a referral system for treatment at the national level. - Determine whether existing services have the capacity to add cervical cancer prevention and control services (including introduction of HPV vaccination), and plan how to address any shortcomings or deficiencies.
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- Consider strategies for programme introduction, including when, how (phased or not) and where (if not nationwide) to introduce HPV vaccine and screening and treatment services; if not nationwide initially, include a tentative future expansion plan for reaching all at-risk women and girls in the country. - Choose service-delivery strategies and possible venues for HPV vaccine delivery, and for screening. - Select which HPV vaccine is to be used in the country.
- Determine which methods will be used for screening and treatment of pre-cancer.
- Determine which hospitals will serve as reference centres for cervical cancer treatment. - Determine the age range, frequency, coverage level, time frame for achieving the coverage, and the health-care level for service delivery for each of the selected interventions. - Establish a training plan for health-care providers and community health workers.
- Establish a plan for information, education and communication (IEC) on cervical cancer, including training for managers and providers on how to implement IEC initiatives targeting consumers and the media. - Plan ahead for M&E; determine the key indicators, frequency of data collection and methods for recording and analysing data.
To facilitate decision-making on cervical cancer prevention and control strategies, programme managers and policy-makers need information on the projected programmatic costs of introducing cervical cancer interventions. The WHO cervical cancer prevention and control costing tool (C4P) has been developed to assist governments to estimate the costs of cervical cancer interventions over a five-year planning horizon. 2 Module 1 of the tool focuses on HPV vaccine introduction while Module 2 focuses on cervical cancer screening and treatment.

# Scalability and sustainability considerations
Two important factors that should be taken into consideration when setting up or improving a cervical cancer prevention programme are sustainability and scalability.
The costs of the cervical cancer prevention and control programme should be included in the national health budget. Planning for sustainability should include determining what is feasible in terms of available financial resources, human resources and infrastructure, with a view to equitable implementation of the various components of cervical cancer prevention and control. Sustainability planning may also include the search for external support from bilateral and multinational agencies 2 Chapter 2. Essentials for cervical cancer prevention and control programmes 57 and large foundations with proven records. For example, for HPV vaccine introduction, support from the GAVI Alliance is available for five years, with the requirement that the country must plan for long-term sustainability beyond the initial five years.
For countries with limited resources that initially can only implement a cervical cancer programme with limited coverage, future scalability is an important consideration. Wide coverage can be achieved using a step-wise incremental approach over a defined time period, based on the feasibility and availability of resources. Plans for scale-up should prioritize women who have not had access to health services and those groups with the greater burden of cancer deaths and suffering. Programme managers have to set realistic targets depending on the number of providers, the available hours of work and the size and sociocultural characteristics of the target population in the geographical area being considered.

# Development of national guidelines
The above decisions will inform the development of guidelines for national cervical cancer prevention and control. This activity needs to be conducted collaboratively by national policy-makers and MOH representatives in consultation with key stakeholders, such as health-care providers, medical professional associations and women's groups. It is also important to include national and international cervical cancer experts and representatives of nongovernmental organizations with experience with cervical cancer prevention and control.
Guidelines must include information on clinical and public health requirements for a successful programme. The elements that should be defined in the guidelines are listed below. - Screening: infrastructure, equipment and supply requirements, quality assurance and quality control approach, coverage - Treatment of precancerous lesions and invasive cancer: infrastructure, equipment and supply requirements, timeliness of treatment, quality assurance and quality control approach - M&E: key performance and impact indicators for each service component, plan for incorporation of necessary data into a management information system (MIS).

# b. Establishment of a programme management structure
To facilitate planning, implementation and monitoring of a national cervical cancer prevention and control programme, it is important to establish a national cervical cancer management team, with clear responsibilities and accountability for the programme.
As shown in Figure 2.2, two key groups should be developed at the national level, led by a designated national coordinator: i. A multidisciplinary management team responsible for the programme and composed of representatives from various national departments and programmes; ii. A stakeholder advisory group composed of representatives of appropriate segments of civil society.
Members of both groups would be selected and invited to participate by the MOH.

# Role of the national coordinator
The role of the national coordinator would include the following activities and responsibilities:
- Raise awareness within the MOH at different levels of the health system on the seriousness of national cervical cancer morbidity and mortality, and the potential to prevent most deaths with relatively few resources. - Advocate to make cervical cancer prevention and control a priority within the MOH, including allocation of a continuous and sustainable supply of resources to the programme. - With input and advice from senior MOH administrators and managers, establish and develop representative membership, roles and responsibilities for the multidisciplinary management team (in accordance with the structure shown in Figure 2.2). - In collaboration with the team, organize and schedule regular team meetings.
- In consultation with the team and with senior MOH administrators and managers, identify and invite key stakeholders from civil society to form the stakeholder advisory group (in accordance with the structure shown in Figure 2.2), and establish group functions and responsibilities. - In collaboration with the stakeholder advisory group, organize periodic meetings to update them on the status of the cervical cancer prevention and control programme and seek their input on the key steps. - Be the principal link and coordinator between and within all service levels in the national cervical cancer prevention and control programme, as well as with other national programmes (such as cancer control, immunization and adolescent health) and with other partners. - Prepare a proposal to ensure that all necessary elements for programme implementation will be in place at all health-care facilities, including equipment, supplies, and trained and supervised staff. This process should involve regional management personnel, and proposals may need to be adapted for different regions. - Produce annual reports on the performance of the cervical cancer prevention and control programme, based on the established programme indicators.

# Role of the national multidisciplinary management team
For the national multidisciplinary management team to be effective, the MOH needs to provide it with the appropriate mandate, decision-making authority, autonomy and resources to direct the planning, implementation, monitoring and evaluation of the national programme. As the national cervical cancer prevention and control programme has several key components, the management team will involve representatives from other national programmes, including community education and social mobilization, immunization, reproductive health, adolescent and school health, sexually transmitted infections and HIV, oncology, M&E, etc. Local and regional representation is important. The overall size of the team may range between approximately 10 and 25 people, depending on the size of the country and the structure of the national programme.
Key responsibilities of the national multidisciplinary management team (MMT):
- Develop national plans for the various components and elements of the programme.
- Develop a detailed budget for planning, implementation, monitoring and evaluation of the programme. - Establish systems for various elements of the programme including: recording data in the existing management information system (MIS); periodic reports (frequency, content and audience); distribution and maintenance of equipment and supplies, among others. - Through monitoring and evaluation activities, assess whether services are functioning effectively and ensure the implementation of corrective action in a timely manner, as needed. - Using a multipronged, evidence-based approach, build awareness of programmatic components at the primary and secondary levels and ensure that health-care providers are kept up-to-date with technical information. - Document and address any misinformation and misconceptions among health-care providers and communities. - Conduct regular monitoring and evaluation of programme activities.

# Principal functions of the stakeholder advisory group:
- Provide support and input to the MOH multidisciplinary management team (MMT) to create a cervical cancer prevention and control programme and/or expand, update or strengthen an existing one. - Attend regular meetings to review past activities, plan new ones and document planned achievements and/or lack of them. - In collaboration with the MMT, form and delegate working groups to focus on specific elements of the national programme, including (but not limited to) those shown in Figure 2.2. - Advise and participate in national, regional and local meetings with the MMT as necessary to define the programme.

# c. Challenges to the development of effective cervical cancer prevention and control strategies
As with all new programmes, challenges can be expected to arise at all levels of the health system pyramid when a national cervical cancer prevention and control programme is first contemplated and developed. There are actions that can be taken at all levels to mitigate the negative effects of these challenges.
Table 2.1 describes the most common challenges and suggests possible actions to address these at the appropriate levels of the health system. Many additional actions can be developed as appropriate in each country based on careful review of the updated contents of all chapters of this second edition of the guide. - Lack of an effective and functioning referral system within the programme services
- Utilize this guide to establish services with an effective and functioning referral system.
Chapter 2. Essentials for cervical cancer prevention and control programmes 63

# Programme planning and preparation
A cervical cancer prevention and control programme requires detailed planning and preparation because:
- it requires involvement, commitment and close coordination between and within several existing ministries (e.g. MOH, Ministry of Education, Ministry of Gender Equality, among others) and multiple programmes within them (e.g. within the MOH, relevant programmes include cancer control, immunization, reproductive health and adolescent health, among others); - it requires consideration of the various responsibilities and linkages between the structures at different levels of the health system: national, regional, clinic and community (see Figure 2.3); - it involves collaboration with nongovernmental organizations, women's groups and professional associations, such as paediatricians, gynaecologists, oncologists, primary care physicians and nurses; and - it requires active participation of key local stakeholders.

# a. Planning: key programmatic considerations
Based on policy decisions that have been made regarding the programme, to move forward with planning and designing an organized programme, the key programmatic considerations include:
- providing an opportunity for health-care providers to provide input on programme planning and preparation, in line with national guidelines; - assessing the service delivery needs at all service delivery facilities and building on what is already available at each, with the aim of sharing resources; - developing an action plan for community education and mobilization, and developing appropriate materials; - procuring and distributing equipment and supplies and setting up local repair/ maintenance and distribution systems for them; - establishing and maintaining an effective referral system;
- establishing a health management information system (paper-based or computerized) to enable monitoring and evaluation; - developing a monitoring and evaluating strategy to regularly assess the programme and institute corrective action in a timely manner; - assuring a well-designed and implemented provider training programme including post-training follow-up and periodic refresher training; - providing for supportive supervision to detect and correct any problems with health services, to keep them in line with national standards; and - establishing implementation strategies with district managers and local decision-makers. Steps in preparing to launch a new national cervical cancer prevention and control programme using a strategic approach A strategic approach to implementing a new national cervical cancer prevention and control programme requires several activities to be completed prior to launching services. The four main steps are described in this section.

# Determine the target population
It is crucial to having a clear definition of the target populations for HPV vaccination and cervical cancer screening, and to know the location and size of these populations. This information can be obtained relatively easily in countries where population records are kept and updated routinely as part of health services or by using census data from the national statistics authorities. In countries where this is not done, regional population estimates from the United Nations can be used. 3 4 Determining the target population is important for the following reasons:
- to provide the denominator for calculating coverage as a core performance indicator - to estimate the needed supplies, staff numbers and time, and other resources - to assist development of the action plans for delivering and monitoring services.

# Conduct a needs assessment
A needs assessment involves visiting, observing, interviewing key informants and stakeholders and documenting existing resources. The following information needs to be obtained:
- the location and condition of all facilities in the selected implementation area, including details about the infrastructure, equipment and supplies;
- the capacity of all cadres of providers for adding cervical cancer prevention and control services; - the quality of general services provided at each facility from the point of view of clinic personnel at all levels (from managers to cleaning staff) and from community representatives, including women and girls in the target age groups (both users and nonusers of services); - the schedule of service hours per day and per week, and out-of-pocket costs for all or selected services, if any; - the existence and functionality of a referral/counter-referral system; - the existence of an adequate system for adding data on cervical cancer services, as these data will be needed for monitoring and evaluating the new programme; - space available for cold chain storage of new vaccines, to determine whether expansion is needed to provide dedicated space for this purpose in the immediate future.

# Map and leverage support from additional local contributors
As cervical cancer prevention and control involves collaboration among various public and private organizations, mapping their locations in the area of implementation, as well as their infrastructure and human resources, can be very useful. It is important to identify and personally contact all potential local contributors, and leverage their collaboration. These potential contributors would include organizations identified for their experience and expertise in provider training, community sensitization and mobilization, design and implementation of vaccination programmes, monitoring and supportive supervision, and establishment and monitoring functionality of the cold chain, among others.

# Decide on and design an introduction strategy
Countries with limited resources can consider initiating cervical cancer prevention and control as a demonstration project in a selected geographic area. This strategy can be very valuable as a way of monitoring elements that may need to be modified or improved before services can be scaled up.
Geographic expansion can be planned using a step-wise approach, applying lessons learnt in the demonstration project and incorporating, if applicable, emerging new evidence-based technology. Scale-up can proceed gradually until the programme serves the entire country.
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# Programme implementation
An operational framework must be developed for the activities that need to be undertaken at different levels of the health care system. See Figures 2.3 and 2.4.
At the community level, activities include creating awareness, providing education, and outreach efforts targeting girls aged 9-13 years and women aged 30-49 years (see Chapter 3,and sections 4.3 and 4.4 in Chapter 4). For patients with advanced disease, the family and community are the principal contributors to palliative care after a woman is discharged from hospital (see Chapter 7: Palliative care).
At the primary-and secondary-level health-care facilities, the screening test or tests that have been selected at the policy development stage can be performed, and clients who screen positive can be treated with cryotherapy or loop electrosurgical excision procedure (LEEP). For lesions that do not meet the eligibility criteria for these treatments, women must be referred to the tertiary level of health services for further evaluation and treatment (see Chapters 5 and 6 on diagnosis and treatment of precancer and invasive cancer, respectively).
Training of health-care providers, supervision, and monitoring and evaluation of services are required, and must be performed continuously at all levels. - providing correct information to the community in clear terms using the local language so that people in the target populations will make use of (and benefit from) these services; - ensuring that services are provided in a timely manner and that referral services are working efficiently; - maintaining meticulous records and registers, which are needed to calculate the monitoring indicators as a basis for assessing whether the goals of the programme are being achieved; and - assuring and continuously improving the quality of services at all levels.

# b. Integrating cervical cancer services with other health services
Integrating services or, at a minimum, informing and arranging linkages between services enables holistic health management for women. The introduction of new cervical cancer prevention and control services provides an opportunity to take a comprehensive approach to women's health.
Integrating cervical cancer screening and treatment with other reproductive health services Links are needed between the demand for and the supply of health services. On the demand side, many women visit health-care facilities seeking advice on a variety of ailments, especially those related to reproductive health. But they may not be aware of the importance of cervical cancer screening and treatment in particular.
On the supply side, primary care facilities often have only one mid-level healthcare provider who is tasked with managing all reproductive health care for women (i.e. family planning, STI management, antenatal care and behaviour change Chapter 2. Essentials for cervical cancer prevention and control programmes Chapter 2. Essentials for cervical cancer prevention and control programmes 2 68 communication). Often this primary care provider does not have the training and/or the necessary equipment to provide pre-cancer screening for women over the age of 30, and might therefore miss the only opportunity to offer this service to a particular client. If screening is not possible at the primary care facility, the provider can, at least, determine the need for this service, educate the client and refer her to the secondary-level facility.
Integrating HPV vaccination into other primary prevention services The HPV vaccination strategy offers valuable opportunities for integration with other school health services and adolescent-friendly primary health care services. Interventions can include screening for common nutritional deficiencies, physical disabilities and illnesses, as well as providing preventive health information, such as information on the dangers of tobacco use, on contraception to prevent unplanned pregnancies, and on condom use for the dual purpose of preventing pregnancies and STIs, including HIV/AIDS.
Integrating HIV and cervical cancer screening and treatment services WHO strongly recommends that in countries with a high prevalence of HIV any contact between a client (or patient) and a health worker be used as an opportunity for HIV counselling and testing (HCT) and provision of appropriate education and care. The integration of cervical cancer and HIV services can occur in two ways:
- Women attending HCT services should be encouraged to seek cervical cancer screening if they are aged 30 years and above; if they are living with HIV and have never had cervical screening, they should be encouraged to get screened immediately regardless of their age, or to get screened within three years if they have previously had a negative cervical screening result. - Women attending for cervical cancer screening in countries with a high prevalence of HIV should be encouraged to attend HCT services if they have not been tested for HIV recently.

# c. Integrating services with screening for other cancers: the case of breast cancer
The same principles for implementing a successful and high-quality cervical cancer screening programme apply to screening for other cancers, such as breast cancer.
The experience and lessons learnt organizing and implementing a programme for cervical cancer could provide the basis for developing a programme for breast cancer. Differences in the target age range for breast cancer screening (usually women aged 50 years and older) need to be considered when approaching women at cervical cancer screening services. At a minimum, cervical cancer services offer an opportunity for building awareness about breast cancer and linking with breast cancer screening services. Similarly, women undergoing breast cancer screening should be asked about cervical cancer screening if they are in the recommended age range for cervical cancer screening, and those who have never been screened should be particularly encouraged to do so.

# d. Challenges to programme implementation
Challenges are not only found at the policy development level, but also arise during programme implementation at the level of the health-care facility and the community, in addition to barriers affecting families and individuals. Table 2.2 summarizes these challenges and provides suggestions for reducing any negative effects of these challenges.  When facing some of these challenges, it may help to bear the following points in mind. While some participants acquire new knowledge and skills quickly, others may need additional time. Extension of practical training beyond the training course can be arranged by having experienced providers take on trainees as apprentices at their facilities on a weekly or rotational basis after they have completed the basic course.
It is crucial to ensure that all providers are confident in their ability to provide the service to the established standard before they commence service provision. Posttraining supervision, the use of job aids, algorithms and other relevant learning tools to reinforce quality performance should be built into the training plan and subsequent programme management.
f. Other components that must be in place for efficient and safe service delivery Procurement and maintenance of equipment and supplies The needs assessment during the planning and preparation phase will provide vital information about the essential equipment and supplies that need to be procured. Strategies for distributing and storing equipment and for regular replenishment of supplies (including consumables, spare parts and reagents) must be established. In addition, an efficient local system for repair and maintenance will be needed, in order to avoid interruption of services or the need to reschedule patients due to broken or malfunctioning equipment. Such interruption of service may discourage clients from returning, and may damage the image of the service quality for actual or potential patients.
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# An infection prevention strategy
Proper management of medical waste items and decontamination and sterilization of reusable equipment is necessary to minimize the spread of infection and harm to clinic personnel, patients and the local community (see Annex 3).
The strategy should provide clear instructions on the following points:
- proper management of medical waste, including sorting, transportation and disposal; - a system for disposal of used vials and syringes used for HPV vaccination (see Practice Sheet 4.4 for the essential elements of injection safety for quality services); - processing of contaminated reusable equipment according to international standards, including decontamination with a bleach solution, rinsing and washing, high-level disinfection or sterilization; and - use of proper protective gear by health-care staff responsible for the management of contaminated waste and/or reusable equipment, including protective clothes, heavy gloves and masks if necessary.

# A national reference laboratory
This will be necessary for quality assurance and quality control when HPV tests are introduced in a programme.
The checklist in Practice Sheet 2.1 may be helpful in planning and implementing the cervical cancer control programme. Also, please consult the list of further reading at the end of this chapter for useful publications and websites containing up-to-date evidence-based information on strategic approaches to programme planning and implementation.

# Programme monitoring and evaluation
Monitoring and evaluation (M&E) in any health programme is conducted to ensure that the processes and systems are developed and adhered to in such a way that the deliverables are of good quality and maximize the benefits to the target population.
The key indicators to use for M&E for a cervical cancer prevention and control programme can be found in the WHO/PAHO 2013 publication Monitoring national cervical cancer prevention and control programmes: quality control and quality assurance for visual inspection with acetic acid (VIA)-based programmes. 5 5  Stakeholders should be involved from the strategic planning stage to ensure that the necessary results will be obtained from the programme and that appropriate corrective measures will be applied as needed. Basic health information systems, either manual (using records and registers), computerized or a combination of both, should be put in place and the data required for M&E should be collected regularly.
Cancer registries are important tools for collecting information on cancer cases and deaths. These data can be analysed to obtain information on the occurrence and trends of cancer in a defined population and to assess the impact of the cervical cancer prevention and control programme. If it is too difficult initially to implement cancer registries across the entire country, sentinel sites representative of different populations can be established and, as lessons are learnt, can be modified and scaled up until there is nationwide coverage. For more information on cancer registration, consult the website of the Global Initiative for Cancer Registry Development (GICR) of the International Agency for Research on Cancer (IARC). 6

# a. Monitoring
According to the WHO Health Systems Strengthening Glossary, 7 monitoring is the continuous oversight of an activity to assist in its supervision and to see that it proceeds according to plan. It involves the specification of methods to measure activity, use of resources, and response to services against agreed criteria.
Monitoring with appropriate corrective action requires a functioning system for gathering, storing and disseminating health information, a supervisory system to ensure adherence to standards, participatory and continuous quality improvement, and local problem-solving methods implemented with the involvement of providers and community members. This sub-section provides further details on health information systems, suggests tools for self-assessment and local problem-solving, and gives information on supportive supervision used for cervical cancer prevention.
Two specific activities in a cervical cancer prevention and control programme that rely heavily on monitoring are continuous quality improvement of service provision and monitoring adverse events following immunization (AEFIs) (see Chapter 4 and Practice Sheet 4.6 for specific issues related to M&E for an HPV vaccination programme).
Continuous quality improvement of service provision should be carried out periodically with remedial action instituted in a timely manner. Improving quality is a responsibility of all staff and should involve all cadres. Methods that can be adapted and used to monitor and improve the quality of services are:
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- Self-assessment and local problem-solving: These are participatory methods that should involve all cadres of providers as well as representative members of the community. EngenderHealth's COPE (client-oriented, provider-efficient services) self-assessment process has produced several tools that can be adapted to assist in this effort: client interview guide, client flow analysis, and COPE action plan. 8 - Supportive supervision: This must be done periodically and the process should be facilitated by trained supervisors. Key roles of the supportive supervision team include:
-observing all aspects of service provision, if applicable (e.g. client registration, counselling, consent procedures, administration of vaccinations, screening, treatment of pre-cancer, infection prevention practices and documentation); -reviewing site-level data relating to recruitment, HPV vaccination coverage (fully and partially immunized), screening and treatment rates, loss to follow-up, rates of AEFIs, etc.; and -mentoring and updating the skills of health workers and working with them to solve any issues noted about the facility-based services or outreach services.

# b. Evaluation
Evaluation is defined by the WHO Health Systems Strengthening Glossary as the systematic and objective assessment of the relevance, adequacy, progress, efficiency, effectiveness and impact of a course of actions, in relation to objectives and taking into account the resources and facilities that have been deployed.
An evaluation plan, developed with the active participation of stakeholders, needs to define the following:
- the person or persons in the multidisciplinary management teams who will be responsible for evaluating the services; - the resources and services that will be evaluated and the methods of the evaluation; - the data that will be collected, and the definition of the key performance and impact indicators for cervical cancer prevention and control (see Practice Sheet 2.2 for the key indicators); - the manner in which corrective action will be taken wherever gaps are detected; and - the budget for implementing the evaluation. Chapter 2. Essentials for cervical cancer prevention and control programmes 2 Chapter 2. Essentials for cervical cancer prevention and control programmes 77 c. Core indicators Core indicators to use for monitoring and evaluating services of a comprehensive cervical cancer prevention and control programme include performance and impact indicators. The core indicators are those that every country is strongly encouraged to adopt, as they provide fundamental information for monitoring and evaluating programme progress and impact as well as global information for intra-and intercountry comparisons (for examples, see Chapter 1, section 1.1.2, which presents data on the global epidemiology of cervical cancer).

# Performance indicators for HPV vaccination:
- Vaccine coverage of the target population: proportion of girls fully vaccinated by the age of 15 every year (measured using the WHO-UNICEF joint reporting form) - Rate of AEFIs: number of AEFIs reported every year (see Chapter 4 for more details).
Performance indicators for cervical cancer screening and treatment: - Coverage of the target population: i. percentage of women aged 30-49 years who have been screened at least once since age 30 (this can be assessed using a survey of women aged 30-49 years that includes a question about whether they have been screened at least once) ii. percentage of women aged 30-49 years who have been screened that year (information can be obtained from service logbooks, taking care to disaggregate first screen from repeat screen)
Note: For both of the above indicators, the denominator is the number of women in the population aged 30-49 years, and it is important to disaggregate the data in five-year groups.
- Screening test positivity: percentage of screened women aged 30-49 years with a positive result in the previous 12-month period (information can be obtained from logbooks) - Treatment rate: percentage of screen-positive women completing appropriate treatment for pre-cancer and treatment for invasive cancer in the previous 12-month period (information can be obtained from logbooks).

# Impact indicator:
- Cervical cancer age-specific incidence and mortality: age-specific incidence and mortality of cervical cancer in the target population.

# Achieving cervical cancer prevention and control
Cervical cancer prevention and control can be achieved if:
- a national policy and national guidelines on cervical cancer control are developed and disseminated, based on the natural history of the disease and data about the prevalence and incidence in different age groups; - financial and technical resources are allocated to support the implementation of the policy and guidelines, making services accessible and affordable to women and girls; - public education programmes and advocacy for prevention are in place to support the national policy; - women and girls in the target age groups participate widely in screening and HPV vaccination; - HPV vaccine is administered as a population-based strategy to adolescent girls between the ages of 9 and 13 years; - screening is organized, rather than opportunistic; - screening services are linked to treatment of pre-cancer and invasive cancer; - a health management information system and a monitoring and evaluation plan are in place to monitor achievements, identify gaps and provide feedback regularly to managers and health-care providers, such that appropriate corrective action can be implemented in a timely manner; - a functioning referral system is established and maintained; and
- an overall strengthened health system is in place. 9  - Outreach, community mobilization, health education and counselling are essential components of an effective cervical cancer prevention and control programme to ensure high vaccination coverage, high screening coverage and high adherence to treatment. - Outreach strategies must reach and engage young girls and women who would most benefit from vaccination and screening, respectively, as well as men and boys and leaders in the community, and key stakeholders. - Community mobilization and health education are essential tools for overcoming common challenges that impede access to and utilization of preventive care; these common barriers include social taboos, language barriers, lack of information and lack of transportation to service sites. - Health education ensures that women, their families and the community at large understand that cervical cancer is preventable. - Health education messages about cervical cancer should reflect the national policy and should be culturally appropriate and consistent at all levels of the health system. - Health-care facilities should have a private room that can be used to provide individual women with information and counselling, if appropriate, to help them make the best choices for their health. - Health-care providers should be trained to discuss sexuality in a nonjudgemental way and to address issues related to cervical cancer and human papillomavirus (HPV) while protecting patient privacy and confidentiality. - It is critical that educational messages emphasize that women with abnormal screening results must return for follow-up.

# About this chapter
This chapter is based on the following WHO guideline:
Cervical cancer, human papillomavirus (HPV), and HPV vaccines: key points for policymakers and health professionals. Geneva: WHO; 2007 (/ hq/2008/WHO_RHR_08.14_eng.pdf).
Other articles and publications on which the chapter is based can be found under Further reading at the end of the chapter.  This chapter addresses the need to include outreach, community mobilization, health education and counselling in effective cervical cancer prevention and control programmes. The goal of these strategies is to motivate women and families to seek preventive services, including early detection and treatment of cervical pre-cancer and vaccination of girls, and ultimately to enable people to increase control over and improve their health.
This chapter consists of five main sections. Section 3.1, Increasing the use of cervical cancer prevention and control services, serves as an introduction to the subject of this chapter, with a focus on the central role of health-care providers. The remaining sections, on Outreach (section 3.2), Community mobilization (section 3.3), Preventive health education (section 3.4) and Counselling (section 3.5), provide information on the most effective approaches and key messages for each of these efforts, including helpful resources for implementing them. The transmission of consistent messages requires good communication skills and the use of nontechnical language appropriate to the target population.
The practice sheets for this chapter list the key messages to be included in health education about cervical cancer, provide answers to frequently asked questions (FAQs) about cervical cancer and HPV, give advice on how to involve men in preventing cervical cancer, and provide information on counselling. Some practice sheets for other chapters will also be of support to health-care providers on communication issues, and these will be referred to in this chapter.

# Increasing the use of cervical cancer prevention and control services
Prevention saves lives and resources. The cost of losing a woman to cervical cancer is enormous, both for the family and the community. Good community outreach, education and counselling helps people to understand and reduce their personal risk of illness, and the risks to their family members and friends, by accepting and utilizing preventive care options such as vaccination and screening, avoiding harmful behaviours and adopting healthier lifestyles.
Many women and families may need support to overcome challenges that prevent them from receiving services. These challenges can range from fear of finding out they have an infection or disease, or shame about undergoing an exam of the genital organs, to confusion about the safety and effectiveness of the HPV vaccine, and/ or lack of time or affordable transportation to reach the service facility. Community mobilization involves a process of working with the community to identify these challenges and develop strategies to overcome them. Anna, a 32-year-old Kenyan woman, was not sick. In fact she was in high spirits. Shortly before, a community health worker's announcement at a funeral had inspired her. He had spoken about a disease that affects women -cancer of the cervix -and explained that the disease is preventable. If early cervical cancer is not detected and treated, a woman can die from the disease.
The community health worker, a person she knew and trusted, gave Anna a card and told her where she should go to have a screening test. "I felt it was important for me to find out if I had any risk because, after all, I could get help." When she returned two weeks later, she was told her test was negative, meaning it was normal. "I was greatly relieved," she said. Now, she only needs to return for another test in five years' time.
Because she was treated so kindly and learnt so much, Anna has begun to speak publicly about her experience. Many women she has spoken to have followed her advice and have been tested. Two of these women have reported to Anna that they were treated for pre-cancer so they would not get cancer. Anna is happy to be helping others: "I don't want anyone to die when there is an opportunity for us to live."
Source : Adapted from Women's stories, women's lives: experiences with cervical cancer screening and treatment. Seattle (WA): Alliance for Cervical Cancer Prevention; 2004.

# The role of the health-care provider
Health-care providers play a central role in preventing and managing cervical cancer by increasing the use of vaccination and screening services by those who are most likely to benefit. The health-care providers who play this role could be doctors, nurses, trained midwives or community health workers -anyone who provides clinical or community services. These providers are key players on a larger team that together can compile and convey information about HPV infection and cervical cancer, how to prevent them, screen for them, and treat women with abnormal screening results. Experience has shown that direct communication between health-care providers and those seeking health services is the most effective method of sharing important health information and influencing health seeking behaviour. Individuals and families look to the provider for health information and services.  Using clear and sensitive language during interpersonal communications, conveying key messages that contain consistent and accurate information, and providing supportive woman-centred services that are conveniently accessible can make a difference in the success of efforts to reduce cervical cancer. See Box 3.1 for the characteristics of a health-care provider who can be a good health educator on the topic of cervical cancer.
Box 3.1: Characteristics and communication skills of an effective health educator on the topic of cervical cancer
- Knowledgeable: Have correct understanding about cervical cancer and how to prevent it, including the reasons for prioritizing particular age groups to receive services. Be able to anticipate and answer questions, and to seek further information as needed. - Comfortable with the topic: Be comfortable talking about women's anatomy, sex and sexuality. - Clear and consistent: Share key messages that are easy to understand and appropriate for your audience, and be consistent with these messages. - Sensitive and non-judgemental: Issues related to sexual health can be very sensitive. Use appropriate language and tone. Ensure that the wording does not contribute to stigma or promote harmful gender stereotypes (see Table 3.1). - Supportive: Be a good listener. Show patience and understanding and help women and families find solutions to their problems and make good decisions about getting the care they need. - Welcoming and encouraging: When people feel welcome they are more likely to return for care when they need it.
Outreach refers to the efforts made beyond the walls of the health-care facility to reach target populations with the goals of increasing knowledge about specific health issues (cervical cancer prevention is one example) and improving access to health services.
The role of the health-care provider includes outreach activities, which need to be carefully planned. The first step in developing an outreach plan is to identify the target population for the particular message, and to be able to clearly communicate the reasoning and importance of prioritizing that target group for the services. Refer to Figure 2.1 in Chapter 2, which identifies the age groups affected and those that can Chapter 3. Community mobilization, education and counselling Chapter 3. Community mobilization, education and counselling 3 benefit most from particular interventions. Working in partnership with the community creates support for prevention, which will facilitate reaching target populations. At the stage of planning outreach activities it is crucial to understand the key obstacles that may be preventing women and girls from receiving preventive health services.
The goal of outreach is to maximize coverage and utilization of cervical cancer prevention and control services. To achieve this there are five target or priority groups that need to be reached with messages relating to cervical cancer prevention:
- Young adolescents (and their families): Research indicates that the HPV vaccines are most effective if provided to girls and/or women prior to the onset of sexual activity and exposure to HPV infection; therefore, the target population for the HPV vaccine, as recommended by WHO, is young adolescent girls aged 9-13 years. 1 However, it is important to include boys in awareness and informational campaigns. - Adult women: The greatest benefit from cervical screening can be gained by limiting the use of screening resources to women in the 30-49 age group, as recommended by WHO. This is because most women are infected with HPV in their teens and twenties and the virus normally takes 10-15 years to produce precancerous changes. Inclusion of family members and particularly male partners when conveying related health education messages is critical to ensuring acceptance of screening services. - Vulnerable groups: Evidence shows that services tend to be used least by those most at risk. It is not enough to set up services and assume that girls and women who are at risk will arrive to make use of those services. Special efforts need to be made to reach the most vulnerable populations. These groups include:
-girls who are hard to reach, especially those not attending formal education; -women who live far from services and have fewer resources; -migrant workers, refugees and other marginalized groups; -women and girls living with HIV and other immunosuppressed individuals who may require a more intensive screening schedule. - Community leaders and champions: Engaging community leaders can greatly facilitate outreach efforts. A few strong leaders who become champions of the cause can bring in community support that will ensure a successful programme. Their contributions may include getting buy-in from local men, securing financial support for families in need, arranging transport to services or providing a venue for a talk or campaign event. - Men: As with other aspects of women's reproductive health, it is crucial to reach and involve men. Men are often the "gatekeepers" of access to services for their Chapter 3. Community mobilization, education and counselling 3 wives and daughters, so their support (or, in extreme cases, their permission) may be needed if women are to attend services. Increasing men's knowledge and understanding of women's health issues helps them make better health decisions for themselves and for their partners and helps build stronger programmes. Information about HPV and cervical cancer can be given to men in clinical and community settings with messages about the importance of encouraging their partners to be screened and treated when necessary (see Practice Sheet 3.3).
Once the target populations have been defined, an outreach plan can include:
- community health workers and peer-to-peer communication strategies to provide information and motivate populations to seek services; - mobile screening units and/or vaccine brigades to bring services to communities; - posters, pamphlets, radio, television and internet-based social media to reach all segments of the target populations, as well as people who can influence them.
See section 3.4.3(c) later in this chapter for more information about delivering health education in the community.

# Community mobilization
Community mobilization is a process of engaging communities and generating support for all those in need of health services (for example, cervical cancer prevention and control), resulting in sustainable community ownership and participation.
Promotion of preventive services can be a challenge in any setting. People are often more likely to seek care if they or their family members are sick than to seek preventive services, and women often relegate their own preventive care to the lowest priority. Effective preventive care at health-care facilities requires not only setting up the service, but -equally important -engaging the community so that they understand and utilize it.

# Engaging the community for prevention
Health-care providers are often overburdened with caring for patients, which makes it difficult to get out into the community. Community health workers, volunteers and facility managers can be mobilized to provide community education and outreach. Community partners -including community leaders, religious leaders, teachers and members of local women's groups -can all help to identify members of the target populations, and can also help to address barriers to access and treatment (see Box 3.2). Community mobilization efforts can expand the reach and impact of the limited resources of health centres and providers.
What men need to know PS3.3 89 Chapter 3. Community mobilization, education and counselling Chapter 3. Community mobilization, education and counselling 3 Box 3.2: Communities can make the difference - More than 25 million families worldwide earn their living through coffee production. In many coffee-growing communities, small farmers have organized themselves into cooperatives, or unions, in order to share processing facilities and increase negotiating power. In Huatusco, Mexico, when coffee cooperative leaders learnt that many of the women in their community were dying needlessly of a preventable illness, they set to work to change the situation. Working with a nongovernmental organization and the Ministry of Health, they began by educating their members (mostly men) on the importance of saving women's lives and their role in giving their wives permission to be screened. They worked with the local health services to designate special days for screening "campaigns" and then used their coffee trucks to provide transport for the women. Family members helped out by taking over household chores and caring for small children. - By making screening a special and visible event, it became acceptable for all women to attend. Women who were afraid were encouraged by their friends and neighbours to participate and, most importantly, women who tested positive were assured of treatment. For those women diagnosed with more advanced cancers, community funds were collected and support was given to the families to help them with what could be devastating costs. Within two years, more than 80% of women in the target age had been screened and 90% of those who screened positive had received treatment. The cooperative gained new members and their workers felt greater loyalty to the group. And of course, women's lives were saved.

# Working with community health workers
Many health systems use trained community health workers (CHWs) to educate community members about prevention and to promote available health services. CHWs can serve as a bridge between health services and the community and are recognized worldwide as an essential part of any health-care team. Their peer-topeer approach helps to gain the trust of families who can benefit from information and advice on both vaccination and screening programmes, addressing any fears or concerns that may be present. For example, when a woman is found to have a positive screening result, the CHW can explain the importance of returning to the clinic for further management; and if parents have concerns about the safety of the HPV vaccine, accurate information can help them to understand about the safety and benefits of the vaccine. Welcoming CHWs to accompany individual women when they attend services at a health centre or hospital, if the woman wishes it, can demonstrate to the community that CHWs are valued and knowledgeable team members.
Chapter 3. Community mobilization, education and counselling Chapter 3. Community mobilization, education and counselling 3 When health-care providers have a good working relationship with CHWs, this can help facilitate:
- communities learning about cervical cancer prevention services, and their importance; - families electing to have their daughters vaccinated, thus protecting more girls from infection with high-risk HPV types; - women getting the support they need to make an informed decision about screening; - eligible women in the community being screened and thus more cervical precancers and cancers being detected early; - women with positive results receiving treatment and care; and - women who are referred for further care getting to those appointments.
If there is a group of community health workers or promoters already working on other health issues, it is best to incorporate cervical cancer information into their existing outreach work, by upgrading their knowledge on the issue. If CHWs do not exist in the community, community leaders and other stakeholders can assist in identifying and recruiting a group for training and service provision (see Practice Sheet 3.7).

# Preventive health education
Health education is an exchange of information with the purpose of increasing awareness and knowledge about how to keep healthy and prevent diseases (such as cervical cancer), including information about resources that are available and the benefits of accessing services.

# Preventive education for individuals and communities
Many barriers to HPV vaccination and cervical cancer prevention and control programmes can be addressed by educating and engaging the community. Resistance to cancer screening may reflect lack of understanding that cervical cancer is preventable through screening and early treatment. It can also be difficult for women to put their own health first when they have so many competing demands on their time and resources. This situation can be exacerbated by gender bias, which can contribute to low uptake of prevention services for women and girls. In addition, community misunderstandings and concerns about vaccine programmes may create obstacles.
Quality health education involves communicating accurate information in simple, understandable language to individuals or groups with the goal of raising awareness, changing behaviour and reducing illness and deaths.  Health education is not a one-time event; it should be a continuous activity and requires constant effort to keep provider knowledge up to date. In cervical cancer prevention and control programmes, key health education objectives include:
- informing people about cervical cancer, its causes (especially HPV) and natural history; - promoting HPV vaccines for girls, when they are available for that community; - promoting screening for women in the eligible age group; - ensuring that women who screen positive receive prompt treatment; - increasing awareness of the signs and symptoms of cervical cancer and encouraging women to seek care if they have them; and - addressing ignorance, fear, embarrassment and stigma related to HPV and cervical cancer.

# How to provide health education
An effective health educator must have a strong knowledge base of relevant information, as well as comfort with the topic and sensitivity in choice of words. The characteristics and communication skills of an effective health educator on the topic of cervical cancer are detailed in Box 3.1 in section 3.1 of this chapter. But an effective health educator must also be proficient in presentation to ensure that his or her messages are fully understood and that participants remain engaged.

# Some presentation tips:
- Give accurate information in a sensitive and nonjudgemental manner.
- Make sure the material is easy to understand and appropriate for the audience.
- Keep core messages consistent, regardless of the audience, but also strive to make messages both locally and culturally appropriate and tailor language to the audience using commonly understood terms whenever possible. - Develop messages in accordance with national guidelines, but also use input from the community and pretest the draft messages and materials with people from the community; use their feedback and advice to revise the messages to ensure they will be fully understood and effective. - Develop messages to address common fears and misconceptions, as well as the stigma sometimes attached to cancer and sexually transmitted infections (see section 3.4.4 and  Remember: Effective communication can increase rates of vaccination and screening, and save women's lives.

# Developing and delivering an educational presentation on preventive health
In order to be most effective in outreach and education efforts it is important to understand the topic well and to have practice presenting the information. The fact that cervical cancer is linked to HPV, which is transmitted through sexual contact, raises some difficult questions that health-care providers need to be prepared to answer. Messages should be developed using nontechnical and culturally appropriate language.

# a. Using key messages
Though cervical cancer prevention and control can be a complicated topic, the key messages can be kept short and simple to help people understand and make good choices.
Five key messages about the HPV vaccine:
- There is a safe, effective vaccine that can protect against cervical cancer. 2. The HPV vaccine works best if received before sexual activity begins.
- All girls in the age cohort or in the school class/grade/year identified as the target population by the national programme should receive the HPV vaccine. 4. HPV vaccines do not treat or get rid of existing HPV infections. 5. Girls who are already sexually active can also be given the HPV vaccine, though it may be less effective.
Chapter 3. Community mobilization, education and counselling Chapter 3. Community mobilization, education and counselling 3
Five key messages about screening and treatment:
- Cervical cancer is a disease that can be prevented.
- There are tests to detect early changes in the cervix (known as pre-cancers) that may lead to cancer if not treated. 3. There are safe and effective treatments for these early changes. 4. All women aged 30-49 years should be screened for cervical cancer at least once. 5. No one needs to die from cervical cancer.
The specific messages developed for use in each country need to comply with the country's national guidelines, including the specified target populations (i.e. age ranges for vaccination of girls against HPV and for women's cervical cancer screening).
Practice Sheet 3.1 provides more detailed messages for use in health promotion and Practice Sheets 3.2 and 4.1 present answers to frequently asked questions (FAQs) about cervical cancer and the HPV vaccine, respectively. These resources can make the health educator's job easier; they can be modified to suit the needs of the provider as well as those of the local community.

# b. Resources
To assist education efforts, additional materials and resources can be developed. Communication strategies and materials are most effective when they have been adapted or created with input from members of the target audience.
Consider using the following tools and resources: - Flipcharts are especially good for group education sessions. Pictures should be easy to see and understand. Telling a story of a woman going for screening and getting treatment can be more effective and easier to understand than complicated pictures of anatomy and viruses. - Brochures can give simple information and prevention messages for community members to take home and discuss with their families and others. - Drama and role-playing can occur in marketplaces or at community meetings and can capture people's attention and teach through storytelling. Peer experiences can be used either in live events or as case studies for drama and role-playing. - Radio and video programmes are effective for telling stories and for transmitting short messages or announcements. Taking part as a guest on a radio or television talk programme enables the presentation of a lot of information to reach many people at once. Local radio stations are particularly useful for announcing services and campaigns and reminding the untreated screen-positive women to return for treatment.

# c. Delivering health education
In health-care facilities Whenever possible, cervical cancer education (including information on HPV vaccination and screening) should be made available when women arrive at a health-care facility for any service, either for themselves or for a family member. Information can be provided to groups in waiting areas through posters, health talks, videos and/or written materials. Information and education on prevention of cervical cancer can be provided to more men and women by integrating it into health talks on antenatal and postnatal care, family planning, care for chronic illnesses, and sexually transmitted infections (STIs), including HIV/AIDS.
In the community Community education may take place in a variety of settings, such as community centres, places of worship and schools, at sports activities, on local health awareness days, or in the context of a screening campaign. Selected members of the community can be trained to deliver key messages: medical professionals, teachers, community leaders, community health workers, traditional healers and midwives. Messages about the benefits of the HPV vaccine (if it is available) should be tailored for girls, boys and their parents or guardians, while messages about the benefits of screening should be targeted at women and their partners.
Examples of community outreach activities include:
- Community health education: Information sessions organized by health-care providers or trained CHWs can increase utilization of cervical cancer prevention and control services. These are also very popular if they are done well and provided in locations where women congregate or wait in a line (queue) for any reason (e.g. food aid, school registration, etc.). - Home visits: CHWs or other community or social workers can provide information about preventive health services, address concerns and questions, and assist women in making arrangements to attend the health-care facility. If a male partner and/or other family members are present, and all present agree, they can be included in the discussion. - Client word of mouth: Satisfied clients can be encouraged to discuss HPV vaccination and cervical cancer screening with their friends and family members. A brochure can serve as a visual aid. - Community cultural activities: Information tables and/or announcements at community events, fairs or festivals are useful opportunities to present messages to the wider community. Market days, too, where both the merchants and buyers are predominantly women, lend themselves to community education.

# Managing misinformation and preventing stigma in health education on HPV and cancer
Stigma relating to HPV and cancer can interfere with access to care and treatment.
Often there is stigma related to diseases of the reproductive tract, particularly STIs, including HPV. Parents may be concerned about vaccinating their daughters with a new vaccine. Women may fear that screening will be painful and may be embarrassed about genital examinations, as well as having concerns about lack of privacy and confidentiality, which may keep them from attending services.
Educating parents on the safety of the vaccine and its effectiveness in protecting their daughters from cervical cancer in the future reduces concerns. Educating a woman privately about what is involved in screening and reassuring her that the screening procedure is safe and painless is a key way of addressing any fears and misconceptions. If such information is followed by skilful, respectful provision of services, women and their families will be more likely to utilize prevention services and will be more likely to recommend vaccination and screening to their friends and family.
Health-care providers play an important role in preventing misinformation and stigma about cervical cancer prevention. Review the messages in Table 3.1, and talk to co-workers and community members about common local misconceptions and how to share information about cervical cancer prevention in a way that does not create stigma or fear. Also see Practice Sheet 3.1 for key messages and Practice Sheet 3.2 for answers to FAQs about cervical cancer.
Chapter 3. Community mobilization, education and counselling Chapter 3. Community mobilization, education and counselling 3 When it is labelled a test for cervical cancer, it is logical for people to think that a positive test means that a woman has cancer. This creates great stress and fear.
- Screening uses a simple test (Pap smear, VIA or an HPV test) to detect very early changes in the cervix (also called pre-cancer), before cancer develops.
Misinformation: There is no point in going for cervical cancer screening. If a woman tests positive, it means she has a fatal condition and she will die.
Few women will go for a screening test if they don't think there is a solution.
- Cervical cancer can be prevented when early changes in the cervix, called pre-cancer (lesions that may become cancer), are found using a simple test. - If a woman has these early changes, there is safe and simple treatment that she can receive. - If women are screened at the right ages, between 30 and 49 years, then cervical cancer can be prevented. - Cervical cancer, if detected early, can be cured.
Intrauterine devices (IUDs) and birth control pills cause cervical cancer.
Women will be afraid to use contraception, even though this is not true.
- IUDs do not increase a woman's risk of cervical cancer. Birth control pills can cause a very slight increase in risk, but the benefits of preventing pregnancy are much greater than the very small increased risk of developing cervical cancer.
continued next page 98 Chapter 3. Community mobilization, education and counselling Chapter 3. Community mobilization, education and counselling 3
Messages that may cause problems

# Unintended results
Better to say Misinformation: The screening test is painful and a part of a woman's body is removed.
Women will be afraid to go for a screening test. Her family might be afraid and stop her from going.
- The speculum examination may make some women uncomfortable but the test is not painful. - During the test, a soft swab or brush gently touches a woman's cervix. - The test is simple and just takes a few minutes. - Screening is not the same as taking a biopsy or having surgery. There is no cutting involved in screening tests.

# Educational information about the HPV vaccine
As with any new health-care product or service, there will be some questions, fears and misconceptions related to the HPV vaccine. Naturally, families want to know about vaccine safety, how well it works, how long it will protect and whether there are any common adverse reactions or events. Such concerns can be addressed by raising awareness about vaccination, using examples of childhood immunizations that also need multiple doses to provide full protection.
Experiences in a number of countries have shown that, when promoting the HPV vaccine, informational messages should not overemphasize that the vaccine prevents an STI; rather, they have found that it is more relevant and more effective to focus on the potential of the vaccine to prevent cancer.
Providing some details about the testing of the vaccines in clinical trials and their excellent safety record will encourage parents to make sure that their daughters receive the vaccine and adhere to the recommended schedule. For community leaders, printed materials about cervical cancer and HPV vaccines are useful in helping them respond to questions from their constituents. Some common misconceptions and key facts about the HPV vaccine are presented in Table 3.2.
Complete information on HPV vaccination can be found in Chapter 4 and its practice sheets.

# Misconceptions found in communities
Facts (based on evidence from large studies)
The vaccine might be dangerous.
The safety of the HPV vaccine has been carefully evaluated since 2002, and is similar to that of other vaccines in wide use internationally (for more details, see Chapter 4).
The vaccine affects fertility and if given to young girls might make them infertile.
The HPV vaccine does not cause infertility or sterility.
My daughter does not need this vaccination now because she is so young and not yet sexually active.
It is important to protect girls before they are sexually active.
This vaccine will promote earlier sexual activity.
The evidence suggests that being vaccinated against HPV has no impact on the age people become sexually active.
Counselling refers to advice or guidance (usually one-on-one) from a knowledgeable person to facilitate personal decision-making. Counselling is generally conducted privately and confidentially. Counselling requires good listening and communication skills as well as knowledge of the subject being discussed. A good counsellor uses verbal and nonverbal communication skills and helps the client feel at ease by empathizing with her situation, reassuring her, and fostering a sense of partnership in addressing her problem.
Providers involved in cervical cancer control at all levels should be trained in basic counselling skills so that they can communicate effectively with clients (see Practice Sheet 3.4).
The content of the counselling encounter will vary according to the client's problems or concerns and her individual circumstances. It can cover prevention, screening, follow-up, referral, diagnosis, treatment of precancerous lesions, treatment of invasive cancer and/or palliative care. The chapters and practice sheets that provide more specific information on how to talk with a woman under each of these circumstances are indicated in the relevant sub-sections in the remainder of this chapter. All women and men who need to make a decision about their health and whether to have a service, medication or treatment may benefit from counselling that includes provision of correct information and a two-way private conversation about the available options, including how the choice to receive or decline a service (e.g. a screening test) might affect her or his present and future health. See Practice Sheet 3.5 for standard counselling steps for before, during and after a client has a test, procedure or treatment.
Girls and their parents can be counselled together or individually about HPV vaccination. Joint counselling provides an opportunity to have a conversation about sexual health with girls and to encourage cervical cancer screening for their mothers. See Practice Sheet 4.1 for answers to FAQs about HPV vaccination.
Women and girls who are living with HIV need to receive information and counselling about their greater vulnerability to HPV infection and their increased likelihood of developing cervical cancer at an earlier age. Women and girls living with HIV should be counselled to start regular screening as soon as possible after they learn of their positive status and to promptly receive treatment for any abnormality found. See Practice Sheet 3.6 on counselling for women living with HIV, and see Chapter 5 for further information on screening for women living with HIV, in section 5.2.5(a), and on diagnostic procedures for women living with HIV, in section 5.4.6(c).
Every woman who tests positive on a cervical screening test for precancerous lesions will need counselling. Ensuring treatment and preventing loss to follow-up may be the most important component of a successful screening effort (see the next section in this chapter, and see Practice Sheet 5.7 in Chapter 5 for how to counsel a patient after a positive screening result).
Counselling should be structured to:
- educate the woman about the natural history of HPV infection and cervical cancer;
- review and explain the screening results and the importance of follow-up care and treatment, if required; - present alternative services and procedures; and - answer all of the client's questions and concerns with appropriate information. It is also fine to acknowledge that you don't have immediate answers to all questions and to say that you will find the correct information and either contact her directly with the information or find another provider who can do this.
- 5.2 Key components of counselling for women with positive results on a test or examination and for women with cervical cancer
Be sure to include the following in the counselling: If a client had a positive screening test and is eligible for cryotherapy or LEEP:
- Does she understand the purpose of the screening test and the possibility of preventing cancer through early treatment? - Does she understand that a positive test probably means that she has early cell changes, and only rarely does it mean she has cancer? - Is there any reason she may have difficulty returning for care, such as an unsupportive or opposing partner, lack of transport, or financial difficulties? If so, discuss possible solutions and help her make a plan to obtain the services she needs.
If a client's examination was suspicious for cancer:
- Ask her if she has someone with her today that she would like to have present for the discussion. - Express concern about the seriousness of the findings, but do NOT tell her she has cancer as it is too early at this point to be sure of that diagnosis. Do tell her that she had a positive screening test and that she needs to be referred for further testing/ evaluation. - Do reassure her that she will receive the help she needs.
- Provide her with clear information about where to go for diagnosis and treatment.
- Invite her to return with any questions she may have.