Quality of cervical screening in the Well Womanclinics in Kalutara District

IntroductionTheobjective of this study was to assess the quality of cervical screening services in Well Woman clinics in the Kalutara District. Methodology A cross sectional survey of service provision, availability of physical facilities, performance of clinic activities including cervical screening in Well Woman clinics (WWC) and quality of follow up of clients in the clinics and field was car-ried out. A scoring system was developed for assessing quality and a consensus standard of quality was set by a panel of experts. Results All clinics (100%) performed Pap smear testing, but only three of the seven clinics conducted four or more clinic sessions a month per DDHS area as recommended in the guidelines sent by the Ministry of Health. The percentage mean scores of quality were: availability of required physical facilities in the WWCs- 73%; performance of general activities-70%; cervical screening procedures — 39.8%. Consensus by experts on expected percentage for above indicators of quality was >90%. The mean duration between Pap test and receiving the report was 3.4 + 2.25 months. Four (9%) clients with abnormal reports were lost to further care. Only one (1) referral from the WWCsto gynaecology of 162 referrals were referred back to WWC from the gynaecology clin-ies. staff be


Introduction
The Ministry of Health in 1996 with the assistance of United Nations Population Fund (UNFPA) set up 300 Well Woman Clinics (WWCs)  Officers of Health (MOH)in the country to implement a cervical screening programme, These clinics also offer screening for hypertension, diabetes mellitus and obesity. The services are provided free of charge by the government. In order to provide good quality care in a cost effective and efficient manner the programme has to be monitored.
The evaluation of the cervical screening programme, which had been set up five years ago,is essential for assessing the coverage and the quality of care (1).
Quality improvement should occuratall levels of service delivery and can be studied underthe following headings: 1. Structure-physical facilities, staffing numbers 2. Process-steps undertaken to perform procedures 3. Outcome-results of procedures undertaken Problems of quality often relate to the process. Process is a series of events or tasks, Quality improvement emphasizes better outcomes by improving processes (2). WHO (1994) identifies good quality services as services available safely and effectively as close as possible to the client community (3). Technically competent health care providers and clear guidelines/protocols should be available. All essential supplies and equipment should be available at hand (3). The care provided should be comprehensive and include continuity of care with facilities and arrangements for follow up. Information and counselling for clients and respectful, non-judgmental services are other characteristics of quality health care (4). In monitoring and-evaluating the quantity and quality of the programmesit is essential to observe whether the objectives have been achieved (5). Indicators facilitate measuring the changes, towards attaining objectives. Such indicators in areas of accessibility, utilization and quality of care have to be developed (5).
As stated by Bindari-Hammed and Smith (1992) much of the information required for assessing Volume 10, 2005 5 quality of care can be collected by utilizing a checklist or a simple scoring system (4). Use of both documented and interview data are helpful in complementing the data from one source with another. This method helps in triangulation to validate information collected automatically (6).

Methodology
Romer and Montoya-Aguliar in 1988 identified that in developing countries the information system is weak (7). Hence in order to obtain valid data to assess the quality of cervical screening services, a wide range of approaches was used in this study. Service provision, availability of physical facilities, performance of clinic activities and cervical screening were assessed using checklists. Follow up care and satisfaction of clients leaving the clinic was determined using an interviewer administered questionnaire. Documented data in the clinic were also obtained to assess the follow up.
The following indicators of quality of care including the recommended standards were developed by obtaining the consensus views of eight experts in disciplines of community medicine, gynaecology and health care providers of maternal and child health.

Quality of Physical Facilities
As shown in Table I, the median score for overall availability of physical facilities in WWCs was 40 (maximum=54) with a mean score wf. 39. 6 + 3.6, which was 73% of the standard requirement.
Percentage availability of general facilities in the seven clinics was 79% and facilities to perform cervical screening were 68%. The mean score for availability of a separate location for different activities was 66% of which spaces for health education and client preparation were present in two and one clinics respectively. An adequate number of clean well maintained toilets were available in two clinics.  Performance of generalactivities on cervical screening was 39% of the stan-All clinics in the selected DDHSareas performed Pap dard requirerhent. None of the clinics smear testing (100%). The overall availability of qualachieved the level recommended by the exity clinic services for the district based on the criteria perts. shownin Table 3 was 64%.
Health education talks were given before the Sterility was ensured over 90% in five clinics. Provi-commencement of screening, mainly focussion of health education to the clients was less than ing on breast cancer and diabetes and there 67% in all seven clinics. was very little discussion on cervical cancer, They educated the clients about the impor-Performanceof cervical screening in WWCs tance of the Pap test but not about the neces-As shownin Table 4 the overall scores on client sity of repeat screening in five years.
Journal ofthe Community physicians ofSri Lanka Volume 10, 2005  It was also observed in all the clinics except in one that cervical screening was performed by the Public Health Nursing Sister (PHNS).
Eighty-one percent of steps of the cervical screening procedure were performed correctly and according to the standard. There were some areas to be improved in taking the smear. None of the clinics' service providers moistened the speculum before introducing,it into the vagina.

Journal ofthe Community physicians of Sri Lanka
The mean score for rotation of the spatula clockwise was 63% and for spreading of the smear evenly over the slide correctly was 62%.
Mean duration of time between the performance of Pap smearand receipt of the results During the survey period 2310 Pap smear specimens had been sent for reporting for which 1962 reports (85%) had been received. In one clinic although some Pap smear reports had been received, they had been given to the clients without entering in the register.
Volume 10, 2005 8 In two clinics the results had been entered in the register but the dates of receipt of the reports were not entered. Hence, the mean duration of time could be analysed only in 1004 reports out of 1962 (51%). As shown in table 5 the mean and median duration between the Pap test and receiving the report were 3.4 (+ 2.25) and 3.2 months, respectively ( Table 5).
Out of the 1962 Pap smear reports, 1924 (98%) were satisfactory. Forty-five (2.3%) of 1924 satisfactory smears had abnormalities. Out of the interviewed chents, 47 (48%) had received the Pap smear report. Thirty-nine (83%) of the clients said it took more than three monthsto receive the results. All the referred clients (50) with either abnormal visual inspection findings or Pap test were given a referral card, address of the gynaecology clinic and 84%, 62% and 32% of the clients were given information on the clinic date, clinic time and name of the VOG respectively.
Of the clients referred (50), 8 (16%) did not visit the referral clinic. Five clients said that they could not attend the clinic due to personal reasons and one client said she could not understand the instructions while two had ignored the instructions given at the WWC. Two (5%) had to visit the clinic three times to get themselves examined.
Three (7%) clients waited for more than 2 hours to be seen in the referral clinic. All the clients who attended the referral clinic accepted the treatment offered, and the reasons for the actions had been explained to them. None of the clients were referred back to the WWCfrom thereferralclinic. Fourteen (28%) clients were visited by the PHMs after they had been referred to a gynaecology clinic, Overall satisfaction on follow up care given by the PHMs amongclients that were visited was 65%.

Client satisfaction on clinic services
At exit interviews (n=100), the mean percentage of satisfaction for the clinic facilities and services varied between 64% and 68%. Ninety eight of the clients agreed that the time of the clinic was suitable for them. Of them, 84% said that the time they spent to see the service provider was reasonable, and 91% was of the view that the service provider spent enough time with them.
Only 12% of the clients had problems to be discussed, and out of them 67% said that they felt comfortable with the discussion. All clients said that they would recommend WWC 'service to the others. Fifty four percent of clients said thatit is essential to improve public awareness, 16% were of the opinion that it is necessary to have a separate clinic session and to improve building facilities; the need for more toilet facilities was stressed (14%). ) Eighteen percent of the-interviewed clients claimed that they did not understand the purpose of the Pap test and 3% could not understand the Volume 10, 2005 explanation given on referral care. Fifty four percent of respondents suggested the need for enhancing community awareness.

Discussion
A study revealed that the cervical screening coverage in the Kalutara District was 2.2% since the inception of the programme (9). Only three DDHS areas (43%) conducted more than four WWCs per month in compliance with the guidelines.
Highest cumulative cervical screening coverage (9.3%) was observed in Bulathsinghale where there were more than four WWCs per month, To increase the coverage and quality of care it is necessary to increase the numberofclinics. The need for increasing manpower and physical facilities, increasing the number of clinics and establishing more outreach clinics was highlighted earlier (9).
The cumulative cervical screening coverage (9.3% and 3%) was found in the two DDHSareas where WWCs were conducted on a day when other clinics were not held. Conducting WWCs on separate days without combining with MCH/ FP clinics could improve the performance of activities.
The recommended standards of physical facilities (>90%) were reached only in a limited numberof clinics. Availability of general facilities in the WWCsin the district was 79% and the availability of equipment to perform cervical screening was 68%. Attention should be focused to provide more toilets and separate locations for health education and client preparation.
Client acceptance at the clinics and education before the cervical screening procedure was very poor; the quality percentage scores for these two indicators were 54% and 39% respectively. The quality. mean percentage score of practice of the correct cervical screening procedure was 81% and had not reached the recommended standard of 90%. Although the recorded data revealed that 98% of the smears in the district were satisfactory, there were some areas to be improved in taking the cervical smear, such as moistening of the speculum with water before introduction, the method of rotation of spatula at cervical os and spreading of smear overtheslide.
The mean and median duration, of time between the Pap test and receiving the report was 3.4 + 2.2 and 3,2 months respectively. Considerable variation of the mean duration of time existed between the two events in individual DDHS areas, None of the areas received the reports within one month Journal of the Community physicians of Sri Lanka of sending the sample as recommended by the WHO. These findings were confirmed by 83% of clients who were interviewed in the field, who claimed that it took more than three months for them to receive the report. Pap smear specimens in all the DDHS areas in the Kalutara District are sent to the Maharagama Cancer Institute for reporting. Since this undue delay may be due to the overload of the work in the laboratory, it highlights the necessity of establishing provincial or district level centres for Pap smear examination.
Out of 1924 Pap smear reports received in the district of Kalutara 2.3% (45) of the reports were abnormal. According to the Mausner and Bahn (1985), the prevalence of unrecognized disease in a community is dependent on the way the population had been screened (12). Hence it can be assumed that the low yield, could be due to poor cervical screening coverage which was 2.2% for the district (9). Of the clients with abnormal findings, four (99%) clients have been lost to further care. WHO(1988) states that loss to follow up of even a single patient with abnormal cytology means a failure of the programme (10). Therefore, it is essential to follow-up all abnormal smears effectively.
In all DDHS areas except in one, over 85% of clients who had abnormalities on visual inspections in the WWCs had been directed for referral care. In this area 48% of the clients had been re- Of those who had been referred to the gynaecology clinic, eight (16%) clients had not followed the instructions. Ignorance and inability to understand instructions given by the clinic staff were found to be the reasons for this lapse, indicating a communication gap between the clients and the service provider.
Only 50% of the clients were satisfied with the follow up visits of the PHMs. Ofthe interviewed clients, 17% were satisfied with the instructions given on follow up care by them, indicating the necessity of improving the knowledge of PHMs on correct follow up care.
A considerable number ofclients, (17, 40%) had to visit the referral clinic more than once and 13 (31%) clients had to wait more than one hour before being seen by a medical officer in the referral clinic creating dissatisfaction among the clients. It highlights the necessity of orientation of referral clinic staff on the objectives of the National Cervical Screening Programmeand to give WWCclients, some degree of priority during the clinic visits.
Journal ofthe Community physicians of Sri Lanka

Recommendations
Increasing the frequency and number of clinics held could improve the coverage ofcare.It is also essential to conduct WWs on separate days without combining with MCH/FP clinics. WWCs should be fully equipped in accordance with recommended guidelines. Follow up care has to be strengthened. All attempts should be made to reduce the mean duration of time between screening and the receipt of reports to less than one month as recommended by the WHO (10).
Supervising officers, e.g. Medical Officer Maternal and Child Health (MO/MCH), require to be trained on the guidelines issued and on monitoring and supervision to ensure and maintain the following: an adequate numberof clinics; adequate number of staff ; optimal resource distribution; practice of correct procedure and provision of quality care.
Secondary care institutional staff, such as referral clinic staff and relevant health managers have to be included in the periodical orientation programmes on cervical screening. Field staff especially public health midwives should be oriented for WWC activities.