Cost-Effectiveness analysis of family planning services offered by mobile clinics versus static clinics in Assiut, Egypt

Cost effectiveness studies of family planning (FP) services are very valuable in providing evidence-based data for decision makers in Egypt. Cost data came from record reviews for all 15 mobile clinics and a matched set of 15 static clinics and interviews with staff members of the selected clinics at Assiut Governorate. Effectiveness measures included couple years of protection (CYPs) and FP visits. Incremental cost-effectiveness ratios (ICER) and sensitivity analyses were calculated. Mobile clinics cost more per facility, produced more CYPs but had fewer FP visits. Sensitivity analysis was done using: total costs, CYP and FP visits of mobile and static clinics and showed that variations in CYP of mobile and static clinics altered the ICER for CYP from $2 -$6. Mobile clinics with their high emphasis on IUDs offer a reasonable cost effectiveness of $4.46 per additional CYP compared to static clinics. The ability of mobile clinics to reach more vulnerable women and to offer more long acting methods might affect a policy decision between these options. Static clinics should consider whether emphasizing IUDs may make their services more cost-effective

Risk factors for cervical cancer among HPV positive women in Mexico / Factores de riesgo de cáncer cervical en mujeres VPH positivas en México

OBJECTIVE: To identify factors that are associated with an increased risk of developing high-grade cervical intraepithelial neoplasia (CIN) or cancer among human papillomavirus (HPV)-positive women in Mexico. MATERIAL AND METHODS: A case-control study design was used. A total of 94 cases and 501 controls who met the study inclusion criteria were selected from the 7 732 women who participated in the Morelos HPV Study from May 1999 to June 2000. Risk factor information was obtained from interviews and from HPV viral load results. Odds ratios and 95 percent confidence intervals were estimated using unconditional multivariate regression. RESULTS: Increasing age, high viral load, a young age at first sexual intercourse, and a low socio-economic status are associated with an increased risk of disease among HPV-positive women. CONCLUSIONS: These results could have important implications for future screening activities in Mexico and other low resource countries.

OBJETIVO: Identificar factores asociados con un mayor riesgo de desarrollar neoplasia intraepitelial cervical (NIC) de alto grado o cáncer en mujeres con virus de papiloma humano (VPH), en México. MATERIAL Y MÉTODOS: Se utilizó un diseño de casos y controles. Un total de 94 casos y 501 controles fueron seleccionados de las 7 732 mujeres que participaron en el Estudio de VPH en Morelos, de mayo de 1999 a junio de 2000. La información sobre factores de riesgo se obtuvo de entrevistas y de los resultados de carga virales de VPH. Se estimaron razones de momios e intervalos de confianza de 95 por ciento con modelos multivariados de regresión no condicionada. RESULTADOS: El incremento de edad, la carga viral elevada, la edad temprana al inicio de la vida sexual y el nivel socioeconómico bajo se asocian con un mayor riesgo de enfermedad en mujeres VPH positivas. CONCLUSIONES: Estos resultados podrían tener implicaciones importantes a futuro para las actividades de tamizaje en México y en otros países de bajos recursos.

Socioeconomic differentials in supplementation of vitamin A: evidence from the Philippines.

The efficacy of supplementation of vitamin A in child survival has been well-demonstrated. However, the effectiveness of a programme of vitamin A supplementation at the population level has been rarely examined. Understanding how programmes reach disadvantaged children can help improve the design of initiatives of vitamin A supplementation. The differentials in receipt of vitamin A by socioeconomic status were assessed using data from the Philippines. Factors associated with receipt of vitamin A during the last six months were examined using the Philippines Demographic and Health Surveys conducted in 1993 and 1998. In total, 6,970 and 6,118 children aged 12-59 months were included in 1993 and 1998 respectively. Logistic regression was used for identifying associations between the outcome and the household socioeconomic variables. The coverage of national-level vitamin A supplementation increased from 27% in 1993 to 79% in 1998. However, children whose mothers did not complete primary education and children living in poor households were less likely to receive supplementation. This disparity increased between the surveys: the adjusted odds of vitamin A intake by poor households compared to middle-class households declined from 0.73 [95% confidence interval (CI) 0.61-0.87) in 1993 to 0.52 (95% CI 0.42-0.63)] in 1998, resulting in an increased health inequity. The vitamin A programme in the Philippines was not uniformly successful in reaching the most vulnerable children. Approaches targeting vulnerable households or approaches not requiring mothers to travel to distribution centres may be more promising.

Improving cervical cancer screening in Mexico: results from the Morelos HPV Study

OBJETIVO: Describir algunos de los resultados del Estudio de VPH en Morelos. El objetivo principal del Estudio de VPH en Morelos es evaluar el uso de la prueba del virus de papiloma humano (VPH), en relación con la prueba de Papanicolaou, para el tamizaje de cáncer cervical. MATERIAL Y MÉTODOS: El Estudio de VPH en Morelos actualmente se está llevando a cabo en México, para examinar la posibilidad de usar la prueba de VPH para la detección de cáncer cervical. Se evaluó el uso de la prueba de VPH en muestras auto-tomadas vaginales y en muestras cervicales tomadas por un clínico. Se comparó la aceptabilidad del uso de la prueba de VPH en muestras auto-tomadas al uso del Papanicolaou. También se realizó un análisis de costo-efectividad y de costo-beneficio. RESULTADOS: Los resultados del Estudio de VPH en Morelos indican que la prueba de VPH tiene una mayor sensibilidad para detectar los casos de neoplasia intraepitelial cervical 2/3 y cáncer cervical que la prueba de Papanicolaou. Los resultados también indican una aceptabilidad menor al uso de la prueba de Papanicolaou que al uso de la prueba de VPH auto-tomada. Los resultados del análisis de costo-efectividad y el análisis de costo-beneficio indican que el tamizaje con la prueba de VPH en mujeres de 20-80 años de edad siempre es más costo-efectivo que el tamizaje con el Papanicolaou. CONCLUSIONES: Nuestros resultados sugieren que la prueba del VPH (ya sea auto-tomada o clínica) podría ser utilizada en los programas de detección y prevención de cáncer cervical, como un complemento o un sustituto efectivo de la prueba de Papanicolaou.

Design and methods of the evaluation of an HPV-based cervical cancer screening strategy in Mexico: The Morelos HPV Study

OBJECTIVE: The purpose of this paper is to describe the design and methodology of the Morelos HPV Study. The main objective of this study is to examine the use of two different methods for obtaining HPV DNA specimens, self-collected vaginal and clinician-collected cervical, to detect pre-invasive cervical lesions and cancer. MATERIAL AND METHODS: This study was conducted within the regular population-based framework of the Mexican Institute of Social Security (IMSS) cervical cancer screening program in Morelos. A total of 7,868 women were recruited between May and October 1999 and are representative of the population of women attending cervical cancer screening services at the 23 IMSS clinics in the state of Morelos in 1999. Women were provided with a detailed description of the study before signing an informed consent form. Basic data were obtained from all participants using a standard IMSS registration form. During the initial recruitment visit, a randomly selected subsample of 1,069 participants were interviewed to collect additional information about cervical cancer risk factors, acceptability of the HPV and Pap tests, as well as patient costs. Before the pelvic exam, participants were asked to provide a self-collected vaginal specimen for HPV testing. All participants underwent a pelvic examination that involved collecting a cervical sample for the Pap smear and a clinician-collected HPV specimen. Data were evaluated from 7,732 women with complete information for the three tests. The 1,147 women who received at least one positive result (Pap, self- and/or clinician-HPV tests) were invited to return for a colposcopic examination. During colposcopy, biopsies were taken as appropriate, to histologically confirm a diagnosis of cervical intraepithelial neoplasia (CIN) 2/3 or invasive cancer. A total of 1,015 women attended colposcopy, and 101 women received a histologically-confirmed CIN 2/3 or cervical cancer diagnosis. CONCLUSIONS: The initial enrollment activities of the Morelos HPV study are the basis for a prevalent case-control study and a prospective cohort study that will investigate the natural history of HPV infections and determine if an HPV-based screening strategy is a safe and cost-effective alternative to Pap screening.