Pivotal Points of Change

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FHI's Quarterly Health Bulletin Network

Pivotal Points of Change

Various factors can facilitate or hinder research utilization.

Network: 2003, Vol. 23, No. 1

Copyright Family Health International, 2003.
Network is reprinted with permission from Family Health International.

Key Points

Straightforward research findings can speed changes in clinical practices.

Research findings that are extensively disseminated are most likely to be used.

Political support for and timeliness of research findings can be essential for moving them into practice.

Increasing interactions among researchers, policy-makers, and practitioners can further hasten research utilization.

Many factors can facilitate the speed and ease with which research results are incorporated into practice. The presence of these factors does not guarantee implementation of research findings, but the more factors that are in place, the greater the chances of success.

One key factor is the nature and complexity of the research question, which often determines how easily it can be investigated and how straightforward the study conclusions will be. Various study designs are used to evaluate different types of research questions pertaining to reproductive health. One of two basic categories of studies — observational — is commonly used to answer questions about disease prevalence, natural history, cause, and risk groups. Observational studies may appropriately be used for ethical, financial, or logistical reasons, or because the research question requires this approach. However, these studies — while identifying associations among variables — are less able to identify direct causal relationships than are randomized controlled trials. Such trials, involving an intervention to prevent or change the course of a disease, are especially well suited to test the safety and efficacy of drugs or devices.¹

Particularly straightforward findings from a randomized controlled trial in Uganda are among several unique factors that recently contributed to rapid and positive changes in clinical practice (see Nevirapine Results Quickly Put into Practice).

The trial determined the effectiveness of single-dose nevirapine versus a specific regimen of short-course zidovudine (AZT) to prevent mother-to-child transmission of HIV.² Enrollment of some 600 women and their infants occurred quickly, and rates of adherence to the drug regimens were high. The proportion of women and infants who remained in the trial through completion, the most important component of avoiding study bias, was also high. "After eight weeks, 98 percent of mother-infant pairs had been followed-up, and at 16 weeks, 97 percent," says Dr. Willard Cates Jr., president of FHI's Institute for Family Health . "In any setting, especially in a resource-poor setting like Uganda, these are phenomenal study vital statistics," he says.

The results of the study were also highly significant, demonstrating that nevirapine was nearly 50 percent more effective than this AZT regimen at preventing transmission. Moreover, the research had a strong potential to make a highly desired public health impact of saving the lives of babies, which it eventually did.

Strategic dissemination

Like the strength of research results, specific ways of disseminating results can help facilitate their use. Most research findings are passively disseminated through academic seminars and publication in peer-reviewed journals, but more active dissemination involving a broad range of stakeholders — key decision-makers, health professionals, and the community — can increase their acceptance.

Type and scale of dissemination are among the best predictors of research utilization, according to a review of eight operations research projects conducted between 1988 and 1993 by the Population Council's Africa Operations Research and Technical Assistance Project I.³ (Operations research seeks to assess factors contributing to programmatic success or failure and to test new and potentially better approaches to service delivery.) Studies with the most extensive dissemination efforts were the most utilized, this operations research in Africa showed.

One study disseminated and utilized most extensively was a pilot project of community-based distribution of contraceptives, conducted from 1990 to 1993 by the Ministry of Health in Mali (see Community-Based Distribution Project Expands Beyond Mali). Dissemination activities included development and distribution of reports on five different aspects of the study; dissemination seminars during the study; an international workshop on the final results; and presentation of study findings at regional and international meetings. Communicating results with messages, and through channels, appropriate to specific audiences was an important dissemination strategy, says Dr. Ian Askew, a Population Council senior program associate and coauthor of the review of the eight operations research projects. "This requires many more resources, but is also much more effective," he says.

Supportive context

Another factor that can facilitate or hinder research utilization is the economic, political, or programmatic environment in which the research is conducted and eventually implemented. The timeliness of research in any of these contexts can be important, as is depicted in a case study regarding IUD provision in Turkey (see IUD Insertion by Nurse-Midwives Increases Use).

In some cases, however, compatibility of research with existing cultural beliefs may be even more important. Lessons learned from interventions and operations research to eradicate female genital cutting (FGC) throughout Africa demonstrate this point. Multiple factors facilitating research utilization have been present in the settings where this research is being conducted (including Egypt, Burkina Faso, Mali, and Kenya). Research clearly shows that FGC has negative health consequences, including hemorrhage, infections, complications during childbirth, and psychological scarring. And the political environment is supportive of eradication: Burkina Faso, Ghana, and Senegal all have national laws banning FGC. Nevertheless, utilization of the FGC research has been slow.

In Mali, where FGC prevalence is more than 90 percent, several nongovernmental organizations (NGOs) have been working to eradicate this practice. In particular, three local NGOs have educated traditional practitioners on FGC's negative health effects, trained them to advocate discontinuation of the practice, and suggested alternative sources of income. But an evaluation of the work of these three NGOs in 1996 showed that many practitioners were not convinced that FGC is a harmful practice and were continuing to perform it, despite the interventions.⁴

Many of these early efforts by NGOs to eradicate FGC emphasized the adverse health effects of the practice, says Dr. Askew, who is also an associate director of the Frontiers in Reproductive Health Program (carried out by the Population Council, FHI, and Tulane University), which conducted the evaluation in Mali. But the original emphasis on health did not sufficiently address the fact that FGC is essentially a cultural practice. "So several groups are now trying different and innovative ways of addressing the practice from a sociocultural perspective," he says.

In Kenya, for example, where FGC is practiced as a traditional rite of passage for young women, the local NGO Maendeleo Ya Wanawake (MYWO) has been working for years to encourage communities to abandon FGC. As an alternative to this tradition, MYWO suggests that families hold similar ceremonies that do not include genital cutting. An assessment in 2000 of this "alternative rite" program showed that families who took part in alternative ceremonies were more likely than others to know about the negative health consequences of FGC and to attribute to MYWO some of their decisions to abandon FGC.⁵

Research utilization mediators

Those who have a stake in utilization of research findings can provide essential support to move research findings into practice. But different stakeholders do not always have the same views on whether or how to push findings forward. A mediator — such as an influential political leader, a researcher, an entire organization, or an advocate or "champion" for utilization — can also help.

"Anything that can bridge the gap between research and practice is important," says Matthew Tiedemann, senior program manager and research utilization expert at FHI. "Use of mediators, which increases interaction between researchers, policy-makers, and practitioners, can help ensure that stakeholders are aware of the others' needs and contributions. That can reduce the time lag between research and its utilization."

In an ongoing project to implement a new single-visit approach for cervical cancer prevention in rural Thailand (see A Single-Visit Approach for Cervical Cancer Prevention), an influential member of the medical community is acting as a mediator, says Dr. Paul Blumenthal, director of JHPIEGO's Cervical Cancer Prevention Program. JHPIEGO is collaborating with the Royal Thai College of Obstetricians and Gynaecologists (RTCOG) on the project.

This single-visit approach, involving visual inspection of the cervix with acetic acid and a light source and then immediate treatment of precancerous lesions with cryotherapy, is safe, acceptable, and feasible in rural Thailand, a recent study has shown.⁶ The mediator — Dr. Khunying Kobchitt Limpaphayom, who is a well-known professor at Chulalongkorn University in Bangkok, the project director of JHPIEGO's Cervical Cancer Prevention Program in Thailand, and a member of the research team — will continue to be especially important as the project is expanded. "Because she is well respected and well connected, and because many people recognize that women's health issues are important to her, Dr. Limpaphayom can draw attention to the topic," says Dr. Blumenthal. "It is also clear that without her, we would not have been able to garner as much collaboration and support as we have."

As president of RTCOG during the project's conception, Dr. Limpaphayom was instrumental in developing an initial RTCOG/JHPIEGO collaboration. She was also pivotal in gaining the support of the Ministry of Public Health and in creating a project advisory board. That board helps convey project information to Ministry members who can consider further project implementation.

"This single-visit approach is important for my country," says Dr. Limpaphayom. "It can help save many lives, since, for the time being, we cannot offer Pap smear screening for all women. My goal is to decrease mortality from cervical cancer, so I want to get this research into practice as quickly as possible. There is no time to waste."

— Kerry L. Wright
References

Stephenson JM, Babiker A. Overview of study design in clinical epidemiology. Sex Transm Inf 2000;76(4):244-47.
Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 1999;354(9181):795-802.
Solo J, Cerulli A, Miller R, et al. Strengthening the utilization of family planning operations research: findings from case studies in Africa. Unpublished paper. New York, NY: Population Council, 1998.
Frontiers in Reproductive Health. Mali Female Genital Cutting. FGC Excisors Persist Despite Entreaties, OR Summary 2. Washington, DC: Population Council, Frontiers in Reproductive Health, 2000.
Frontiers in Reproductive Health. Kenya Female Genital Cutting. Community Sensitization Must Precede Alternative Coming-of-Age Rite, OR Summary 27. Washington, DC: Population Council, Frontiers in Reproductive Health, 2002; Chege JN, Askew I, Liku J. An Assessment of the Alternative Rites Approach for Encouraging Abandonment of Female Genital Mutilation in Kenya. Nairobi, Kenya: Population Council, 2001.
Royal Thai College of Obstetricians and Gynaecologists (RTCOG) and the JHPIEGO Corporation Cervical Cancer Group. Safety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project. Lancet 2003;361(9360):814-20.

Nevirapine Results Quickly Put into Practice

A randomized controlled trial conducted in the late 1990s in Kampala, Uganda,¹ helped to create — at an unprecedented pace — a standard for preventing mother-to-child transmission of HIV in the developing world.

The rate of HIV transmission from mother to child in developing countries is estimated to be as high as 43 percent,² with most cases occurring late in pregnancy or during labor and delivery.³ Recognizing the urgent need to reduce these transmission rates, the international HIV Network for Prevention Trials (HIVNET), established by the National Institute of Allergy and Infectious Diseases (NIAID) in the United States, supported the Ugandan trial. As trial coordinator, FHI collaborated with Makerere University in Kampala, Johns Hopkins University in Baltimore, MD, USA, the University of Washington and the Fred Hutchinson Cancer Research Center in Seattle, WA, USA, and several other partners to test the safety and efficacy of the antiretroviral nevirapine versus a specific regimen of the antiretroviral zidovudine (AZT) for preventing transmission from more than 600 pregnant, HIV-infected women to their infants.

Half of the women in the trial were randomly assigned to receive a single dose of nevirapine at the onset of labor, and their infants received a single dose within 72 hours of birth. The other half of the women were assigned to receive doses of AZT at the onset of labor and every three hours until delivery, and their infants received twice-daily doses of AZT for a week after birth. Results showed that nevirapine was 47 percent more effective than AZT: Fourteen to 16 weeks after delivery, only 13 percent of infants given nevirapine were infected with HIV, compared with 25 percent of infants given AZT.

The strength of the study findings and their potential for a substantial public health impact — uniquely coupled with other facilitating factors such as political interest and support, strong advocacy, and nevirapine's low cost, readily available supplies, and relatively easy storage and administration — helped propel the findings into practice. In July 1999, interim data were reviewed by the data and safety monitoring board overseeing the study, and the findings were immediately released to the public. In August 1999, nevirapine was included on the agenda of an international working group meeting on mother-to-child transmission of HIV, held by the Joint United Nations Programme on HIV/AIDS (UNAIDS) to develop recommendations for using new antiretroviral regimens. In September 1999, the findings were formally published. By the next year, the Elizabeth Glaser Pediatric AIDS Foundation had raised more than U.S. $15 million to establish a "Call to Action" project to support implementation of the findings.

Approximately 50 nevirapine programs have now been established in at least 17 countries, and this simple regimen is now the standard for preventing mother-to-child transmission of HIV in many parts of the developing world. Recent research has confirmed the safety and effectiveness of nevirapine,⁴ which may help governments in other countries adopt the practice.

"We estimate that more than 250,000 women have been offered voluntary HIV counseling and testing through Call to Action programs established by the Elizabeth Glaser Pediatric AIDS Foundation, more than 27,000 HIV-infected women have been identified, and at least half of these women have received nevirapine," says Dr. Willard Cates Jr., president of FHI's Institute for Family Health. "Thousands of infants have been spared HIV infection as a result of this finding and its utilization."

— Kerry L. Wright

References

Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 1999;354(9181):795-802.
The Working Group on Mother-to-Child Transmission of HIV. Rates of mother-to-child transmission of HIV-1 in Africa, America, and Europe: results from 13 perinatal studies. J Acquir Immune Defic Syndr Hum Retrovirol 1995;8(5):506-10.
Rouzioux C, Costagliola D, Burgard M, et al. Estimated timing of mother-to-child human immunodeficiency virus type I (HIV-1) transmission by use of a Markov model. The HIV Infection in Newborns French Collaborative Study Group. Am J Epidemiol 1995;142(12):1330-37; Bertolli J, St. Louis ME, Simonds RJ, et al. Estimating the timing of mother-to-child transmission of human immunodeficiency virus in a breast-feeding population in Kinshasa, Zaire. J Infect Dis 1996;174(4):722-26.
Moodley D, Moodley J, Coovadia H, et al. A multicenter randomized controlled trial of nevirapine versus a combination of zidovudine and lamivudine to reduce intrapartum and early postpartum mother-to-child transmission of human immunodeficiency virus type 1. J Infect Dis 2003;187(5):725-35.

Community-Based Distribution Project Expands beyond Mali

An operations research project to introduce community-based distribution (CBD) of contraceptives into two rural areas of Mali has expanded to thousands of Malian villages and has been replicated in at least six countries. This is also an excellent example of how research and program implementation can inform, build upon, and strengthen each other through repeated interplay.

According to the 1987 Mali Demographic and Health Survey, nearly half of Malian women wished to use a contraceptive method. But, largely due to lack of information or family planning services in rural areas, contraceptive prevalence was only 1 percent.¹

Spurred by this dramatic evidence of unmet need, the Family Health Division of the Ministry of Health (MOH), with funding from the U.S. Agency for International Development (USAID) mission in Mali, began in 1990 a three-year CBD pilot project to bring contraceptive services to rural Malians.

"Community involvement was a very important part of the project," says Dr. Seydou Doumbia, a program associate in the Mali office of the New York-based Population Council, which provided technical assistance through its Africa Operations Research and Technical Assistance Project I. At the start of the CBD project, the study team held meetings with community leaders and members from 54 Malian villages in the Sikasso and Koulikoro regions to gain commitment to the project. Because men are traditionally the heads of households and the decision-makers in Mali, it was especially important to reach them. This took some time, says Dr. Doumbia, but after nine months of meetings, the study team gained their support.

The next step was to select CBD workers. One male and one female CBD worker were selected from each of the 54 villages. They were then trained to provide family planning information and to sell condoms, spermicides, and oral contraceptive pills.

The main component of the project was a large information, education, and communication strategy designed specifically for Mali, where oral communication and theater groups are the traditional communication channels. CBD workers held weekly meetings with village members to deliver family planning messages; they also made home visits to counsel clients and provide contraceptives. A local theater group then emphasized the CBD workers' messages during performances at the village meetings.²

An evaluation of the project in 1993 showed that knowledge of family planning increased from 40 percent to 85 percent in project areas, and contraceptive prevalence increased from less than 1 percent to more than 30 percent, says Dr. Doumbia. After an aggressive campaign to disseminate project findings, the MOH decided to create a national CBD program, and the USAID mission in Mali provided about U.S. $8 million for the expansion.

"From 1993 to 1999, we expanded the project to five regions in Mali, and now we are working in about 3,000 villages with 6,000 CBD workers," says Dr. Doumbia. "Through this project, we were able to bring family planning services to more than 20 percent of rural villages in Mali."

The CBD program in Mali is now being sustained through the MOH (without USAID funding) and has been adapted in many West African countries, including Burkina Faso, Cameroon, Côte d'Ivoire, Guinea, Niger, and Senegal.

"Senegal represents the most recent example of the CBD expansion," says Dr. Diouratié Sanogo, program associate for the Frontiers in Reproductive Health Program, which is leading the effort, and a Population Council representative in Dakar.

There, researchers are comparing two models for providing reproductive health services to rural communities. One involves strengthening the capacity of traditional community health huts by updating equipment and retraining workers to provide reproductive health services. (Health hut workers, including traditional birth attendants, hygienists, and health communicators, are traditionally trained to provide only basic health care and prevention services to rural community members who visit the huts). To provide more mobile services, the second model uses voluntary community workers who are trained to provide reproductive health services and act as CBD workers. Evaluation of the two models is under way.

— Kerry L. Wright

References

Centre d'Études et de Recherches sur la Population pour le Développement, Institut du Sahel and Demographic and Health Surveys Institute for Resource Development/Westinghouse. Enquête Démographique et de Santé au Mali 1987. Bamako, Mali, and Columbia, MD: Centre d'Études et de Recherches sur la Population pour le Développement, Institut du Sahel and Demographic and Health Surveys Institute for Resource Development/Westinghouse, 1989.
Doumbia S. Male and community involvement in family planning: community-based distribution project in Mali (1990-1999). The 122nd annual meeting of the American Public Health Association, Washington, DC, 1994.

IUD Insertion by Nurse-Midwives Increases Use

Over a 15-year period, intrauterine device (IUD) prevalence more than doubled in Turkey after recommendations from a collaborative operations research effort influenced ratification in 1983 of the national family planning law that, among other changes, allowed trained nonphysicians to provide IUD services.
Before that, in the 1970s, only physicians could provide IUDs, and most physicians were male. But many women were uncomfortable being examined or having an IUD inserted by a male physician, thus limiting acceptance and use of the IUD.

Together, the Ministry of Health (MOH) and researchers in the Public Health Department of Hacettepe University in Ankara, Turkey, recognized this problem. Supported by the World Health Organization (WHO) Programme in Human Reproduction, the researchers began studying whether trained nonphysicians — particularly nurse-midwives — could adequately provide IUD services.

"The lead investigator from Hacettepe University had the foresight to involve the Ministry of Health in the project from the outset," says Dr. Iqbal Shah of the Department of Reproductive Health and Research at WHO. Furthermore, the Director General of Maternal and Child Health and Family Planning at the time was a coinvestigator of the project, facilitating wide dissemination of results and mobilizing support for research utilization, he says.

Research has shown that the Copper T IUD
can be safely provided by trained nonphysicians.

In 1979, 13 female nurse-midwives from a district near Ankara learned to provide IUD services using a training program designed specifically for this research. The program involved use of a specially developed WHO manual for providing IUD services, followed by practice. Nurse-midwives in training used pelvic models, gave real pelvic examinations, and performed supervised IUD insertions.¹ Researchers then determined how well the trained nurse-midwives provided IUD services, compared with six male and two female physicians.² After 238 IUD insertions by physicians and 257 by nurse-midwives, no significant differences were found in terms of IUD expulsions, IUD removals, pregnancies, losses to follow-up, and referrals to obstetrician/gynecologists.

Study findings were published in February 1983 and disseminated to the MOH, policy-makers, and the medical community in Turkey. Findings from a similar, unpublished WHO-supported study of some 200 nurse-midwives were also disseminated, with a recommendation that legislation be changed to allow nonphysicians with appropriate training to provide IUD services. Policy-makers and the medical community showed some resistance, but the MOH and Hacettepe University countered with several advocacy meetings to convince the two groups of the proposal's merits.³

The resistance eventually weakened. On May 24, 1983, the second anti-natalist population planning law, which included a provision allowing nonphysicians to provide IUD services, went into effect.

"In my opinion, if we had not performed this operations research on these sensitive issues, it would have been either impossible or too hard to change the existing population planning law" to include that provision, says Dr. Ayse Akin, the lead investigator from Hacettepe University.

Training of nurse-midwives to provide IUD services was added to regular national training programs, and in the 15 years after the law was ratified, IUD prevalence among contracepting women steadily increased from 9 percent to 20 percent, says Dr. Akin.

The studies that influenced ratification of the population planning law in Turkey, which also included research from the Philippines,⁴ focused on the Lippes loop IUD. FHI and others have conducted similar studies on Copper T IUD provision in Turkey, Mexico, Nigeria, Brazil, and Thailand, showing that nonphysicians with proper training can also safely provide services involving this type of IUD.⁵

—Kerry L. Wright
References

Akin A, Gray RH, Ramos R. Training auxiliary nurse-midwives to provide IUD services in Turkey and the Philippines. Stud Fam Plann 1980;11(5):178-87.
Eren N, Ramos R, Gray RH. Physicians vs. auxiliary nurse-midwives as providers of IUD services: a study in Turkey and the Philippines. Stud Fam Plann 1983;14(2):43-47.
Akin A, Ozvariüs SB, Fisek N. Integrating an Expanded Range of Reproductive Health Services in Primary Health Care: Turkey's Experience. International Council on Management of Population Programmes. Available online.
Akin, Gray, Ramos; Eren.
Farr G, Rivera R, Amatya R. Non-physician insertion of IUDs: clinical outcomes among TCu380A insertions in three developing-country clinics. Adv Contracept 1998;14(1):45-57; Lassner KJ, Chen CHC, Kropsch LAJ, et al. Comparative study of safety and efficacy of IUD insertions by physicians and nursing personnel in Brazil. Bull Pan Am Health Organ 1995;29(3):206-15; Wright NH, Sujpluem C, Rosenfield AG, et al. Nurse-midwife insertion of copper T in Thailand: performance, acceptance, and programmatic effects. Stud Fam Plann 1977;8(9):237-43.

A Single-Visit Approach for Cervical Cancer Prevention

The recent demonstration of the safety and acceptability of a single-visit approach for cervical cancer prevention in rural Thailand emphasizes the importance of having appropriate resources and infrastructure to implement research findings.

Nearly half a million women develop cervical cancer each year worldwide, and it is the leading cause of death due to cancer among women in developing countries. Several countries, including Thailand, have traditional cervical cancer prevention programs based on the Pap smear, a cytology-based screening tool. But Pap smears require special training, laboratory equipment, and repeat visits for clients. (Screening can be performed in one visit, but results can take quite a while to obtain, diagnoses can only be confirmed later, and women must return to the clinic if treatment is necessary.) The infrastructure in many resource-poor settings cannot sustain such programs, and screening rates remain low. In Thailand, only about 5 percent of women have been screened.¹

Nurses in Thailand learn to use a new single-visit approach to cervical cancer prevention that research has shown to be safe, effective, and inexpensive.

An alternative to Pap smears is visual inspection of the cervix with acetic acid and a light source, followed by provision of cryotherapy (freezing) of suspected precancerous cervical lesions — all in a single visit.

Researchers from U.S.-based JHPIEGO's Cervical Cancer Prevention Program and the Royal Thai College of Obstetricians and Gynaecologists (RTCOG), with support from the Ministry of Public Health in Thailand, conducted a demonstration study of this single-visit approach in Roi-et Province in 2000.² Twelve nurses were trained to use the approach and then used it to screen nearly 6,000 women in village centers and district hospitals. Both low-cost³ and effective at detecting most precancerous lesions,⁴ the single-visit approach also proved safe and very acceptable to women.

"Now it is time for the local Ministry of Health to decide whether it wants to adopt this approach on a larger, if not a national, scale," says Dr. Paul Blumenthal, director of JHPIEGO's Cervical Cancer Prevention Program.

For now, the Ministry of Public Health has decided not to officially change any national service delivery policies to include the new approach. But it is supporting implementation in more provinces, as long as the provinces have sufficient resources.

The most difficult step for the provinces is going to be program start-up, says Dr. Blumenthal. This will require extensive training, purchases of equipment, and development of infrastructures to deliver the new services. Once these factors are in place and the programs are running well, they should be sustainable, he says.

The chief provincial health officer of Roi-et Province at the time of the initial study has since moved to Nong Kai Province, where he and the Ministry of Public Health are spearheading an effort to expand the single-visit approach. The team from JHPIEGO and RTCOG has provided training and supervision of nurse providers for the program, which screened its first patient earlier in 2003.

"We are also helping in training and preparation for another four provinces in northeast Thailand to implement this single-visit approach," says Dr. Khunying Kobchitt Limpaphayom, project director of JHPIEGO's Cervical Cancer Prevention Program in Thailand. "Northeast Thailand is considered the area with the fewest resources, so implementation will require a lot of leadership and commitment from the chief provincial health officers there. The results remain to be seen."

— Kerry L. Wright

References

Royal Thai College of Obstetricians and Gynaecologists (RTCOG) and the JHPIEGO Corporation Cervical Cancer Group. Safety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project. Lancet 2003;361(9360):814-20.
Royal Thai College of Obstetricians and Gynaecologists (RTCOG).
Mandelblatt JS, Lawrence WF, Gaffikin L, et al. Costs and benefits of different strategies to screen for cervical cancer in less-developed countries. J Natl Cancer Inst 2002;94(19):1469-83; Goldie SJ, Kuhn L, Denny L, et al. Policy analysis of cervical cancer screening strategies in low-resource settings: clinical benefits and cost-effectiveness. JAMA 2001;285(24):3107-15.
University of Zimbabwe and JHPIEGO Cervical Cancer Project. Visual inspection with acetic acid for cervical-cancer screening: test qualities in a primary-care setting. Lancet 1999;353(9360):869-73.

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