Stanford fellow addresses burden of cervical cancer in Mongolia

Stanford fellow addresses burden of cervical cancer in Mongolia

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Cervical cancer is the third most common cancer among women worldwide and Mongolia has one of the highest incidence rates in Eastern Asia. Prevention and early detection programs are essential to counteract its prevalence, especially in developing countries.

However, women encounter barriers to knowledge and access to cervical cancer screening services in Mongolia – a country with low population density. The urban–rural divide, lagging healthcare reform, and cultural differences are cited as core factors leading to lack of awareness and treatment.

 Gendengarjaa Baigalimaa

To address the rising burden, a national cervical cancer screening program was implemented in August 2012 by Mongolia’s Ministry of Health (MOH) facilitated by a grant from the Millennium Challenge Corporation.

Gendengarjaa Baigalimaa, the 2013-14 Developing Asia Health Policy Fellow at Stanford’s Walter H. Shorenstein Asia-Pacific Research Center in the Freeman Spogli Institute, has been evaluating the effects of that program. She serves as a gynecological oncologist at the Mongolian National Cancer Center (NCC). Her early findings show that awareness of cervical cancer has increased, and more women and girls are now getting screened. Gendengarjaa recently talked about her research, which she will present at a seminar on April 9.

What does your “typical” patient look like at the NCC and how has your work informed your research?

Patients typically arrive at the NCC with an advanced stage of disease – 70 percent of these women have progressive forms of cervical cancer. Of course it is not easy to work with patients who are this far along, especially if we are unable to offer full palliative services. As the only cancer center in the nation, just 10 gynecological oncologists are available to take on the high demand for treatment services. Healthcare providers and policymakers designed the Mongolian Cervical Cancer Program to address the alarming incidence rate. My research analyzes behavioral change before and after the introduction of the national screening program, bearing in mind my experiences with my own patients.

What does the national cervical cancer screening program facilitate? 

Local doctors and midwives received training on how to administer cervical cancer screening.

Before the program was implemented, regular cervical cancer screening did not exist in Mongolia. The program diffused and strengthened primary care screening services (Pap test) as well as prevention programs. Gynecological doctors from the NCC were systematically dispatched to the 338 soums or districts throughout the nation. They trained local doctors and midwives on how to administer the Pap test.  The program coordinated two initiatives: a pilot HPV vaccination program for girls aged 11-15 years from four select areas and a Pap test program for women aged 30-60 years. The women and girls who participated are urged to get screened every three years thereafter. Health education campaigns were also broadcast on select television and radio programs targeted at women and girls.

Comparing a survey taken at the program’s outset in 2010 to your survey at the program’s conclusion in 2013, what behavioral changes have been observed?

Our preliminary results have shown increased knowledge about risk factors and screening services. Women in both rural and urban areas are now more informed about cervical cancer risk factors. Awareness of the need for a Pap test increased from 15.3 percent in 2010 to 45.3 percent in 2013. The respondents also reported being more educated about the suggested frequency of visiting a doctor, and the availability of services outside of Ulaanbaatar. Due to increased knowledge, 54.2 percent of the women surveyed confirmed that they had attended cervical screening services.

What impact did the program have on younger generations?

We analyzed mothers’ attitude toward the HPV vaccination and their openness to their daughters receiving it. Awareness of the vaccine’s ability to prevent cervical cancer improved from 15.3 percent in 2010 to 45.3 percent in 2013. Our results show that 81.7 percent of mothers agreed on the importance of vaccination for their daughters once they become aware of the option. The same study conducted in 2010 showed only 28 percent of the respondents were aware of the vaccine’s existence and its connection to cancer prevention. Positive perceptions toward vaccination are very important because the vaccine can prevent one of the major causes of cervical cancer.

How were geographical divisions and local stigmas toward cancer considered?

An example of a poster that advertises cervical screening now found in local clinics.

Mongolia has 21 aimags or provinces further divided into numerous baghs or villages; each population has different priorities. Cultural relevance is key in advertising and implementing cancer screening and vaccination programs. For example, the program sought out input from local women’s and community groups in each aimag to inform about local customs. Cervical cancer screening was also linked to important events in a women’s life, i.e. becoming a mother or grandmother, to make it easier for the patient to validate resources spent. The program also set up a system of sending personalized invitations for screening during patients’ birthday months every three years.

What secondary reinforcements were used to campaign for cancer screening?

Media and targeted marketing were used to strengthen the message outside of the doctor–patient setting. Printed materials were placed in family practice clinics. The first lady of Mongolia generated media attention regarding the HPV vaccine for young girls. Beyond individual counseling, group awareness and other reinforcements can motivate participating women to follow treatment recommendations and reinforce satisfaction. The hope is that these women will then encourage other women to get screened.

Gendengarjaa will present her research with Naranbaatar Dashdorj, founder and chairman of the Onom Foundation and a 2014 Sloan Fellow at the Stanford Graduate School of Business, on April 9. The event is open to the public; more information can be found by clicking the link below.