An Elective In Paradise
By Irum Sunderji
Levuka Hospital, Ovalau, Fiji Islands
With special thanks to the Womens Visiting Gynaecological Club for their generous donation without whom this elective would not have been possible.
I spent my 7-week elective in the sleepy town of Levuka, otherwise known as the old capital of Fiji. The hospital was small, the facilities and equipment often lacking and internet was a luxury that the hospital simply could not afford. With only 3 doctors to staff the hospital, elective students were warmly welcomed.
During my elective I took part in a variety of activities to assist in the improvement of Women's health in Ovalau. Each week was different, providing different opportunities and as my rapport with patients and staff progressed I was able to discover more of the difficulties and challenges of women's healthcare in Fiji. Furthermore, each week my own learning and experiences enabled me to consider solutions to some of these problems that, if properly implemented, could help the healthcare of women beyond my stay in Levuka Town.
The advantages of health education and lifestyle choices in preventing disease presentation, is becoming more apparent and the focus of much of healthcare in both the developed and developing world. Its importance is even more apparent in rural areas such as Levuka, which are resource poor and where patients often present at such advanced states of disease that little can be done for them. At this point, they must somehow make their own way to Suva on the Mainland for healthcare, which they are unlikely to be able to afford.
With this in mind, I focused much of my attention during my elective on the Cervical Screening Programme in Fiji. Despite being preventable, cervical cancer is the most common neoplasm amongst women in the Pacifics and the average life expectancy after diagnosis is as little as 6 months.
Weeks 1-2:
Although the hospital was a General Hospital, specialist clinics were held (although run by general doctors, rather than specialists). 3 out of 5 afternoons a week were dedicated to antenatal and postnatal clinics. During the first few weeks I spent a considerable amount of time in these clinics. Many of these women had large families, on average 5 children but for some this may have been their 10th or 11th pregnancy. Contraception was forbidden for the majority, as the main practicing faith on the island was Roman Catholicism. As such, we could only advise women on the withdrawal method or monitoring their cycle and avoiding intercourse during the predicted of ovulation
During clinics, if it was the woman's first pregnancy or if there were any signs of complications that would increase the need for a Caesarean Section, they would be sent to Suva, as Levuka Hospital did not have the facilities nor the specialist doctors to handle this procedure.
These clinics were a perfect opportunity to speak with patients about their understanding of cervical cancer and the screening programme. Surprisingly, despite the low national coverage rates, many women were aware of the screening programme. However, despite assuring me that they understood the purpose of the smear programme, after probing a little deeper it became apparent that some had been misinformed whilst others had been given very little information. Some had been told that once a woman became pregnant she could no longer get cervical cancer and therefore there was no need to have a smear. Others were afraid of the procedure or had a smear in the past but had not received any results, information or follow-up advice after.
Whilst talking to patients in clinic, I also became aware of cultural and social issues that were not at first apparent. The island of Ovalau is comprised of Levuka Town and 28 villages scattered around the island. There are only 2 nursing stations in addition to Levuka Hospital (1 of which is next to the hospital) that have the equipment and staff to perform cervical smears. Transportation links from those villages further away can be poor resulting in only one bus to a nursing station each week.
Furthermore, many husbands are dismissive of the need for their wives or daughters to visit Levuka Hospital, as this would waste an entire day. Village and household tasks such as cleaning, meal preparations or child minding would need to be taken care of through alternative methods, which is not always possible with the husband working in the plantation.
Although not related to women's health, one of the more extreme instances in which this was so clearly illustrated was a lady who's eye was infected due to recent trauma and inappropriate care. Having already lost her sight in the infected eye, she was advised to have it surgically removed before the infection spread causing permanent loss of vision bilaterally, sepsis or even eventual death. The woman's husband vehemently refused to allow his wife to return the following day for the procedure as there would be no-one at home to have prepared his meal once he returned from the plantation after a hard day's work. Fortunately, in this instance after heavy debate we were able to convince the husband that the procedure was necessary and that they should return the following day.
Another cultural issue that came to light was that if a woman came to have a smear performed she was sexually active. In Roman Catholicism it is frowned upon to have intercourse before marriage. Furthermore, for several reasons including lack of enforcement of regulations and the community atmosphere on the island between hospital staff and villagers, confidentiality is still somewhat of a foreign concept making it difficult for women to attend for a smear without others in her village knowing.
Having spent the first 2 weeks of my elective delving in to the heart of these issues pertaining to the Smear Programme I decided to conduct an audit of how well the programme was run on the island of Ovalau. I felt that this data would highlight the need for improvement and my discussions with women during clinics and in the community would give some idea of the ways in which the programme could be improved.
Week 3: The Outreach Programme
During the 3rd week of my elective, clinics, audits and all other work was postponed as an Outreach team of 60 staff including specialist doctors, nurses, pathologists etc. arrived at Levuka Hospital with the intention of seeing as many patients as possible in the space of 4 days. I attached myself to the lead Obstetrician and Gynaecologist and assisted in a series of workshops on cervical screening and sexually transmitted infections (STIs), which was carried out for the nurses of the island.
The first 2 days of workshops focused on Cervical Cancer. Epidemiology, pathology, investigations and management were discussed in addition to the 1995 Fijian Ministry of Health Cervical Smear Programme and the impact this can have on reducing the incidence of Cervical Cancer. Many of the healthcare staff were unaware how frequently smears ought to be carried out, what age-range should be tested or even how to perform a smear.
Due to the nature of Fiji being composed of many islands, there was also the practical issue of how to transport smears that had been taken safely to the mainland and ensure that results were received back in an appropriate timeframe if at all! For some of the neighbouring islands to Ovalau, it was decided that in instances where it was impossible to transport the smears, a visual inspection with acetic acid should be performed instead. If any abnormalities were seen, they should immediately be referred to Suva for further testing. This is currently being trialled on many of the smaller islands in Fiji.
Recognizing some of the issues patients face when deciding to come for a smear, we also discussed the issues of confidentiality and empathy with patients. And finally to conclude the smear training session, nurses were taught how to perform a smear test or a visual inspection with acetic acid. Unfortunately, there were no models for the nurses to practice on and so the first time they were able to try the procedure was either on a patient or each other in the weeks that followed.
The latter half of the week focused on recognizing STIs and how to manage them. Again, empathy and confidentiality was taken in to consideration as if knowledge of this were to be passed around the village it could have devastating consequences for the woman involved. The rates of STIs in Ovalau were particularly high as condoms are frowned upon in Roman Catholicism.
Weeks 4-7:
During the final weeks, I was able to fully concentrate on auditing the Smear Programme in Ovalau and focus on how this could be further improved. Before visiting Levuka, I had hoped to visit the community to teach women and raise awareness of Cervical Cancer, however due to cultural traditions it would have taken far longer than I had during my elective to gain permission to access the villages as certain rituals must be performed. Instead, I continued to use clinics opportunistically to target women who were within the Ministry of Health criteria for screening and encourage them to educate their family and friends in the villages nearby. In addition, I also encouraged nurses, doctors and Fijian medical students to offer smears to all women of reproductive age who attended clinics. Many of the women seen during general outpatient and postnatal clinics went on to have smears performed at the nursing station on the same day.
During my spare time I was able to access records that had been manually documented over the last 5 years from the hospital and both health centres on the island. Using this information I created an electronic database of every woman on the island who had had a Smear performed in the last 5 years. Using this, I was also able to monitor those who had undergone repeat smears as per the Fijian Ministry of Health guidelines.
During the last week, I had the opportunity to present my results at a grand hospital meeting to all the hospital staff and nursing staff from the nearby nursing station. During this talk, I suggested the implementation of guidelines for the following year. The Ministry of Health gave explicit guidelines as to the protocol of how often smears should be carried out for women who receive normal results but it neglected to advise how abnormal results should be managed and the age at which smears should commence and finish. With this in mind, I combined the guidelines advised by the World Health Organization for developing countries and the Ministry of Health guidelines to suggest a policy for Levuka Hospital. This included not only a timeline for carrying out smears but also appropriate follow-up steps should results return as abnormal.
In addition I gave a copy of the electronic database to the hospital before my departure and was able to teach the hospital administrators how to use the database appropriately and advise them on how frequently to update it over the months and years to come. I inserted 2 new columns to those already manually recorded: contact telephone number and repeat smear, so that nurses are able to call patients who are unable to make frequent visits to the hospital to deliver their results or remind patients who have forgotten that they are due for a repeat smear.
Finally, during the audit I noticed that one of the principal flaws of the Smear Programme in Levuka was poor documentation. Over 20% of women had 1 or more fields missing including age, result and in some cases even name! This made it even more difficult to monitor the programme and I suspect in many cases, the results had not been received meaning women had not been followed-up.
To close the audit cycle, I suggested that a re-audit occur in 6 months time to see whether the Ovalau coverage rate had increased and whether documentation and follow-up had improved.
Concluding remarks:
My time in Levuka was a great learning tool and I hope that during my stay I was able to contribute as much as I took away from the elective. Although aware of the social and cultural limitations before arriving, experiencing them first hand was incredibly difficult and humbling at times. I realised a passion I had for teaching both patients and staff alike and this is a skill I will endeavour to continue developing during my years of professional training in the UK.
The experience also raised an awareness of the importance of auditing existing programmes. The focus of the island was on non-communicable diseases having assumed that programmes implemented in the past including the smear programme, were running effectively. The results gleaned from the audit will hopefully contribute towards the goals for the hospital's targets next year. Furthermore, it gave me good insight in performing my own audit. It helped me to develop knowledge in collecting data and analysis including simple statistical interpretation.
Whilst considering how to improve the coverage rate of smears in an area with a weak economy, I realised how simple measures can be used to substantially improve healthcare in resource poor areas. Many of the implementations suggested during the course of the audit require very little in the way of financing, yet have the potential to increase the Smear coverage rate of the island substantially.