To date, the world continues to grapple with the escalating challenges of the unrelenting COVID-19 pandemic. At the same time, patients with other illnesses try to navigate a healthcare system that is barely coping with the pandemic. To ensure that such patients are not neglected or fall short of curative care, it is important for us to adapt to the current situation and work differently to ensure the impact of COVID-19 on other health issues can be minimized.
Cervical screening service is one of the most disrupted health services in most settings due to the pandemic (Ivanuš et al., 2021; Miller et al., 2021; Villain et al., 2021). In Malaysia, low cervical screening uptake has been the major obstacle in the effort to eliminate cervical cancer and the condition is now aggravated by the pandemic. In the pre-COVID-19 pandemic era, only 4 out of 10 Malaysian women has attended a regular cervical screening (National Institutes of Health, 2019).
Despite the pandemic, I had a chance to volunteer at several cervical screening events organised by the ROSE Foundation, a non-profitable organisation that offers free cervical screening (Program ROSE) to underprivileged women. The first event was conducted in a suburban area in Selangor. The planning and conduct of the screening event certainly took more effort compared to the pre-pandemic era and much of the preparation was conducted on-line. Program ROSE utilised self-sampling HPV testing which allowed women to collect their own sample in a private space allowed physical distancing protocols to be adhered to. Through online engagement with the stakeholders, pre-registration and appointment systems were implemented. Instead of having a large crowd at one time, appointments were given at a more specific time with mandatory mask-wearing and physical distancing in well-ventilated spaces.
Effective education and understanding are important for a successful screening program, especially in COVID-19 times. Many women who undertook the screening test were not aware of HPV testing initially as it is relatively new in Malaysia. It was a challenge to educate these women with terminologies and languages that they can understand in the fastest possible way. We took advantage of visual educational materials, prepared short videos and even a whiteboard to help them understand better and quicker. The whole screening process took less than 15 minutes for each woman and not a single COVID-19 case was reported out of this event! With the assistance of the local community volunteers, 50 women were screened in this event. This may not be a huge number, but it is certainly a good start to reinitiate cervical screening service in these hard times.
In another screening event under the “Frontliners against cervical cancer” campaign, a “drive-thru” method was used to provide cervical screening to the nurses and doctors at a primary care clinic at a village in Hulu Langat, Selangor. Just like the previous event, online pre-registration was conducted, and self-sampling kits (vaginal swabs) were prepared beforehand. Educational materials were also shared across the healthcare providers that signed up for this screening using mobile applications such as WhatsApp. Communications with all participants were carried out effectively using mobile phone days before the event. All questions and doubts had been clarified beforehand. Therefore, on the event day, we only need to pass a box containing all the swabs (from the car) and collect it back after 2 hours!
Personally, after such prolonged ‘social disconnections’, it felt really good to be able to go out to the field and meet people. Each woman we screened shared a different life story. All these stories touched me and reinforced my decision to undertake this project/PhD. One particular really moved me; a 40-year-old single mother who is the sole breadwinner in the family never had time to perform a health check-up at any healthcare facility. She undertook the self-sampling HPV testing in less than 15 minutes, without needing to leave her son alone at the hawker stall for long. The quick and convenient nature of the screening approach allowed her to finally, take good care of herself. There is another woman who accompanied her sister but ended up taking the test after she listened to our explanation. The reason of reluctance at the beginning was lack of confidence. She attended regular Pap smear for the past 10 years and could not believe that a cervical screening test can be done via a self-sampling procedure.
These are just one or two out of many real stories. From these stories, I understand that solutions that are acceptable and accessible are two important factors that we need to consider in the design of an organised cervical screening program. These are human stories we need to incorporate into the science and deliver public health measures that is within reach. Other than that, it is also critical to build trust in science. Public health is the bridge that connects science to people. The pandemic might have changed many aspects of our lives, but things can be done differently via public health innovations.
Ivanuš, U., Jerman, T., Gašper Oblak, U., Meglič, L., Florjančič, M., Strojan Fležar, M., . . . Gobec, M. (2021). The impact of the COVID-19 pandemic on organised cervical cancer screening: The first results of the Slovenian cervical screening programme and registry. The Lancet Regional Health – Europe, 5. doi:10.1016/j.lanepe.2021.100101
Miller, M. J., Xu, L., Qin, J., Hahn, E. E., Ngo-Metzger, Q., Mittman, B., . . . Chao, C. R. (2021). Impact of COVID-19 on Cervical Cancer Screening Rates Among Women Aged 21-65 Years in a Large Integrated Health Care System – Southern California, January 1-September 30, 2019, and January 1-September 30, 2020. MMWR Morb Mortal Wkly Rep, 70(4), 109-113. doi:10.15585/mmwr.mm7004a1
National Institutes of Health. (2019). National Health and Morbidity Survey 2019.
Villain, P., Carvalho, A. L., Lucas, E., Mosquera, I., Zhang, L., Muwonge, R. et al. Group, f. t. I. C.-I. S. (2021). Cross-sectional survey of the impact of the COVID-19 pandemic on cancer screening programs in selected low- and middle-income countries: Study from the IARC COVID-19 impact study group. International Journal of Cancer, 149(1), 97-107. doi:https://doi.org/10.1002/ijc.33500