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Issues and challenges in implementing cervical cancer screenings in the emergence of HPV vaccination in Thailand
Collegian (2012) 19, 45—50
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journal homepage: www.elsevier.com/locate/coll
Issues and challenges in implementing cervical cancer screenings in the emergence of HPV vaccination in Thailand Phanida Juntasopeepun a,∗, Patricia M. Davidson b, Jatupol Srisomboon c a
Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand Centre of Cardiovascular and Chronic Care, University of Technology Sydney, Curtin University, Australia c Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand b
Received 27 April 2011; received in revised form 4 August 2011; accepted 5 August 2011
KEYWORDS Thailand; HPV vaccination; Cervical cancer screening
Summary The discovery of the HPV vaccine has been a major breakthrough in preventing cervical cancer and other HPV-related diseases around the globe. Cervical cancer is a significant public health problem in Thailand. Despite the long-time availability of cervical cancer screening programs in Thailand, the uptake among the target female population remains low. HPV vaccines were approved by the Food and Drug Administration of Thailand in 2007. As of March 2011, due to financial limitations, HPV vaccines have still not been included in the national immunization program under the public health benefit plans although individuals has the option to pay privately for the vaccine. This paper discusses the issues and challenges in implementing cervical cancer screening programs in the era of HPV vaccination in Thailand. Recommendations to increase the uptake of cervical cancer screening and further research to inform a policy regarding the cervical cancer screening measures are proposed. © 2011 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction Cervical cancer is the third most common cancer among women worldwide. In 2010, it was estimated that there were 553,000 new cases of cervical cancer diagnosed among women. The incidence of cervical cancer is generally higher in developing countries, accounting for more than 85% of all cases around the globe. In terms of mortality rates, cervi-
∗
Corresponding author. Tel.: +66 53 949 019; fax: +66 53 217 145. E-mail address: [email protected] (P. Juntasopeepun).
cal cancer leads to more than 288,000 deaths among women worldwide. Almost 90% of women who die from cervical cancer reside in developing countries (56,000 in Africa, 34,000 in Latin America and the Caribbean, and 168,000 in Asia) (Ferlay et al., 2008). The 5-year survival rate of cervical cancer patients in developing countries is less than 50% compared with 66% in the developed world (Parkin & Bray, 2006). Currently, Thailand has a population of approximately 63.87 million, with about 25.83 million women aged 15 years and older who are at risk of developing cervical cancer (Department of Provincial Administration/Ministry of Interior, 2011). In Thailand, cervical cancer is the second most frequent cancer among women between 15 and 44
1322-7696/$ — see front matter © 2011 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.colegn.2011.08.002
46 years of age, occurring at an aged adjusted incidence of 29.2 per 100,000 which is relatively high among developing countries in southern and southeastern Asia and the world (Ferlay et al., 2008).
Cervical cancer screenings Cervical cancer is preventable through both primary and secondary preventive measures. Primary prevention of cervical cancer through HPV vaccination has recently become available and secondary prevention of cervical cancer can be achieved through various screening methods. Cervical cytology either conventional Pap smear or liquid-based cytology, high-risk human papillomavirus (HPV) testing, and visual inspection with acetic acid (VIA) are methods of screening (Franco, Duarte-Franco, & Ferenczy, 2001). In many developed countries where the resources exist, well-organized cervical cancer screening programs to detect and treat precancerous abnormalities and the early stages of cervical cancer have been very successful and proven to significantly reduce cervical cancer incidence and mortality rates (Denny, Quinn, & Sankaranarayanan, 2006). However, effective cervical cancer screening services and referral of patients with abnormal tests for further histological diagnosis and treatment usually are not well performed in low-resource countries. As a result, the majority of women with cervical cancer in these countries are diagnosed at an advanced stage and incurable by the time they go to hospital, leading to higher death rates and shorter survival rates (Denny et al., 2006). In Thailand, cervical cancer prevention and control has been the responsibility of the Ministry of Public Health (MOPH). The Pap smear test has been used in health care facilities for almost 60 years since 1952 under the supervision of the Department of Medical Services, MOPH (Kietpeerakool, 2006). The test was used mainly for diagnostic purposes rather than for cervical cancer screening and available for screening on a demand basis. In 2000, the VIA test was launched for women aged 30—45 years in some areas of Thailand. The Department of Health, MOPH is responsible for this ‘‘screen-and-treat service’’. This preventive method combines VIA with cryotherapy as a single-visit approach which would minimize loss to followup. Studies on VIA in Thailand have demonstrated that this method is programmatically feasible and sustainable and should therefore be considered in a national investments to control cervical cancer (Gaffikin, Blumenthal, Emerson, & Limpaphayom, 2003). When Thailand launched a new public health insurance policy under the Universal Coverage (UC) Scheme in 2004, these two screening measures were added into the public health benefit package for disease prevention which is available free of charge in all government health care settings in Thailand (Tangcharoensathien et al., 2008). Due to a lack of laboratories, trained pathologists and technicians, as well as financial resources, Thailand is similar to other developing countries in that it is unable to screen women with Pap smear or VIA as frequently as recommended by some Western-developed country guidelines (American Cancer Society, 2010). Throughout 2005—2009, the MOPH introduced the organized cytology-based screening program for the entire Thai female population aged 35—60 years to
P. Juntasopeepun et al. undergo Pap smear every 5 years. Due to the limited budget, only 4 million out of a total 10 million women were targeted (Yothasamut, Putchong, Sirisamutr, Teerawattananon, & Tantivess, 2010). At the end of the program, only 2 million women were screened resulting in only 20% coverage of the total women at risk. In 2010, a major effort was subsequently made to scale up cervical cancer screenings in Thailand when the MOPH launched the nationwide screening initiative to increase public awareness and the coverage of cervical cancer screening programs. The target age of women was 30—60 years, translating to 13 million screened every 5 years or 2.6 millions per year (Yothasamut et al., 2010). Despite the long-time availability of cervical cancer screening programs in Thailand, these programs are considered inefficient because the coverage of the target female population remains low (Sriamporn, Khuhaprema, & Parkin, 2006) and incidence and mortality rates from the disease among Thai women are still high. Recent statistical reports from World Health Organization (WHO)/Institut Català d’Oncologia (ICO) Information Centre on HPV and Cervical Cancer estimate that annually 9999 Thai women are diagnosed with cervical cancer, 5216 of which will die from the disease (WHO/ICO Information Centre on HPV and Cervical Cancer, 2010). Like other countries in the developing world, it is obvious that the coverage of cervical cancer screening programs are inadequate in Thailand, and access to precancerous treatment is limited as it is only available in certain health care facilities (Tangcharoensathien et al., 2008). A number of studies throughout Thailand have reported that significant numbers of Thai women have never received any cervical screenings despite the fact that the services are available free of charge under the UC Scheme (Boonpongmanee & Jittanoon, 2007; Sriamporn et al., 2006) and delay in seeking treatment for abnormal cervical cancer symptoms, leading to advanced stage of disease at diagnosis (Ratanasiri, Boonmongkon, Upayokin, Pengsaa, & Vatanasapt, 2000). Attempts have been made to identify obstacles for implementing cervical cancer screening programs in Thailand. In relation to health care service and policy, one study found that the lack of effective program coordination for the two screening measures, which are managed separately by two departments of the Ministry of Public Health, leads to inadequate performance of cervical cancer screening services in Thailand (Tangcharoensathien et al., 2008). The political crisis in Thailand over the past few years has interfered with several government plans, including the MOPH’s national cervical screening campaign programs. The campaign was considered not successful and did not achieve desirable target numbers (Yothasamut et al., 2010). One reason for low rates of cervical cancer screening utilization in Thailand may stem from women’s preventive health behaviors. A complex network of women’s knowledge, attitudes, beliefs, and sociocultural factors also play a crucial role in limiting Thai women’s uptake of cervical cancer screening. Past attempts have been made to identify factors influencing cervical cancer screening behaviors in Thailand. For example, perceived low susceptibility and seriousness of cervical cancer, lack of knowledge about screening measures, and lack of awareness of the importance of early detection were significantly
Issues and challenges of cervical cancer screenings in Thailand associated with cervical cancer screening among Thai women (Duangsong, 2004; Keelapang, 2005). The Thai cultural value of respect to modesty is considered a barrier to cervical screening practice. Embarrassment about exposing the genital area for examination by male health care providers has repeatedly been reported in the literature (Boonpongmanee & Jittanoon, 2007; Rungsrisuwan, 1999; Tsui & Tanjasiri, 2008). The influence of significant others (e.g. female relative, partner) is also a significant predictor of cervical cancer screening behaviors. Some Thai women seek screening tests only after being prompted by others (Supanaum, 2008). This could be explained based on the fact that Thailand is viewed as a collectivist society. People in collectivist societies see themselves as interdependent with their groups, pay more attention to the relationships within their groups, and behave primarily based on group norms (Triandis, 2001). Additionally, cervical cancer is primarily a cancer of women. Some women hold multiple roles, such as mother, wife, and employee. They may have several responsibilities in their daily lives. These responsibilities interfere with their ability to seek screening tests (Mongkondee, 2005). Thai society still assumes that women should take a traditionally subordinate role. Thai women are expected to support their husband’s efforts and decisions, are in charge of childcare and the household, and take care of parents. As a result, in Thai culture, it is expected that women will sacrifice themselves for their families, prohibiting them from seeking screening services. These issues must be taken into consideration when designing interventions to scaling up cervical cancer screenings in Thailand.
HPV vaccination HPV infection is the most common sexually transmitted disease. Contracting HPV is considered the greatest risk factor for developing cervical cancer (Hutchinson & Klein, 2008). Factors associated with HPV persistence and development of cervical cancer include long-term use of hormonal contraceptives, early sexual debut, multiple sexual partners, having sex with a partner who has had multiple sex partners, and vulnerable immune systems (Bedford, 2009; Franco et al., 2001; Louie et al., 2009; World Health Organization, 2007). There are more than 100 types of HPV and at least 13 of these types are cancer-causing. The most common HPV types that infect the anogenital tract are HPV types 6, 11, 16, and 18. Among these, HPV types 16 and 18 are the major causative agents for cervical cancer which cause approximately 70% of all cervical cancer worldwide, whereas HPV types 6 and 11 are most commonly associated with benign lesions such as genital warts and low-grade lesions of the cervix (World Health Organization, 2007). The recent discovery of the HPV vaccine is a major breakthrough in preventing cervical cancer and other HPV-related diseases around the globe. Currently, two HPV vaccines, the quadrivalent HPVs 6/11/16/18 vaccine (Gardasil® ) and the bivalent HPVs 16/18 vaccine (Cervarix® ) are available for primary prevention of cervical cancer. The Food and Drug Administration (FDA) in the United States approved the quadrivalent vaccine in 2006 and the bivalent vaccine in 2010. The quadrivalent vaccine is targeted to prevent
47 cancer precursors of the cervix, vulva, and vagina caused by HPV 16 and 18 and external genital lesions caused by HPV 6 and 11, while the bivalent vaccine aims to prevent cervical cancer caused by HPV 16 and 18 only (World Health Organization, 2007). Clinical trials have shown that HPV vaccination is most effective in preadolescent or adolescent and young women prior to the onset of sexual activity because they have not yet acquired any of the HPV types covered by the vaccine. The two vaccines have been proven more than 90 percent effective in preventing precancerous cervical lesions when administered prior to the onset of sexual activity (World Health Organization, 2007). Due to the difference of epidemiology and age of sexual debut, the age range recommended for HPV vaccination are likely to vary from country to country (Wright, Van Damme, Schmitt, & Meheus, 2006). Both vaccines were approved by the FDA of Thailand in 2007, the bivalent for women aged 10—25 years and the quadrivalent for women aged 9—26 years. The Royal Thai College of Obstetricians and Gynaecologists (RTCOG) and Thai Gynecologic Cancer Society (TGCS) recommend young women aged 11—26 years receive HPV vaccine especially before commencing sexual intercourse. The use of the HPV vaccination in women older than 26 years and in sexually exposed women should be individualized (The Royal Thai College of Obstetricians & Gynaecologists, 2010). Approximately 8.6% of Thai women in the general population are estimated to harbor HPV infection at a given time, and 73.8% of invasive cervical cancers are attributed to HPVs type 16 or 18 (WHO/ICO Information Centre on HPV and Cervical Cancer, 2010). In many industrialized countries, the HPV vaccines have been introduced into the national immunization program where young girls can be vaccinated free of charge. However, the situation is different in lowresource countries where the cost of vaccines is the greatest concern of the government, Thailand included. Soon after the launch of the HPV vaccines in Thailand, the Director General of the Department of Disease Control, the Ministry of Public Health revealed that Thailand is unable to afford the high price of the HPV vaccine due to government budget limitations and suggested that the conventional cervical screening measures, Pap smear and VIA, are still effective. However, HPV vaccines are available and widely used within the private sector, if an individual can afford the vaccine themselves (Sarnsamak, 2007). Additional efforts have been made to study the costeffectiveness of HPV vaccination and to conduct an economic comparison of the HPV vaccination and other cervical screening measures in Thailand. In 2008, one study entitled ‘‘Research for the development of an optimal policy strategy for prevention and control of cervical cancer in Thailand’’ was conducted by health policy researchers from two institutes under the Ministry of Public Health the International Health Policy Program Thailand (IHPP) and the Health Intervention and Technology Assessment Program (HITAP) (Tangcharoensathien et al., 2008). Both institutes have a significant role in generating evidence-based information on health for policy makers in Thailand. Findings from this study suggested that the Pap smear and VIA are proven to be effective and cost-saving and have the potential to significantly reduce the morbidity and mortality of cervical cancer in Thailand, both services of which are covered by the UC Scheme in Thailand. The study also
48 illustrated difficulties and barriers of the current cervical cancer screening services and proposed a number of strategies to prevent and control the disease. However, given the current market price of the HPV vaccines in Thailand, HPV vaccination was not a cost-effective policy choice suggesting that Thailand should not adopt this new HPV vaccine as public policy (Tangcharoensathien et al., 2008). When it was evident that the affordability of the HPV vaccine was a key consideration of the Thai government, the two vaccine producers offered Thailand a price reduction in 2009 (Yothasamut et al., 2010). Given the fact that the vaccine producers decreased the vaccine cost by almost 50 percent, another major study was conducted to assess the cost-effectiveness of the HPV vaccines again. In contrary to the previous study’s findings when the vaccine price was still high, results from this more recent study revealed that the HPV vaccine is cost-effective in the long term, encouraging a government decision to include it in the national immunization plan to reduce the burden of cervical cancer in Thailand in the future. Researchers held a national press conference in November 2010 to disseminate the study results and to call for the Thai government’s decision and action for instance, negotiating the vaccine price with the pharmaceutical companies for the large-volume vaccine purchases (Bangkokbiznews, 2010). As of March 2011, the HPV vaccines have not still been incorporated into the national immunization program under the public health benefit plans.
Future directions Cervical cancer is a significant public health problem. In Thailand, cancer screening programs exist, but have not been well-performed/organized because the target population coverage of Pap smear and VIA remains low. Barriers to the screening programs have been highlighted in the literature. Lack of financial resources and inadequate quality of cervical cancer screening programs play a critical role in hampering the success of cervical cancer prevention and control in Thailand. These issues pose a challenge to Thailand while it is still faced with financial resource limitations, political instabilities, and other competing health priorities other than cervical cancer such as the human immunodeficiency virus (HIV) infection. Increasing coverage of cervical screening services either with Pap smear or VIA in Thailand should be continued. However, there is a great need to improve cervical screening systems that identify target populations, and invite screening and follow-up, including systems to manage abnormalities, refer, and follow-up those treated in Thailand. Increasing the uptake of cervical cancer screening in the context of Thai society, community-based health care providers play a major role in educating women about screening of cervical cancer. It is crucial to understand the variables associated with underutilization of cervical cancer screening services in order to enable Thai women to respond positively to cervical cancer screening. The designing of programs to increase the uptake of cervical cancer screening in Thailand should be locally and culturally appropriate and be aware of multiple barriers that women may experience in accessing services. It would be unwise to mimic the screening programs of Western countries which have
P. Juntasopeepun et al. different socio-cultural backgrounds and different health care systems from those in Thailand. In terms of HPV vaccination, it is evident that the vaccine price is the greatest barrier that influences vaccine program decisions. HPV vaccines will have an enormous impact on the reduction of cervical cancer morbidity and mortality in the future (next 10—30 years) if they are delivered to all target populations. Achieving broad coverage of adolescents will be a challenging issue for the Thai government to reduce the burden of cervical cancer. The Thai government must make careful decisions to create systems to vaccinate adolescents at the population level. To inform government decision making, clear and accurate information must be made available to the government decision makers on the knowledge, attitudes and practices of adolescents. More research is needed to provide policy makers with evidence-based information within in the social, cultural, and economic context of Thailand. Presently, it is obvious that further actions from the Thai government are needed to negotiate the vaccine price with the vaccine companies to lower the cost for mass vaccine purchases. HPV vaccines should possibly be injected to girls aged 12—14 years nationwide. This measure would take a long time, certainly 10—30 years to show the reduction in the incidence of cervical cancer. However, it is expected that Thai girls/women in next 10—30 years will not develop cervical cancer caused by HPV 16/18. At least 70—75% of cervical cancer will be eliminated from Thai women in the future. The remaining cervical cancer caused by non-HPV 16/18 are not aggressive and take a long time to develop. It is clear that adolescents worldwide have limited knowledge and awareness about HPV and related issues, which is likely to affect their vaccine acceptance (Klug, Hukelmann, & Blettner, 2008). HPV vaccines have been available in the private sector in Thailand for a few years. To date, little is known about Thai adolescents’ knowledge, attitudes, and adoption of this vaccine. Since HPV vaccines are targeted towards young children, parents will obviously play a critical role, such as whether or not they can afford or are willing to have their children vaccinated. Previous research has demonstrated that young adolescents and parents of adolescents in developed countries had positive attitudes towards HPV vaccination (Dempsey, Zimet, Davis, & Koutsky, 2006; Lazcano-Ponce et al., 2001), although some parents were concerned that the HPV vaccine would encourage risky sexual behavior (Davis, Dickman, Ferris, & Dias, 2004). Additionally, studies have illustrated that health care provider recommendations also play a crucial role in HPV vaccine acceptability in developed countries and have been identified as an important source of HPV information (Daley et al., 2006; Kahn et al., 2005; Riedesel et al., 2005). Successful HPV vaccination programs will depend on health care providers’ recommendation of the HPV vaccination to parents. To date, there is a great need in Thailand for more research on knowledge, attitudes, and acceptability of HPV vaccines for adolescents and parents of adolescents, including health care provider’s attitudes about HPV vaccine recommendation. If Thai adolescents and parents have a clear understanding of HPV infection and its association with cervical cancer, it is likely that they will be more willing to accept HPV vaccines. While the HPV vaccines have not yet been included in the national immunization program
Issues and challenges of cervical cancer screenings in Thailand for Thai adolescents who are not able to afford the vaccine out of their own pocket, efforts should be made to provide information about the prevention of HPV infection. HPV education campaigns, particularly school or collegebased cervical cancer education will be needed to increase awareness and educate young adolescents in preventing HPV infection.
Conclusions Cervical cancer is a common cancer among women in Thailand and is largely preventable through screening and vaccination programs. Developing affordable and accessible programs that are culturally appropriate is critical in decreasing the disease burden among Thai women.
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available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/coll
Issues and challenges in implementing cervical cancer screenings in the emergence of HPV vaccination in Thailand Phanida Juntasopeepun a,∗, Patricia M. Davidson b, Jatupol Srisomboon c a
Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand Centre of Cardiovascular and Chronic Care, University of Technology Sydney, Curtin University, Australia c Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand b
Received 27 April 2011; received in revised form 4 August 2011; accepted 5 August 2011
KEYWORDS Thailand; HPV vaccination; Cervical cancer screening
Summary The discovery of the HPV vaccine has been a major breakthrough in preventing cervical cancer and other HPV-related diseases around the globe. Cervical cancer is a significant public health problem in Thailand. Despite the long-time availability of cervical cancer screening programs in Thailand, the uptake among the target female population remains low. HPV vaccines were approved by the Food and Drug Administration of Thailand in 2007. As of March 2011, due to financial limitations, HPV vaccines have still not been included in the national immunization program under the public health benefit plans although individuals has the option to pay privately for the vaccine. This paper discusses the issues and challenges in implementing cervical cancer screening programs in the era of HPV vaccination in Thailand. Recommendations to increase the uptake of cervical cancer screening and further research to inform a policy regarding the cervical cancer screening measures are proposed. © 2011 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction Cervical cancer is the third most common cancer among women worldwide. In 2010, it was estimated that there were 553,000 new cases of cervical cancer diagnosed among women. The incidence of cervical cancer is generally higher in developing countries, accounting for more than 85% of all cases around the globe. In terms of mortality rates, cervi-
∗
Corresponding author. Tel.: +66 53 949 019; fax: +66 53 217 145. E-mail address: [email protected] (P. Juntasopeepun).
cal cancer leads to more than 288,000 deaths among women worldwide. Almost 90% of women who die from cervical cancer reside in developing countries (56,000 in Africa, 34,000 in Latin America and the Caribbean, and 168,000 in Asia) (Ferlay et al., 2008). The 5-year survival rate of cervical cancer patients in developing countries is less than 50% compared with 66% in the developed world (Parkin & Bray, 2006). Currently, Thailand has a population of approximately 63.87 million, with about 25.83 million women aged 15 years and older who are at risk of developing cervical cancer (Department of Provincial Administration/Ministry of Interior, 2011). In Thailand, cervical cancer is the second most frequent cancer among women between 15 and 44
1322-7696/$ — see front matter © 2011 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.colegn.2011.08.002
46 years of age, occurring at an aged adjusted incidence of 29.2 per 100,000 which is relatively high among developing countries in southern and southeastern Asia and the world (Ferlay et al., 2008).
Cervical cancer screenings Cervical cancer is preventable through both primary and secondary preventive measures. Primary prevention of cervical cancer through HPV vaccination has recently become available and secondary prevention of cervical cancer can be achieved through various screening methods. Cervical cytology either conventional Pap smear or liquid-based cytology, high-risk human papillomavirus (HPV) testing, and visual inspection with acetic acid (VIA) are methods of screening (Franco, Duarte-Franco, & Ferenczy, 2001). In many developed countries where the resources exist, well-organized cervical cancer screening programs to detect and treat precancerous abnormalities and the early stages of cervical cancer have been very successful and proven to significantly reduce cervical cancer incidence and mortality rates (Denny, Quinn, & Sankaranarayanan, 2006). However, effective cervical cancer screening services and referral of patients with abnormal tests for further histological diagnosis and treatment usually are not well performed in low-resource countries. As a result, the majority of women with cervical cancer in these countries are diagnosed at an advanced stage and incurable by the time they go to hospital, leading to higher death rates and shorter survival rates (Denny et al., 2006). In Thailand, cervical cancer prevention and control has been the responsibility of the Ministry of Public Health (MOPH). The Pap smear test has been used in health care facilities for almost 60 years since 1952 under the supervision of the Department of Medical Services, MOPH (Kietpeerakool, 2006). The test was used mainly for diagnostic purposes rather than for cervical cancer screening and available for screening on a demand basis. In 2000, the VIA test was launched for women aged 30—45 years in some areas of Thailand. The Department of Health, MOPH is responsible for this ‘‘screen-and-treat service’’. This preventive method combines VIA with cryotherapy as a single-visit approach which would minimize loss to followup. Studies on VIA in Thailand have demonstrated that this method is programmatically feasible and sustainable and should therefore be considered in a national investments to control cervical cancer (Gaffikin, Blumenthal, Emerson, & Limpaphayom, 2003). When Thailand launched a new public health insurance policy under the Universal Coverage (UC) Scheme in 2004, these two screening measures were added into the public health benefit package for disease prevention which is available free of charge in all government health care settings in Thailand (Tangcharoensathien et al., 2008). Due to a lack of laboratories, trained pathologists and technicians, as well as financial resources, Thailand is similar to other developing countries in that it is unable to screen women with Pap smear or VIA as frequently as recommended by some Western-developed country guidelines (American Cancer Society, 2010). Throughout 2005—2009, the MOPH introduced the organized cytology-based screening program for the entire Thai female population aged 35—60 years to
P. Juntasopeepun et al. undergo Pap smear every 5 years. Due to the limited budget, only 4 million out of a total 10 million women were targeted (Yothasamut, Putchong, Sirisamutr, Teerawattananon, & Tantivess, 2010). At the end of the program, only 2 million women were screened resulting in only 20% coverage of the total women at risk. In 2010, a major effort was subsequently made to scale up cervical cancer screenings in Thailand when the MOPH launched the nationwide screening initiative to increase public awareness and the coverage of cervical cancer screening programs. The target age of women was 30—60 years, translating to 13 million screened every 5 years or 2.6 millions per year (Yothasamut et al., 2010). Despite the long-time availability of cervical cancer screening programs in Thailand, these programs are considered inefficient because the coverage of the target female population remains low (Sriamporn, Khuhaprema, & Parkin, 2006) and incidence and mortality rates from the disease among Thai women are still high. Recent statistical reports from World Health Organization (WHO)/Institut Català d’Oncologia (ICO) Information Centre on HPV and Cervical Cancer estimate that annually 9999 Thai women are diagnosed with cervical cancer, 5216 of which will die from the disease (WHO/ICO Information Centre on HPV and Cervical Cancer, 2010). Like other countries in the developing world, it is obvious that the coverage of cervical cancer screening programs are inadequate in Thailand, and access to precancerous treatment is limited as it is only available in certain health care facilities (Tangcharoensathien et al., 2008). A number of studies throughout Thailand have reported that significant numbers of Thai women have never received any cervical screenings despite the fact that the services are available free of charge under the UC Scheme (Boonpongmanee & Jittanoon, 2007; Sriamporn et al., 2006) and delay in seeking treatment for abnormal cervical cancer symptoms, leading to advanced stage of disease at diagnosis (Ratanasiri, Boonmongkon, Upayokin, Pengsaa, & Vatanasapt, 2000). Attempts have been made to identify obstacles for implementing cervical cancer screening programs in Thailand. In relation to health care service and policy, one study found that the lack of effective program coordination for the two screening measures, which are managed separately by two departments of the Ministry of Public Health, leads to inadequate performance of cervical cancer screening services in Thailand (Tangcharoensathien et al., 2008). The political crisis in Thailand over the past few years has interfered with several government plans, including the MOPH’s national cervical screening campaign programs. The campaign was considered not successful and did not achieve desirable target numbers (Yothasamut et al., 2010). One reason for low rates of cervical cancer screening utilization in Thailand may stem from women’s preventive health behaviors. A complex network of women’s knowledge, attitudes, beliefs, and sociocultural factors also play a crucial role in limiting Thai women’s uptake of cervical cancer screening. Past attempts have been made to identify factors influencing cervical cancer screening behaviors in Thailand. For example, perceived low susceptibility and seriousness of cervical cancer, lack of knowledge about screening measures, and lack of awareness of the importance of early detection were significantly
Issues and challenges of cervical cancer screenings in Thailand associated with cervical cancer screening among Thai women (Duangsong, 2004; Keelapang, 2005). The Thai cultural value of respect to modesty is considered a barrier to cervical screening practice. Embarrassment about exposing the genital area for examination by male health care providers has repeatedly been reported in the literature (Boonpongmanee & Jittanoon, 2007; Rungsrisuwan, 1999; Tsui & Tanjasiri, 2008). The influence of significant others (e.g. female relative, partner) is also a significant predictor of cervical cancer screening behaviors. Some Thai women seek screening tests only after being prompted by others (Supanaum, 2008). This could be explained based on the fact that Thailand is viewed as a collectivist society. People in collectivist societies see themselves as interdependent with their groups, pay more attention to the relationships within their groups, and behave primarily based on group norms (Triandis, 2001). Additionally, cervical cancer is primarily a cancer of women. Some women hold multiple roles, such as mother, wife, and employee. They may have several responsibilities in their daily lives. These responsibilities interfere with their ability to seek screening tests (Mongkondee, 2005). Thai society still assumes that women should take a traditionally subordinate role. Thai women are expected to support their husband’s efforts and decisions, are in charge of childcare and the household, and take care of parents. As a result, in Thai culture, it is expected that women will sacrifice themselves for their families, prohibiting them from seeking screening services. These issues must be taken into consideration when designing interventions to scaling up cervical cancer screenings in Thailand.
HPV vaccination HPV infection is the most common sexually transmitted disease. Contracting HPV is considered the greatest risk factor for developing cervical cancer (Hutchinson & Klein, 2008). Factors associated with HPV persistence and development of cervical cancer include long-term use of hormonal contraceptives, early sexual debut, multiple sexual partners, having sex with a partner who has had multiple sex partners, and vulnerable immune systems (Bedford, 2009; Franco et al., 2001; Louie et al., 2009; World Health Organization, 2007). There are more than 100 types of HPV and at least 13 of these types are cancer-causing. The most common HPV types that infect the anogenital tract are HPV types 6, 11, 16, and 18. Among these, HPV types 16 and 18 are the major causative agents for cervical cancer which cause approximately 70% of all cervical cancer worldwide, whereas HPV types 6 and 11 are most commonly associated with benign lesions such as genital warts and low-grade lesions of the cervix (World Health Organization, 2007). The recent discovery of the HPV vaccine is a major breakthrough in preventing cervical cancer and other HPV-related diseases around the globe. Currently, two HPV vaccines, the quadrivalent HPVs 6/11/16/18 vaccine (Gardasil® ) and the bivalent HPVs 16/18 vaccine (Cervarix® ) are available for primary prevention of cervical cancer. The Food and Drug Administration (FDA) in the United States approved the quadrivalent vaccine in 2006 and the bivalent vaccine in 2010. The quadrivalent vaccine is targeted to prevent
47 cancer precursors of the cervix, vulva, and vagina caused by HPV 16 and 18 and external genital lesions caused by HPV 6 and 11, while the bivalent vaccine aims to prevent cervical cancer caused by HPV 16 and 18 only (World Health Organization, 2007). Clinical trials have shown that HPV vaccination is most effective in preadolescent or adolescent and young women prior to the onset of sexual activity because they have not yet acquired any of the HPV types covered by the vaccine. The two vaccines have been proven more than 90 percent effective in preventing precancerous cervical lesions when administered prior to the onset of sexual activity (World Health Organization, 2007). Due to the difference of epidemiology and age of sexual debut, the age range recommended for HPV vaccination are likely to vary from country to country (Wright, Van Damme, Schmitt, & Meheus, 2006). Both vaccines were approved by the FDA of Thailand in 2007, the bivalent for women aged 10—25 years and the quadrivalent for women aged 9—26 years. The Royal Thai College of Obstetricians and Gynaecologists (RTCOG) and Thai Gynecologic Cancer Society (TGCS) recommend young women aged 11—26 years receive HPV vaccine especially before commencing sexual intercourse. The use of the HPV vaccination in women older than 26 years and in sexually exposed women should be individualized (The Royal Thai College of Obstetricians & Gynaecologists, 2010). Approximately 8.6% of Thai women in the general population are estimated to harbor HPV infection at a given time, and 73.8% of invasive cervical cancers are attributed to HPVs type 16 or 18 (WHO/ICO Information Centre on HPV and Cervical Cancer, 2010). In many industrialized countries, the HPV vaccines have been introduced into the national immunization program where young girls can be vaccinated free of charge. However, the situation is different in lowresource countries where the cost of vaccines is the greatest concern of the government, Thailand included. Soon after the launch of the HPV vaccines in Thailand, the Director General of the Department of Disease Control, the Ministry of Public Health revealed that Thailand is unable to afford the high price of the HPV vaccine due to government budget limitations and suggested that the conventional cervical screening measures, Pap smear and VIA, are still effective. However, HPV vaccines are available and widely used within the private sector, if an individual can afford the vaccine themselves (Sarnsamak, 2007). Additional efforts have been made to study the costeffectiveness of HPV vaccination and to conduct an economic comparison of the HPV vaccination and other cervical screening measures in Thailand. In 2008, one study entitled ‘‘Research for the development of an optimal policy strategy for prevention and control of cervical cancer in Thailand’’ was conducted by health policy researchers from two institutes under the Ministry of Public Health the International Health Policy Program Thailand (IHPP) and the Health Intervention and Technology Assessment Program (HITAP) (Tangcharoensathien et al., 2008). Both institutes have a significant role in generating evidence-based information on health for policy makers in Thailand. Findings from this study suggested that the Pap smear and VIA are proven to be effective and cost-saving and have the potential to significantly reduce the morbidity and mortality of cervical cancer in Thailand, both services of which are covered by the UC Scheme in Thailand. The study also
48 illustrated difficulties and barriers of the current cervical cancer screening services and proposed a number of strategies to prevent and control the disease. However, given the current market price of the HPV vaccines in Thailand, HPV vaccination was not a cost-effective policy choice suggesting that Thailand should not adopt this new HPV vaccine as public policy (Tangcharoensathien et al., 2008). When it was evident that the affordability of the HPV vaccine was a key consideration of the Thai government, the two vaccine producers offered Thailand a price reduction in 2009 (Yothasamut et al., 2010). Given the fact that the vaccine producers decreased the vaccine cost by almost 50 percent, another major study was conducted to assess the cost-effectiveness of the HPV vaccines again. In contrary to the previous study’s findings when the vaccine price was still high, results from this more recent study revealed that the HPV vaccine is cost-effective in the long term, encouraging a government decision to include it in the national immunization plan to reduce the burden of cervical cancer in Thailand in the future. Researchers held a national press conference in November 2010 to disseminate the study results and to call for the Thai government’s decision and action for instance, negotiating the vaccine price with the pharmaceutical companies for the large-volume vaccine purchases (Bangkokbiznews, 2010). As of March 2011, the HPV vaccines have not still been incorporated into the national immunization program under the public health benefit plans.
Future directions Cervical cancer is a significant public health problem. In Thailand, cancer screening programs exist, but have not been well-performed/organized because the target population coverage of Pap smear and VIA remains low. Barriers to the screening programs have been highlighted in the literature. Lack of financial resources and inadequate quality of cervical cancer screening programs play a critical role in hampering the success of cervical cancer prevention and control in Thailand. These issues pose a challenge to Thailand while it is still faced with financial resource limitations, political instabilities, and other competing health priorities other than cervical cancer such as the human immunodeficiency virus (HIV) infection. Increasing coverage of cervical screening services either with Pap smear or VIA in Thailand should be continued. However, there is a great need to improve cervical screening systems that identify target populations, and invite screening and follow-up, including systems to manage abnormalities, refer, and follow-up those treated in Thailand. Increasing the uptake of cervical cancer screening in the context of Thai society, community-based health care providers play a major role in educating women about screening of cervical cancer. It is crucial to understand the variables associated with underutilization of cervical cancer screening services in order to enable Thai women to respond positively to cervical cancer screening. The designing of programs to increase the uptake of cervical cancer screening in Thailand should be locally and culturally appropriate and be aware of multiple barriers that women may experience in accessing services. It would be unwise to mimic the screening programs of Western countries which have
P. Juntasopeepun et al. different socio-cultural backgrounds and different health care systems from those in Thailand. In terms of HPV vaccination, it is evident that the vaccine price is the greatest barrier that influences vaccine program decisions. HPV vaccines will have an enormous impact on the reduction of cervical cancer morbidity and mortality in the future (next 10—30 years) if they are delivered to all target populations. Achieving broad coverage of adolescents will be a challenging issue for the Thai government to reduce the burden of cervical cancer. The Thai government must make careful decisions to create systems to vaccinate adolescents at the population level. To inform government decision making, clear and accurate information must be made available to the government decision makers on the knowledge, attitudes and practices of adolescents. More research is needed to provide policy makers with evidence-based information within in the social, cultural, and economic context of Thailand. Presently, it is obvious that further actions from the Thai government are needed to negotiate the vaccine price with the vaccine companies to lower the cost for mass vaccine purchases. HPV vaccines should possibly be injected to girls aged 12—14 years nationwide. This measure would take a long time, certainly 10—30 years to show the reduction in the incidence of cervical cancer. However, it is expected that Thai girls/women in next 10—30 years will not develop cervical cancer caused by HPV 16/18. At least 70—75% of cervical cancer will be eliminated from Thai women in the future. The remaining cervical cancer caused by non-HPV 16/18 are not aggressive and take a long time to develop. It is clear that adolescents worldwide have limited knowledge and awareness about HPV and related issues, which is likely to affect their vaccine acceptance (Klug, Hukelmann, & Blettner, 2008). HPV vaccines have been available in the private sector in Thailand for a few years. To date, little is known about Thai adolescents’ knowledge, attitudes, and adoption of this vaccine. Since HPV vaccines are targeted towards young children, parents will obviously play a critical role, such as whether or not they can afford or are willing to have their children vaccinated. Previous research has demonstrated that young adolescents and parents of adolescents in developed countries had positive attitudes towards HPV vaccination (Dempsey, Zimet, Davis, & Koutsky, 2006; Lazcano-Ponce et al., 2001), although some parents were concerned that the HPV vaccine would encourage risky sexual behavior (Davis, Dickman, Ferris, & Dias, 2004). Additionally, studies have illustrated that health care provider recommendations also play a crucial role in HPV vaccine acceptability in developed countries and have been identified as an important source of HPV information (Daley et al., 2006; Kahn et al., 2005; Riedesel et al., 2005). Successful HPV vaccination programs will depend on health care providers’ recommendation of the HPV vaccination to parents. To date, there is a great need in Thailand for more research on knowledge, attitudes, and acceptability of HPV vaccines for adolescents and parents of adolescents, including health care provider’s attitudes about HPV vaccine recommendation. If Thai adolescents and parents have a clear understanding of HPV infection and its association with cervical cancer, it is likely that they will be more willing to accept HPV vaccines. While the HPV vaccines have not yet been included in the national immunization program
Issues and challenges of cervical cancer screenings in Thailand for Thai adolescents who are not able to afford the vaccine out of their own pocket, efforts should be made to provide information about the prevention of HPV infection. HPV education campaigns, particularly school or collegebased cervical cancer education will be needed to increase awareness and educate young adolescents in preventing HPV infection.
Conclusions Cervical cancer is a common cancer among women in Thailand and is largely preventable through screening and vaccination programs. Developing affordable and accessible programs that are culturally appropriate is critical in decreasing the disease burden among Thai women.
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