Publication: Evaluación de la implementación del programa de detección precoz del cáncer del cuello uterino-región Meknès-Tafilalet, Marruecos
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2017-06-20
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Universidad Complutense de Madrid
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Abstract
El programa de detección precoz de cáncer de cuello de útero, basado en la inspección visual con ácido acético, para reducir la morbilidad y la mortalidad ligadas a este cáncer, se ha puesto en marcha en Marruecos de manera progresiva desde el año 2011. El objetivo principal de esta tesis consiste en evaluar la implantación de dicho programa en la región de Meknès-Tafilalet, una de las primeras zonas en las que se ha puesto en marcha, así como formular, igualmente, ciertas recomendaciones de adaptaciones para aumentar las oportunidades de lograr los fines establecidos. El método de trabajo se basa en las principales claves de evaluación de los programas europeos expuestos por la Comisión Europea. Los datos recabados por el estudio provienen de diferentes fuentes: revisión de la literatura, explotación de la documentación del programa (convención, circular, guía…), visita a las estructuras sanitarias; entrevista con los actores regionales y nacionales, profesionales sanitarios y mujeres; observación de los procedimientos de las pruebas IVA y colposcopia y revisión de los registros del programa y de las historias clínicas de las mujeres registradas. Nuestro enfoque nos ha llevado a describir con detalle la implantación regional del programa y analizar los elementos favorables y desfavorables a esta implantación. El programa se ha ejecutado de manera progresiva en la región y los recursos asignados han sido relativamente suficientes para su implementación. La tasa de captación de la población diana ha sido, sin embargo, muy baja en comparación con el objetivo del programa, con un número muy elevado de mujeres positivas pérdidas de vista. El tratamiento de las lesiones precancerosas no se realiza siempre según el protocolo seleccionado en el programa. En lo referente a la calidad del servicio, los profesionales sanitarios han aconsejado bien a las mujeres con diagnóstico negativo (85.5%) y han orientado apropiadamente a las mujeres con diagnóstico positivo (85.1%). La población diana ha tenido una actitud favorable hacia el programa y ha valorado los cuidados brindados. Los principales elementos favorables a esta implantación han sido: la adhesión unánime de los profesionales a los objetivos del programa y a la pertinencia de un programa de cribado sistemático, las cooperaciones desarrolladas en el contexto del programa presentan un carácter innovador y prometedor para alcanzar la sostenibilidad de las acciones y la actitud muy favorable de las mujeres hacia el programa basado en la prueba IVA y la valoración de los cuidados recibidos en el marco del mismo. El análisis ha revelado también la existencia de factores desfavorables a la implantación del programa, tales como: múltiples visitas propuestas a las mujeres dentro del programa, la insuficiencia de las acciones educativas para dar a conocer el programa a la población diana, los fallos del sistema de información, la divergencia percibida de intereses entre los diferentes actores implicados, la ausencia de una estrategia de control de calidad, la escasa coordinación entre los diferentes niveles asistenciales. Según los resultados observados, se ha propuesto recomendaciones a ser implementadas a corto, medio y largo plazo, con la finalidad de resolver las dificultades actuales del proceso de implantación. Las principales recomendaciones se sustentan en la mejora de la cobertura y la reactivación de los participantes después de tres años, la aplicación de los requisitos relativos a garantizar la calidad y la mejora del seguimiento de las mujeres, así como el acceso al tratamiento de aquellas con diagnóstico positivo.
The national cervical cancer early detection program, based on visual inspection with acetic acid, to reduce morbidity and mortality related to this cancer has been launched in Morocco progressively since 2011. The principal aim of this thesis is to evaluate the implementation of the program in the region of Meknes-Tafilalet, one of the first areas in which it has launched and to formulate recommendations to increase the opportunities to reach the established purposes. The method was based on the European programs evaluation presented by the European Commission. The data was collected by different sources: literature review, exploitation of the program documentation (convention, circular, guide ...), visit to health facilities, interview with regional and national actors, health professionals and women, observation of the procedures of VIA and colposcopy testing and review records of women registered. Our approach has led us to describe in detail the regional implementation of the program and analyze the favourable and unfavourable elements to this implementation. The program has been implemented progressively in the region and the resources have been relatively sufficient for its implementation. The rate of uptake of the target population has been, however, very low compared to the objective of the program, with a highest number of missing positive women. The treatment of precancerous lesions is not always performed according to the protocol selected in the program. Regarding the quality of VIA procedures, the health professionals counseled well VIA negative women (85.5%) and advised VIA positive women appropriately (85.1%). The target population has had a favourable attitude toward the program and appreciated the care given. The main positive elements to this implementation are: the unanimous support of the professionals to the objectives of the program and to the relevance of a systematic screening program, the cooperation developed in the context of the program was very innovative and promising for achieving the sustainability of the actions and the favourable 6 attitude of women towards the screening program by VIA testing and their satisfaction with respect to the screening service provided. The analysis has also revealed unfavourable factors associated with the implementation of this program, such as: multiple visits proposed into the program, inadequate educational activities to publicize the program to the target population, Information System failure, divergence of interests between the different actors involved, absence of a strategy of assurance quality and poor coordination between different levels of care. According to these results, it has proposed recommendations to be implemented in the short, medium and long term, in order to resolve the current difficulties. The main recommendations are based on improving the coverage, the recall system, the implementation of the quality assurance program and the continuous monitoring of women, especially those with positive diagnosis.
The national cervical cancer early detection program, based on visual inspection with acetic acid, to reduce morbidity and mortality related to this cancer has been launched in Morocco progressively since 2011. The principal aim of this thesis is to evaluate the implementation of the program in the region of Meknes-Tafilalet, one of the first areas in which it has launched and to formulate recommendations to increase the opportunities to reach the established purposes. The method was based on the European programs evaluation presented by the European Commission. The data was collected by different sources: literature review, exploitation of the program documentation (convention, circular, guide ...), visit to health facilities, interview with regional and national actors, health professionals and women, observation of the procedures of VIA and colposcopy testing and review records of women registered. Our approach has led us to describe in detail the regional implementation of the program and analyze the favourable and unfavourable elements to this implementation. The program has been implemented progressively in the region and the resources have been relatively sufficient for its implementation. The rate of uptake of the target population has been, however, very low compared to the objective of the program, with a highest number of missing positive women. The treatment of precancerous lesions is not always performed according to the protocol selected in the program. Regarding the quality of VIA procedures, the health professionals counseled well VIA negative women (85.5%) and advised VIA positive women appropriately (85.1%). The target population has had a favourable attitude toward the program and appreciated the care given. The main positive elements to this implementation are: the unanimous support of the professionals to the objectives of the program and to the relevance of a systematic screening program, the cooperation developed in the context of the program was very innovative and promising for achieving the sustainability of the actions and the favourable 6 attitude of women towards the screening program by VIA testing and their satisfaction with respect to the screening service provided. The analysis has also revealed unfavourable factors associated with the implementation of this program, such as: multiple visits proposed into the program, inadequate educational activities to publicize the program to the target population, Information System failure, divergence of interests between the different actors involved, absence of a strategy of assurance quality and poor coordination between different levels of care. According to these results, it has proposed recommendations to be implemented in the short, medium and long term, in order to resolve the current difficulties. The main recommendations are based on improving the coverage, the recall system, the implementation of the quality assurance program and the continuous monitoring of women, especially those with positive diagnosis.
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Enfermería, Fisioterapia y Podología, leída el 05/07/2016